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ICS Explained

Overview of Integrated Care Systems and Relevant Guidance

This briefing gives an overview of Integrated Care Systems and links to useful guidance and resources to help you navigate and engage with wider systems – e.g., the new Integrated Care Boards and Partnerships, local authorities within an defined ICS area and other key stakeholders such as VCSEs and Healthwatch.

Overview

On 1 July 2022, Integrated Care Systems (ICSs) were placed on a statutory footing by the Health and Care Act 2022 while CCGs were abolished and their commissioning powers transferred to the new bodies. ICSs are partnerships which bring together providers and commissioners of NHS services across a specific geographical area with Local Authorities and other local partners to collectively plan health and care services to meet the needs of their population and reduce health inequalities.

While local arrangements and the size of populations will vary, the ICSs are made up of three levels:

System
Place
Neighbourhood

An infographic created by the King’s Fund, gives a helpful illustration of this structure. You can see this here.

At the top level is the ‘System’ which covers a defined geography of around 1 to 2 million people. This is the level where the strategic planning takes place for joining-up health and care, as well as system performance and budgetary power. The Integrated Care Board (ICB) and Integrated Care Partnership (ICP) have the strategic oversight of the system. Provider Collaboratives (which can be systems based or place-based) are one of the delivery structures for the strategy, operating either across a system or between systems – more on this in our summary of the guidance.

The next level down has been dubbed ‘Place’ level in NHS documentation and covers places with populations between 250,000-500,000. This might be town, city or council level where health and care providers and LAs serve the community. The Place-Based Partnerships sit at this level while Provider Collaboratives can cut across multiple Places at this level. Health and Wellbeing Boards also sit here, although the guidance allows them to potentially work system-wide as well.

The lowest level is made up of ‘Neighbourhoods’ with populations of around 30,000 to 50,000 people. Primary Care Networks (PCNs) bring together services at this level.

A full outline of the detail, structure and core expectations of the ICSs can be found in the ICS Design Framework Document which was published in June 2021. We anticipate updated guidance now that the Health and Care Act is in law.

A note on terminology

We are aware that many ICSs which were established before the Health and Care Act was introduced have been calling their Place-based partnerships ‘Integrated Care Partnerships’ or ‘Boards’. This is rather confusing because the NHSE guidance and legislation reserves the terms ‘Integrated Care Partnership’ and ‘Integrated Care Board’ to mean the highest part of the system. What many members are calling ICPs, may in fact be place-based partnerships. We will be following the terminology as laid out in guidance.

Integrated Care Boards

ICBs (sometimes referred to as ‘ICS NHS Board’ or the ‘Board of the ICS NHS Body’ in older guidance) will be statutory organisations that bring the NHS together locally to plan to meet population health needs, allocate resources, ensure that services are in place, facilitate the transformation of services, co-ordinate and improve people and culture development, and oversee the delivery of improved outcomes for the population. In doing this they will establish shared strategic priorities within the NHS, connecting to partnerships across the NHS and the wider ICS. Local Authorities are represented on these boards. The Health and Care Act does not allow for membership other than representatives from the NHS or LAs.

These boards lead the entire system – although they should also show ‘due regard’ to the Integrated Care Plans produced by the Integrated Care Partnerships when commissioning, making decisions and delivering services. ICBs will absorb the powers of the CCGs but will have more flexibility when it comes to commissioning. See this interim guidance on ICBs for more details.

Integrated Care Partnerships

The ICP is a broad alliance of organisations and representatives concerned with improving the care, health and wellbeing of the population, jointly convened by local authorities and the ICB. There will be a statutorily equal partnership between the NHS and local government in this arrangement. The Partnership acts as a forum to align the ambitions, purpose and strategies of partners across the system. The ICPs have a specific responsibility to develop an ‘integrated care strategy’ for the whole ICS population covering health and social care, and addressing wider determinants of health and wellbeing – such as employment, environment and housing. When creating these plans, they should be informed by the local assessments of needs and assets identified at place level, based on Joint Strategic Needs Assessments and Health and Wellbeing Board strategies. To be clear, this means that Health and Wellbeing Boards are separate entities from the ICPs. The former sit at Place level and the latter System level. Representation from the Health and Wellbeing boards can be co-opted into the structures of the ICP at system level if desired. Any strategies should also be co-produced with those that draw upon services in the ICS footprint.

The guidance for ICPs outlines 5 expectations for the Partnerships:

ICPs are a core part of ICSs, driving their direction and priorities
ICPs will be rooted in the needs of people, communities and places
ICPs create a space to develop and oversee population health strategies to improve health outcomes and experiences
ICPs will support integrated approaches and subsidiarity
ICPs should take an open and inclusive approach to strategy development and leadership, involving communities and partners to utilise local data and insights

Unfortunately, despite the necessity for contribution from adult social care to meet these aims, only the ICBs and LAs will be statutorily required members. The Health and Care Act also specifies that Local Healthwatch organisations whose areas coincide with or fall wholly or partly within an ICS area, should be involved in the preparation of an integrated care strategy and the guidance suggests that they could also be members of the ICP. When it comes to adult social care providers, the guidance states there is an expectation that there will be some form of representation but it suggests that this may not require full ICP membership which is concerning and we are working to address this.

In short, the membership of the ICPs is deliberately not prescriptive – adult social care is not automatically represented, an assumption appears to have been made that Local Authorities adequately represent the strategic level of social care. The intention appears to be to allow systems to develop the partnership arrangements that work best for them.

We have raised our concerns about this approach and are working with DHSC and the NHS to encourage a more proactive approach to the involvement of adult social care and to inform future guidance relating to engagement with social care.

In the absence of this, we hope this briefing enables providers to be proactive in engaging with ICSs. We will be producing a range of wider resources to support members to do this, including: case studies, key messages for system leaders and top tips on how to engage with the Integrated Partnerships and other levels of ICSs. Do also note that the guidance for the VCSE sector may also be a route to representation for some non-profit social care providers, giving us another avenue to representation. The ICP guidance also acknowledges this.

The initial guidance on ICPs can be found here.

ICS Leadership

From 1 July 2022 ICSs will have an ICB Chair (taking over from existing ICS Independent Chairs) and an ICB CEO (taking over from existing ICS Executive Leads). In quite a few cases the ICB designate chair is the same person as the existing ICS chair.

A full list of ICB Chair Designates and ICB CEO Designates can be found here.

In terms of the Chair for the Integrated Care Partnerships, this has been left up to the ICB and LAs. Two options are suggested by guidance:

They can either jointly select a Partnership Chair or;
The ICB Chair Designate can also Chair the Partnership to ensure coordination.

There is currently no list of Integrated Partnership Chairs because they cannot be formally selected until the designated Chair and CEO of the ICBs are in place. In the meantime, the guidance asks for an interim ICP and chair to be established which has to have representation from the ICB and LAs at the very least.

In any case, all of these contacts will be key for engaging with the ICSs – and it will be worth trying to make contact with the ICB designates to ensure social care is at the forefront of their minds.

Provider Collaboratives

The full guidance can be found here.

Provider collaboratives are partnership arrangements involving at least two NHS trusts working at scale across multiple Places (or Systems), with a shared purpose and effective decision-making arrangements, to:

Reduce unwarranted variation and inequality in health outcomes, access to services and experience
Improve resilience by, for example, providing mutual aid
Ensure that specialisation and consolidation occur where this will provide better outcome and value

While social care providers can be part of these collaboratives, the guidance is heavily focused on NHS providers working together to achieve NHS outcomes, sometimes with the help of non-NHS providers. They are focused on NHS delivery. All of the examples given in the guidance are health or clinically focused and the governance of the collaboratives is NHS dominated. ICBs are able to delegate powers and budgets to Trusts (including specialist trusts) or directly to NHS providers to establish these Collaboratives. Provider Collaboratives can subcontract to other providers – perhaps of interest to members providing specialist services.

Some Provider Collaboratives already exist, such as Cancer Alliances and clinical networks and so one of the first tasks of the ICBs will be to map these and ensure they align with the aims of the ICS.

The role of adult social care providers is not as central as we would like in the guidance which assumes that their role is on the Place-Based Partnerships (see below) by default. It states: ‘Local authorities and social care providers will be able to work with provider collaboratives to share knowledge and engage in dialogue to better understand the impact that service transformations will have across all services, communities and populations.’

Nevertheless, it is very clear that social care involvement in these Collaboratives will be essential if they are to meet their stated aims. The structures that allow collaborative work across Places and Systems also provide a useful means for social care to make its voice heard. This in turn strengthens the case for ICP representation. We need to ensure that social care providers take every opportunity to be involved.

You may also want to read this useful briefing from The King’s Fund.

Place-Based Partnerships

The full guidance can be found here.

Place-based partnerships are collaborative arrangements formed by the organisations responsible for arranging and delivering health and care services in a locality or community. They are the foundations of the ICSs and have been put on a statutory footing in the Health and Care Act. Membership will likely involve NHS, local government, health and social care providers, VCSEs, and people from a specific place. Like the ICPs, membership is not-prescribed and up to the needs and wants of a particular area and there is no fixed model for what the partnerships should look like. Health and Wellbeing Boards are one example of a Place-Based Partnership, but it can be larger or smaller than these or take on different functions. The geographical scope is defined:

‘the footprint of a place should be based on what is meaningful to local people, has a coherent identity and is where they live their lives – such as a town, city, borough or county.’

Decision making should be ‘guided by the principle of subsidiarity, with decisions taken as close to local communities as possible, and at a larger scale where there are demonstrable benefits or where co-ordination across places adds value’

The place-based partnership and ICB leadership are expected to define the role of the specific partnership and how it can effectively monitor performance within its part of the system and share data and intelligence to other parts of the system. Some place-based partnerships will be able to take on delegated statutory functions from the ICB.

The guidance lists a set of guiding principles:

There is no single approach to defining how, and at what scale, partners should come together to work in an ICS. Place-based partnerships should start from understanding people and communities and agreeing shared purpose before defining structures.
Effective partnerships are often built ‘by doing’ – acting together and building collaborative arrangements to support this action as it evolves
Governance arrangements must develop over time, with the potential to develop into more formal arrangements as working relationships and trust increase.
Partnerships should be built on an ethos of equal partnership across sectors, organisations, professionals and communities.
Partners should consider how they develop the culture and behaviours that reflect their shared values and sustain open, respectful and trusting working relationships supported by clearly defined mechanisms to support public accountability and transparency.

Integration White Paper

The Integration White Paper adds another piece to Place level guidance by elaborating on the place-based partnership guidance in chapter 3.

There is an expectation that all local areas create place-based arrangements to bring together NHS and local authority leadership. This will include responsibility for effective commissioning and delivery of health and care services. Local health and care leaders are expected to set and agree the shared outcomes and will be held accountable for delivery of these outcomes.

The white paper proposes a model to do this using a ‘Place-based board’, although other models are available. In this arrangement, a ‘place board’ brings together partner organisations to pool resources, make decisions and plan jointly – with a single person accountable for the delivery of shared outcomes and plans, working with local partners. In this system, the council and ICB would delegate their functions and budgets to the board.

By 2023, all ‘Places’ within an ICS are expected to have adopted a model of accountability, like this one, with a clearly identifiable person responsible for delivering outcomes, working to ensure agreement between partners and providing clarity over decision making. The attempt to turn the ‘Place-based board’ model into a diagram shows that this will be a complicated task:

This is clearly a highly political model. It is very hard to see how a single individual can be accountable for an integrated ‘Place-based board’ that sits between the LA and the NHS. This individual and the Place Board are delegated commissioning powers by the Integrated Care Board (ICB) and LA. Other parts of the white paper also talk about making it easier to pool or align funding between the NHS and LAs to enable such place-based working but nothing concrete is suggested.

For a fuller analysis of the white paper see our summary briefing on the Integration White Paper.

Partnerships with the voluntary, community and social enterprise sector (VCSE)

The full guidance can be found here.

As the NCF membership is not-for-profit, the guidance for VCSE engagement is also particularly relevant. The guidance sets the expectation that the VCSE sector is a key strategic partner at every level of the ICS and VCSE partnership should be embedded in how the ICS operates, including involvement in governance structure in population health management and service redesign work, and in system workforce, leadership and organisational development plans. The aim is that by the time ICBs go live, they have developed a formal agreement for engaging and embedding the VCSE sector in system-level governance and decision-making.

At place-level, VCSE infrastructure organisations (sometimes called CVS or Voluntary Action) already exist and work with the NHS and LA.

The guidance emphasises the role that VCSE should have in regards to ICBs, ICPs, Place level, Neighbourhood level and also with provider collaboratives. As the VCSE sector is diverse and support sometimes focuses on specific conditions, the guidance promotes the creation of VCSE alliances.

ICBs and ICPs are expected to have a formal arrangement for engaging and embedding the VCSE sector. This should be achieved by working through VCSE Alliances to support engagement with the diversity of the sector.

The detail of partnership arrangements will depend on existing local infrastructure and approaches.
Partnership arrangements should include agreed ways of working such as a memorandum of understanding and sets of principles.
There is a national ICS and VCSE sector partnership programme to support this work

Place-Based VCSE Involvement – Alliances can build on existing arrangements at place level as this is where most of the voluntary sector funding is allocated. Provider collaboratives should link closely with VCSE. VCSE alliances should be integral parts of place-based partnerships in ICSs.

Neighbourhood VCSE Involvement – ICSs should also consider how VCSE organisations can help at the neighbourhood level and be in multidisciplinary neighbourhood teams.

The expertise of VCSE organisations will help provider collaboratives when co-designing and delivering health and care services. Social care providers need to be involved with VCSE alliances.