One of the lessons from the COVID-19 pandemic and the vaccine rollout was the level of local collaboration between the NHS, local authorities, and local partners in the best interests of residents. In many areas, the pandemic galvanised joint working and showed what could be achieved if the different parts of the system worked together to achieve shared objectives.
Improving outcomes and experience through the integration of services can be done where the NHS, local authorities, social care providers, voluntary and community organisations, social enterprises, and wider partners come together to deliver in the best interests of residents in their area.
The Health and Care Bill’s proposed duty on integrated care boards (ICBs) and local authorities to form integrated care partnerships (ICPs), seeks to put this best practice at the heart of the health and social care system, and make collaboration and co-operation across bodies an intrinsic part of how the health and care system delivers.
This paper sets out what we heard as part of a trilateral engagement exercise undertaken by the Department of Health and Social Care (DHSC), NHS England (NHSE) and the Local Government Association (LGA) over recent months. This engagement included stakeholders with an interest in the formation ofICPs, and will inform howDHSC, NHS England and the Local Government Association guide and support the development of these new partnership arrangements ahead of their implementation in July 2022 and beyond.
This paper seeks to inform and shape conversations taking place across England, aiding local areas to find the arrangements that suit their populations and circumstances, rather than imposing a one-size-fits-all model from above. It forms part of an ongoing process of engaging, listening and supporting which will continue up until the establishment of integrated care partnerships and beyond.
We hope that this document will prove to be of use as designateICBleaders; local authorities and system partners navigate this important development in the health and care landscape. We want to help develop a health and care system which is passionate about partnership and its potential to deliver better outcomes for people.
This document summarises the trilateral engagement undertaken byDHSC,NHSEandLGAfollowing the publication ofICPengagement document: integrated care system (ICS) implementation in September 2021 by the Department of Health and Social Care (DHSC), NHS England (NHSE) and the Local Government Association (LGA).
Our engagement was based on the 5 expectations of integrated care partnerships (ICPs), we have summarised our main findings below and included our key conclusions.
Strong relationships and a collaborative culture are critical to the development ofICPs. The level of development of these relationships differed in each area but where systems were undertaking broad engagement early, system development was working well.
The legislation enables this in a number of ways, including through the statutory duties in the Health and Care Bill and the proposed Care Quality Commission (CQC) reviews ofICSs, that will look at the functioning of the system for the provision of relevant health care, and adult social care. We expect that those reviews will look at the dynamic between theICPand the integrated care board (ICB).
There was strong support for the inclusive engagement of people and communities in the activities of theICP. However, there were some questions about the potential for duplication of engagement between systems and places. TheICPshould draw upon insights from the existing work of partners to inform its work.
Representation within theICPwas frequently raised in our engagement. The permissive nature of the legislation allows for local areas to make arrangements that are most appropriate for their circumstances and is conducive to collaborative working. Where appropriate, however, we have set our expectations or given suggestions about whatICBsand LAs will want to consider when establishing their partnerships. The Department of Health and Social Care (DHSC), NHS England (NHSE) and the Local Government Association (LGA) will continue to engage with stakeholders on the representation of specific voices over the coming months and asICPsare established.
There was support for the idea thatICPswill play a crucial role within the system to bring together partners and look beyond traditional organisational boundaries to address population health, health inequalities and the wider determinants of health, by giving the space to look at complex, long-term issues that require integrated approaches to succeed. This approach will be further reflected in the integrated care strategy guidance due to be published this summer.
We expect that public health experts, including directors of public health and their teams, will play a significant role as they can support, inform, and guide approaches to population health management and improvement.
Much of our engagement confirmed the importance of ensuring that work at system level complements and supports the work undertaken at place level. Much of the transformation and integration will happen at place level and theICPshould avoid duplicating the work of the Health and Wellbeing Board or other work underway at place level, especially where there are similar geographical footprints. The Health and Care Bill andDHSC’s recently published Integration White Paper reflect these intentions, including through the single accountable person for shared outcomes at place.
There was also discussion about some of the practical roles that theICP, rather than places could undertake including:
There was a consensus that there should be an open and inclusive approach to strategy development byICPs. WhilstDHSCdoes not intend to produce detailed guidance on what should be in every integrated care strategy, there was interest in who should be engaged in its development, beyond the statutory requirements.
Leadership and culture were also key factors that were raised, including who should be theICPChair. This is a matter for local areas, but we would expect the local authority andICBto be actively involved in the choice of Chair so that maximum consensus can be built. A good culture will be driven by an approach that is based on shared goals and evidence and is informed by the local communities thatICPsserve. This will be underpinned by strong relationships, dedication, and hard work from the leaders within the system.
A broad and diverse range of approaches toICPgovernance models are emerging, including forums, and small committees amongst theICSareas who are further along in theirICPdevelopment.
Some areas intend for theICBChair to also chair theICP, subject to the passage of the Bill, whilst some will have a Chair drawn from an LA. Some have opted for a shared or rotating co-chair model.
Membership of theICPvaries across areas, but commonly membership includes theICBCEO, representatives from LAs, NHS healthcare providers, voluntary, community and social enterprise (VCSE) representatives, Healthwatch and public representatives. ManyICPshave also planned to have place representatives, and others are planning to draw representation from other partners including; higher education and further education, social care providers, housing, police, justice, and Local Enterprise Partnerships.
Case studies have been included in Annex B to illustrate how systems are setting up governance models and some of the partnership working thatICPsmight champion in their strategies. These case studies are intended to support conversations within systems about how they might set up theirICPsand the themes they might wish to address through partnership.
DHSC,NHSEand theLGAhave several resources and support programmes in place. There are others in development including:
Recognising thatICPswill be at different stages of development, and vary in complexity, we have set out an indicative timeline to help all systems identify the key milestones in developing theICPand the integrated care strategy, with 2022 to 2023 being a transitional year.
|April – June 2022||DHSCto engage with systems to inform the guidance on the integrated care strategy|
|July 2022||ICPformally established by local authorities andICBs(subject to parliamentary passage)|
|July 2022||DHSCto publish guidance on the integrated care strategy|
|December 2022||EachICPto publish an interim integrated care strategy if it wishes to influence theICB’s first 5-year forward plan for healthcare to be published before April 2023.|
|June 2023||DHSCrefreshes integrated care strategy guidance (if needed)|
We expect that the CQCICSreviews will assess the functioning of the system for the provision of relevant healthcare and adult social care, and we expect that they will look at the relationship between theICB, andICP.
Guidance on the integrated care strategy can further reinforce the role of theICPto focus on the challenges and opportunities that go beyond traditional boundaries and are best addressed at system level.
Following the publication of the Integrated Care Partnership (ICP) engagement document: integrated care system (ICS) implementation in September 2021,DHSC,LGAandNHSEengaged with a range of stakeholders (see list at Annex A) between September 2021 and January 2022 onICPimplementation.
Key ICP requirements in the Health and Care Bill
Other key areas of policy that were both developed byDHSCconcurrently with this document were the Adult Social Care White Paper published in December 2021, and the Integration White Paper, published in February 2021. The Integration White Paper focuses on ambitions to go further and faster in joining up integration of health and social care. It sets out the ambition for developing shared outcomes for systems which will galvanise joined up approaches. It isDHSC’s aim that this will both empower place-based delivery within systems and support and drive more integrated approaches at every level.
The Adult Social Care White Paper is also designed to escalate the scale and pace of integration of health and care services at place level. It isDHSC’s view thatICPswill play an important role in bringing together housing, transport, care providers and other system partners to realise the ambition of the white paper on delivering person-centred care and support.
Furthermore, the NHS Planning Guidance for 2022 to 2023, published in December 2021, identified July 2022 as the target period for Integrated Care Boards to go live, subject to the passage of the Health and Care Bill. This followed a joint assessment betweenDHSCandNHSEon the factors affecting timing, including an assessment of the time needed to allow proper scrutiny of the Bill by Parliament.
This document, developed in partnership withNHSE, and theLGA, summarises the topics that were regularly raised during our engagement. In response, we have drawn out some of the initial findings from our engagement and indicated where we plan to take further action. The document has been designed with the intention of aiding those who are responsible for establishingICPsfrom July 2022 (subject to the passage of the Bill), that is, local authorities andICBs. It will also be of interest to those system partners who are critical to the success ofICPs.
This document is not a one-size-fits-all guide on how to set up and runICPs, nor do we intend to provide that, as local areas will be able to find the arrangements most appropriate for them.
DHSCwill publish statutory guidance on the integrated care strategy in July 2022. However,DHSCdoes not intend to produce detailed guidance on what should be in every Integrated Care Strategy, as there was no demand for further detailed or prescriptive guidance in this space. Rather, it intends to focus on the challenges and opportunities on whichICPsare best placed to lead, such as work that would benefit from a partnership approach, and the inclusion of specific voices.
Whilst we recognise thatICPswill be at different stages of development and that 2022 to 20 23 is a transition year as systems get established, we are encouraging, but not mandating that allICPsto have at least an interim integrated care strategy by the end of 2022. This will ensure that, as far as possible,ICPstrategies can inform and influence the first 5-year forward plan[footnote 1]which eachICB, must publish before April 2023 to fulfil their statutory duty. We would expectICPsand their integrated care strategies to continue to evolve and mature over time.
We are grateful to everyone who engaged with this document and gave us feedback. This has shaped the document and, in turn, the work to support the development and implementation ofICPs. If you have any further feedback, please contact: email@example.com
What we heard
We engaged with a wide range of stakeholders from September 2021 – December 2021 (see Annex A for the full list). This chapter summarises our main findings, to help local areas develop the most appropriateICPfor their circumstances. This section also commits to further actions to supportICPdevelopment and implementation.
Over the course of our engagement, conversations evolved as stakeholders’ awareness and understanding of the proposals in the Bill grew. Our conversations captured the diversity ofICSprogress and opinion across England. Generally, there is support for the Bill’s permissive approach; and the phrase “one size isn’t going to fit all” came up repeatedly. However, there was also a view that the transition from existing system working toICPsshould build upon, and enhance, existing structures. We noted that positive culture, behaviours, and relationships enabled swifter progress.
Our engagement discussions were largely framed around the 5 expectations we set forICPsin our original engagement document. As such, we have also structured this paper to report back on what we heard about these 5 themes:
We heard broad support for the 5 expectations forICPsset out in ourICPengagement document. This support was accompanied by significant discussion about how they could be embedded in practice, and what some of the challenges might be. We address what we heard about each expectation in more detail below.
This expectation is key to ensuring we achieve our vision for systems, by ensuring that partnership approaches are at the heart of everyICS. Our engagement conversations focussed significantly on the importance of this expectation and how it can be successfully implemented.
We heard that many felt this period – prior toICBsandICPsbeing established in law subject to the passage of the Health and Care Bill – was critical to the successful implementation ofICSs. Some stakeholders said they were already communicating with the Chair designate of theICBabout how they would work together on the establishment of theICP. In most areas,ICBChair designates and local authorities are already working well together to establish theirICParrangements. Several stakeholders reinforced that all partners should be engaging proactively to build the foundations for strong future relationships.
However, this was not the case everywhere. Some local authorities did not yet feel like they had established the ‘equal partnership’ withICBsthat the Health and Care Bill aspires to. Furthermore, some potential partners outside of the NHS or local authorities said that they were unclear on who they should be contacting regardingICPestablishment, and that they were unsure of how to get involved. In our engagement, it was clear that for some areas, the current focus on the operational and technical work required to establishICBsmeant thatICPswere being established more slowly.
We would expect local authorities andICBChair designates in every area to be having discussions about their vision for theICP, and how they want to work together and lead it. If there are areas where this is not happening,ICBChair Designates and local authority leaders should be reaching out urgently to make those connections.
Whilst we recognise that theICBwill play a key role in the establishment of theICP, we heard from stakeholders that where system development seems to be working best is when designateICBleaders, local authorities and local stakeholders engage early in the process of establishing theirICP. We expect local authorities andICBsto be co-designingICPsand we are clear that designateICBleaders should not be leading the design ofICPsalone, as these are not NHS structures.
Some concerns were raised about the fact that no additional funding is being provided to support the establishment ofICPs. We expect this to be considered as part of the governance arrangements forICPsas there are no plans for national funding to be made available for theICPs. We do recognise that this will challenge organisations who are facing funding or resourcing pressures. However, we expect that investment inICPswill improve partnerships and enable a better response to local needs, which will, in time, lead to a more efficient and sustainable system. To achieve this, theICBand local authorities will want to consider how best to mutually support theICPin its establishment phase.
We heard concerns that theICPmay struggle to influence theICB, a statutory NHS body with local NHS priorities where these priorities may differ from those of theICP. Some concerns were also raised about the potential for theICBto dominate within a system given its scale; the resources available to it, and its status as a statutory body rather than a statutory committee like theICP. We have listened carefully to those concerns and want to provide reassurance that the Health and Care Bill is specifically designed to counter this dynamic as theICBandICPare complementary and intrinsically connected within the legislative framework.
The Health and Care Bill includes a statutory duty for allICBsto have regard to the integrated care strategy when exercising their functions and specifically in developing their 5-year forward plans. The Bill also requires that local authorities have regard to the integrated care strategy in exercising their functions. The legislation also provides that theICBand LAs will establish theICPjointly, we would therefore expect theICBto be fully engaged with the work of theICP. Whilst the relationship and dynamic between theICPandICBmay differ across systems, it is important that theICBandICPshould agree how they will work together and set out these arrangements including how the integrated care strategy will be reflected in theICBsplans. For more detail about the duties of the Health and Care Bill relating toICPs, please see Annex C.
The proposed CQC reviews of Integrated Care Systems will allow the CQC to look broadly across the system to review howICBs, local authorities and providers of health, public health and adult social care services are working together. This can include, for example, the role of theICPand ensuring thatICBsandICPsare equal partners within the system. DHSCwill continue to engage with CQC on these issues as they develop theirICSreview methodology.
DHSC,NHSEand theLGAare clear that allICBsand their partner NHS trusts will need to demonstrate how they have considered any relevant joint local and health and wellbeing strategies, joint strategic needs assessment, and the integrated care strategy in preparation of their 5-year forward plans. We are clear that theICBcan only exercise its statutory responsibility if it is taking full account of the integrated care strategy.
Many areas are already working to ensure a balanced relationship between theICPand theICB, by creating a strong and empoweredICPfrom the outset. There is much to learn from these examples; establishing a collaborative and outcomes-focused culture and approach from the outset will be the key to delivering a successful and influentialICP.
We expect that the CQCICSreviews will assess the functioning of the system for the provision of relevant healthcare and adult social care, and we expect that they will look at the relationship between theICB, andICPis operating effectively.
We expect that the design ofICPswill place people, communities, and places at their heart. There was strong support for involving partners and communities in an inclusive way, but this expectation generated some questions and discussion concerning the respective role of systems and places in engaging with the needs of people and communities and about membership.
ICPswill specifically be tasked to work with people and communities on the development of their integrated care strategy through existing engagement channels of all partners, making connections to existing community fora and democratic representatives. This will allow decision making within theICPto be informed by the views of people and communities.
NHSEandDHSCare producing statutory guidance forICBsand providers on working with people and communities. This will be subject to public consultation before publication in Summer 2022. We recognise the need to ensure that broader engagement is aligned across the different parts of systems, and that people and communities are involved from neighbourhood level upwards. We will therefore need to ensure that guidance for the integrated care strategy is aligned with guidance forICBsand providers on working with people and communities.
We heard some concerns around duplication of engagement within systems.ICPsshould use insights from existing work with residents to inform the strategy and work of theICP, and not duplicate engagement already being done by partners.ICPsshould draw on the diverse thinking of local people, including those who need care, and unpaid carers to shape their plans, working with Healthwatch andVCSEpartners to reach local communities.
Healthwatch has a specific statutory role withinICPs. The proposed legislation will requireICPsto involve their local Healthwatch organisations on the preparation of their strategies. Healthwatch England sees the role of local Healthwatch organisations within theICPas embedding a culture of active listening, responding to community concerns across the whole system, and scrutinising local decisions. Local people and patients will want to know that their voices are being heard and their views are acted upon. As the public champions in health and social care, and with links into seldom heard communities, local Healthwatch organisations are well placed to support work of theICP. In determining their arrangements,ICPswill want to consider how they will engage their local Healthwatch organisations, and other organisations focused on public involvement, in their work, and arrangements, especially true where there are multiple, similar organisations in an area. We will continue our work to involve Healthwatch England in the development ofICPsand ensure that they are rooted in the needs of people and communities.
Our engagement also covered the broader question of membership ofICPs. We understand the desire for clarity on the structure and membership of theICP. However,ICPswill have the freedom and flexibility to find the best arrangements for their areas. We will work with systems and places to identify good practice inICPdevelopment from which other areas can learn, and we welcome further engagement from stakeholders on models that are working well for their geography or sector.
Some stakeholders expressed a preference for amending the legislation to extend statutory membership ofICPs. We recognise concerns about ensuring appropriate representation but feel this is a decision best left for local determination, recognising the diversity in approaches and circumstances across systems.
Some local authority stakeholders were concerned that theICPmay not understand Borough and District Councils’ contributions to health and wellbeing. The legislation will allow for systems to determine their structures and memberships to reflect the breadth of the local authorities’ contributions to health and wellbeing most appropriately. In some areas, there will be place-based representatives, andICPsmay choose, where applicable, to have their lower-tier local authorities represented. Stakeholders that sit across the footprint of more than oneICSarea were concerned about capacity if they have to sit on more than oneICP, for example, Ambulance trusts. We expectICPsto consider the capacity of their partners, and where appropriate, make arrangements that will facilitate the effective involvement of those partners.
Social care providers were keen to play a part in developing the integrated care strategy but also concerned about their capacity to play an active role inICPsdue to the time and resource required to participate. We would expectICPsto find ways of working with social care providers to enable their participation. One home care provider felt that they were “quite literally invisible”, sometimes “GPs do not even know who their home care providers are.” We recognise this challenge, given the number of social care providers and settings in any given system. This is why,DHSCandNHSEare working with organisations representing social care providers to support the involvement of the sector in both theICPandICBand to ensure systems understand the important role that social care providers play.
There was an ask for greater clarity about what “representation” means in the context ofICPs, and whether non-statutory members will have voting rights on the Partnership. We understand that the issue of voting rights is an important matter for many, but we would expect partners to work together to build a shared strategy and that theICPwill determine its arrangements in a way that builds consensus for that strategy.
Because of the scale and breadth thatICPsare intending to cover, engagement will be broad and someICPsmay need a steering group to bring the strategy together. We expect the partnership arrangements and culture to extend far beyond formalICPmeetings, to relationship building that generates real alliances, insights, trust-based relationships, and genuine influence over the direction of travel. This might be via working groups, or wider reference groups and workstreams. InICPs, the ability to influence should be the key factor, rather than voting rights.
There was particular concern from the following groups about how their specific voices would be heard byICPsand we have set out our response so far to these concerns below.
Subject to the passing of the Health and Care Bill, the Secretary of State will issue statutory guidance forICPsin connection with the preparation of the integrated care strategy. We intend that this will, contain guidance on how theICPcan best consider the assessed needs of children and young people, including their health and wellbeing outcomes. The legislation provides thatICPsmay include in the strategy a view on how arrangements could more closely integrate health services, social care services and health related services. It is intended that the guidance will particularly include how anICPcan address integration of children’s and family services.
DHSCare working with providers to support their engagement in the work ofICPsand systems.
It is expected that mental health representatives will play a significant role in these partnerships, given the importance of ensuring parity of esteem across mental and physical health. To reinforce this, the Government brought forward an amendment to the Health and Care Bill to clarify that the meaning of “health” includes “mental health” (unless the context otherwise requires).
The Health and Care Bill provides an opportunity to create a health and care system that is more accountable and responsive to the people that use it. As part of this we are committed to ensuring that the voices of carers – as well as those who access care and support – are properly embedded in Integrated Care Systems (ICSs). The Bill provides a duty on integrated care boards (ICBs) to and involve carers when exercising their commissioning functions and we would expectICPsto also involve carers.
There is of course a broad spectrum of stakeholders who will be keen to have their voices heard onICPs, so this list is not intended to be exhaustive of the range of voices we heard during the engagement process, but it does provide a sense of the range of interest groups. Local Healthwatch organisations andVCSEpartners will have a critical role to play in ensuring a broad range of voices are engaged in theICPs’ work. TheICPwill need to ensure that when determining their arrangements, they are mindful of the level of resource and capacity available to the local Healthwatch organisations, andVCSEpartners to contribute effectively to the work of theICP.DHSC,NHSEandLGAwill continue to engage with stakeholders on these issues over the coming months as appropriate and asICPsare established.
In our engagement, we heard support for the idea that theICP, when developing their integrated care strategy, will bring together wider system partners to address health inequalities; to tackle the wider determinants of health that require a joined-up, multi-agency approach. This was seen as one of the key opportunities forICPs– to marshal the experience of health and care organisations, but also to reach beyond the traditional boundaries. This may be to organisations such as, but not limited to,VCSEsector, housing, family hubs, employment, and criminal justice partners. There are also opportunities to engage with organisations with an interest and role in supporting the design and delivery of health and care services to the whole population. This will also include groups who represent those with mental health needs, learning disabilities and autism, babies, children, young people, and unpaid carers. This approach to joint working will develop proactive and preventative approaches that turn the dial on population health; health inequalities and improve people’s overall experience of care and support.
Stakeholders, particularly those outside of the NHS, were concerned to ensure that the system, andICPsin particular, take a wider perspective on population health. TheICPis intended to provide a protected space within each system to consider longer-term issues which are complex to solve and require joined-up approaches, such as, but not limited to, addressing the health needs of socially excluded and marginalised populations such as inclusion health groups.
ICPsprovide an opportunity to look beyond traditional organisational boundaries by sharing learning and insights. We expect the approach to be led by local data and evidence, as well as co-production with the wider health and care system and community representatives. This will be further reflected in the guidance on the integrated care strategy thatDHSCintend to publish in July 2022.
Directors of public health (DPHs) have sought greater clarity on their role inICPsand across theICSas a whole. We expect public health experts to play a significant role in these partnerships. Local authority directors of public health and their teams can support, inform, and guide approaches to population health improvement, and in plans to identify and address health disparities, with directors of public health having an influential role in theICBsand Partnership.DHSCare working with stakeholders to help describe further, the outcomes we hope to collectively achieve and the ways in which directors of public health can best add value to the system’s impact on health overall. For example, the Bill includes a duty on Integrated Care Boards to seek advice from persons with the appropriate expertise on prevention and public health – this may include directors of public health (which complements the existing duty in section 6C regulations for local authorities to provide the NHS with public health advice).
Guidance on the integrated care strategy can further reinforce the role of theICPto focus on the challenges and opportunities that go beyond traditional boundaries and are best addressed at system level.
Our engagement reiterated the importance of ensuring that the work undertaken at system level complements, supports, and enables the work undertaken at place level. There was a broad agreement that integration and transformation happen largely at place level, where much of the collaboration between the NHS and local authorities will be devolved from system to place level. We are clear theICPshould not be duplicating or undermining that work. Decision making and service delivery needs to happen at the right level and in many cases, when it came to integration, that level was place.
This thinking is embedded in the design of the legislation – it is why the legislation, if passed, will require the integrated care strategy to set out how the needs assessed in the joint strategic needs assessment (JSNA) for theICBarea are to be met by the exercise of NHS and local authorities functions. In the preparation of the JNSAs, the responsible local authorities, and partnerICBsmust involve the Local Healthwatch organisations for the area and involve the people who live or work in that area; and where applicable, each relevant district council. TheJSNAswill be complemented by the Joint local Health and Wellbeing Strategy prepared by each local authorities’ health and wellbeing board and their partner integrated care board/s in response to the integrated care strategy, which are expected to be particularly important in largeICSswith multiple local authorities. For Further detail on the Health and Care Bill, see Annex C.
This thinking underlines that identifying needs and integrated solutions to meet them starts with individuals, their families, and neighbourhoods, building up to place. From April 2023, as set out inDHSC’s Integration White Paper, it is proposed that there will be a single accountable person for shared outcomes at place. This will then build up to system level, joining up care for whole populations.
TheICPwill need to work with places to agree on the right activity at the right level and avoid duplicating work. This was an issue raised particularly in those systems that were geographically small, where there is often only a single ‘place’ per system.
In many of those areas, solutions were already being found. In some smaller systems, theHWBandICPcover a similar geography and will meet at the same time, with largely the same membership. However, the meeting agenda will make clear that there are different statutory roles being undertaken by each body.
In other areas, where there are multiple places and local authorities within anICSfootprint, there was clear acknowledgement that place will play a strong role in transformation and integration. TheICPwill provide an overarching set of strategic shared priorities and enabling strategy, with flexibility for places to develop priorities specific to each place.
During our next engagement exercise, between April to June 2022, we will be using the opportunity to further engage around what will be the responsibilities of theICP. We had initial conversations about some of the practical roles that theICP, rather than places, would best undertake, including:
TheICPshould consider the existing and potential role of place and neighbourhood to ensure that there are clear mechanisms to enable subsidiarity of decision making and that decisions are taken once at the most appropriate local level. During the establishment phase,ICPsshould actively learn from emerging models around place andICPgovernance, so that they can see how similar systems are designing themselves.
It was generally agreed that there should be an open and inclusive approach to strategy development, particularly given that all local areas already have Health and Wellbeing Strategies, and that non-statutoryICSsmay already have some form of integrated strategy.DHSCdoes not intend to produce detailed guidance on what should be in every integrated care strategy, as participants in our engagement did not want further detailed or prescriptive guidance in this space. However, there was some interest in who should be engaged on the development of the strategies – such as children, young people and families, and social care providers.
On the question of inclusive leadership, there was keen interest in who would be appointed to chair theICP, which will be a decision for theICPfounding organisations (one from each local authorities and one from theICB). In some areas, the designateICBChair was also the proposed chair of theICP. In other areas, it was felt that a democratic representative would make the best chair, such as a councillor or directly elected mayor. The appointment of theICPChair is a local matter, but we would expect the local authorities andICBin an area to be actively involved in the choice of chair. We would be interested to hear further if there are specific areas where the choice ofICPChair has been a cause of concern, and to understand why.
The open and inclusive culture we are expecting fromICPsrelies on encouraging and instilling the right behaviours, building trust-based relationships, and encouraging supportive and respectful engagement within and across partnerships. We heard some inspiring examples of where these sorts of cultures are already in place. We also heard of areas where more work is required to develop this sort of culture.
We recognise that the proposed legislative change is not a ‘silver bullet’. Changing culture requires hard work and dedication from all local leaders and communities. It is important that, once these relationships are established, the approach is driven by evidence and informed by the communities served by theICP. Below we outline the support to systems to encourage an effectiveICP. This will also be addressed inDHSCguidance on theICP’s integrated care strategy in July 2022.
Emerging models ofICPsand next steps
There is significant variation inICSgeographies across the country and, unsurprisingly, we also heard about significant variation in approaches toICPs.Areas with a small well-defined geography or where the existing non-statutoryICSis already fulfilling much of the future role of theICPtended to have more developed thinking onICPs, but this was not yet the case everywhere.
There is large variation across systems in the emerging models and approaches toICPs. For example, some areas are approaching theICPas a broad forum with over forty members whilst others will be less than half that size.
The approach to the chair also varies with some proposing theICBChair will also be theirICPChair, whilst others are proposing that they will be chaired by a local authority representative, typically an elected member on a permanent basis, co-chair with theICBchair or a rotating convenor.
Membership typically includes theICBCEO, local authority representatives (including particular professions or expertise e.g., children’s services), NHS providers,VCSErepresentatives, Healthwatch and public representatives. ManyICPsare also planning to have specific place representatives. Some areas plan to draw representation from educational institutions (higher education and further education), social care, housing organisations, police, justice, and Local Enterprise Partnerships.
We have provided some case studies (Annex B) to illustrate how systems currently are working on setting up their governance models. These examples are not a blueprint but are intended to support conversations and reflections on how systems could approach theirICPin particular to give insight into the relationship with theICBand with place.
Several resources are already in train or planned to supportICPestablishment and development.DHSCwelcome views on what further support and resources would be most useful.
DHSC,NHSEandLGAwill continue to share emergingICPpractice, building on the case studies and examples that accompany this report, and using mechanisms such as national webinars, websites, and network meetings.
NHSEregional teams and theLGACare and Health Improvement Advisers and Principal Advisers work closely with NHS and local government partners at system and place footprints and are well placed to understand specific support needs and opportunities and signpost to appropriate regional and national support.
The NHS Confederation’sICSNetwork is an independent national network which supportsICSleaders. This will include a dedicated national network forICPChairs, delivered in partnership with theLGA.
NHSEcommissions a sector-led Leading Integration Peer Support Programme from theLGA, NHS Providers and the NHS Confederation to support partnership development in health and care systems includingICPsand can be deployed for tailored support to systems that would value this.
DHSCcommissions theLGA-led Care and Health Improvement Programme which can also be deployed to supportICPdevelopment involving local government and wider system partners such as the NHS and social care providers.
Recognising thatICPswill be at different stages of development, and vary in complexity, we have set out an indicative timeline to help all systems identify the key milestones in developing theICPand the integrated care strategy, with 2022 to 23 being a transitional year.
|April to June 2022||DHSCto engage with systems to inform the guidance on the integrated care strategy|
|July 2022||ICPformally established by local authorities andICBs(subject to parliamentary passage)|
|July 2022||DHSCto publish guidance on the integrated care strategy|
|December 2022||EachICPto publish interim a strategy if it wishes to influence theICB’s first 5-year forward plan for healthcare to be published before April 2023.|
|June 2023||DHSCrefreshes integrated care strategy guidance (if needed)|
Annex A: list of stakeholders
During our engagement, we heard feedback from the following stakeholders:
Association of Ambulance Chief Executives
Carers Trust: Network Partner’s Policy Forum
Home Care Providers
ICSClinical and Care Professional Leader’s Network
ICSReadiness Reference Group (Healthwatch)
Integrated Care Delivery Partners’ Group
LGACommunity Wellbeing Board
Local Government Health and Care Sounding Board
Mental Health Policy Group
National Children’s Bureau
NHS Confederation -ICSNetwork
NHSEIRegional Roadshow: Southeast
NHSEIRegional Roadshow: East of England
Social Enterprise UK
The Care Provider Alliance
Annex B: case studies
During our engagement we heard examples of where systems were already thinking about how to structure theirICPas well as inspiring examples of how partnership approaches can lead to improved outcomes and experiences. We had requests to share examples that other systems could learn from. We expect allICPs, including the examples below, will continue to evolve and mature. We hope that these examples will help systems to reflect on their own approach and support productive conversations, but recognise that these are a snapshot in time, and may yet be subject to change. We aim to add to our repository of case studies over time.
The examples below show the approach that some systems are taking when developing theirICP. These are not the final position given that the legislation has not yet been commenced and will continue to evolve over time, but they give an idea of the proposed membership and role of theICP.
Surrey Heartlands are designing theirICPto be a collaborative forum where local government, the NHS and the voluntary, community and faith sector can build a partnership rooted in the needs of Surrey’s people, communities, and places. This builds on a long standing and ambitious partnership between Surrey Heartlands and Surrey County Council.
The key intentions for theICPare to:
The ambition is that, by harnessing the involvement of the wider system, theICPcan build greater collaboration between the NHS, local government, and the community sector, and leverage the resources and the influence of the wider system to improve health and care outcomes for residents, addressing health inequalities to ensure that no one is left behind.
The strategic direction of Surrey HeartlandsICP, in addressing health inequalities, will build on and align with the priorities and goals of the Surrey-wide Health and Wellbeing Strategy. The ambition is that theICPbecomes the forum that drives Surrey Heartlands Health and Care Partnership’s preventive and community-led approach to tackling health inequalities. The partnership will address shared challenges such as workforce, estates, and digital transformation, supporting theICS’s work with the wider system.
TheICPwill start meeting in shadow from March 2022 and is currently developing the terms of reference. The partnership will be chaired by the Leader of Surrey County Council, who is also Chair of Surrey’s Health and Wellbeing Board. Membership of theICPis drawn from Surrey HeartlandsICS, Surrey County Council, representatives of Surrey’s district and borough councils and representatives from Surrey’s voluntary, community, and faith sector. The Partnership includes the Director of Public Health, the Executive Director of Children, Families and Lifelong Learning, the Joint Executive Director for Integrated Commissioning and Adult Social Care (a joint appointment between Surrey HeartlandsICSand Surrey County Council) and the Joint Executive Director for Public Service Reform, whose role supports pan-ICSthinking with regards to estates, data and business intelligence, research and innovation and the wider public sector reform agenda.
Since December 2017, Coventry and Warwickshire Health and Wellbeing boards (HWBs) have been meeting as the Coventry and Warwickshire Place Forum. Coventry City Council and Warwickshire County Council are key partners in supporting the development of theICSarrangements for Coventry and Warwickshire.
Leaders within Coventry and Warwickshire have agreed the primacy of place within theICS. As part of this they have endorsed the creation of 2 ‘place-based partnerships’ referred to as the Coventry Care Collaborative and Warwickshire Care Collaborative. The care collaboratives will constitute a partnership of organisations responsible for organising and delivering health and social care within the Coventry and Warwickshire footprints. They will take responsibility for translating theICBplan andICPstrategy into action for Coventry and Warwickshire respectively ensuring they meet the healthcare needs of the population.
The Coventry and Warwickshire Health and Care Partnership Board works across organisational boundaries for all communities across Coventry and Warwickshire. The Partnership Board has an Independent Chair, and its other Partnership Board members include the chief executives and most senior leaders of the NHS, public health, and social care services. The Partnership Board oversees all the Coventry and Warwickshire Health and Care Partnership work programmes
The Coventry and WarwickshireICSPartnership Board is supported by the health and care partnership arrangements that have been developed in each of the 4 places: Coventry, Warwickshire North, Rugby, and South Warwickshire. Each of these has their own Place Partnership Board which will bring together local organisations. The Warwickshire North Place Partnership’s stakeholders, for example, include representatives from theVCSEsector through the Warwickshire Community Action and Voluntary Action group, as well as the police, Healthwatch, community pharmacists, primary care networks, and district and borough councils
Frimley has a complex geography which covers more than one local authority area including Bracknell Forest, Royal Borough of Windsor and Maidenhead, Slough, Surrey Health and North East Hampshire, including Farnham.
Frimley has taken a collaborative approach to the development and future working of its integrated care partnership (ICP). It undertook a period of intense stakeholder engagement during the Autumn which included a series of semi-structured interviews with elected members, local authority executives and primary care practitioners. This engagement period explored options for the development of theICPwith several thematic issues identified which are being built into the final design choices being made.
Proposals for the composition of the integrated care board (ICB) and a set of principles for the operation of theICPwere based on this engagement work and a design group was established co-chaired by theICBChair Designate, Dr Priya Singh, and a local authority representative. The design group is currently working through the final level of detail required to establish theICPwith the aim of leading by example around their key principles, including taking a behavioural and values approach to change.
TheICPis an important part of our new way of working; it must have broad representation from all organisations, includingVCSEand patient representatives.
To ensure continued collaboration theICPwill operate as an assembly to bring members together to discuss issues, to reach a conclusion about what they think should happen. The Partnership will be led by a convenor elected on a time limited basis rather than by a chair.
Membership will be drawn from all local authority organisations within theICBarea (Unitary, County Council and District / Borough Councils) including:
TheICPwill start meeting in shadow form later in 2022.
Future membership of theICPis likely to include alumni from Frimley’s own leadership academy network established in 2018 to encourage and cultivate leaders in its system who are innovative, empowered, and influential leaders working at the coal face, to make change happen working across traditional organisational boundaries to positively impact the local population and communities.
This shadowICP’s primary purpose will be to act in the best interest of people, patients, and the system as a whole rather than representing the individual interests of any one constituent partner, although during phase one, membership will include representation from both partners and individual organisations.
Members are selected to be representative of the constituent partnerships, although it is acknowledged that in phase 1 individuals may be representing both their respective organisations and their constituent partnerships and will attend to promote the greater collective endeavour.
Members are expected to make good 2-way connections between theICPand the constituent partners, modelling a collaborative approach to working and listening to the voices of people, patients, and the public. District council members attend on behalf of the other district councils and therefore have an obligation to feed in and out from the broader group of district councils.
It is expected that members will prioritise these meetings and make themselves available; exceptionally where this is not possible a deputy of sufficient seniority may attend. They will have delegated authority to make decisions on behalf of their organisation in accordance with the objectives set out in the terms of reference for this group. For local authority representatives, this will be in accordance with the due political process. Members are expected to attend at least 75% of meetings held each calendar year.
The membership is as follows:
Rotating chairs (3):
Vice chair: as above
Statutory local authority officers (3) comprising:
Political leadership (4) comprising:
Statutory district council chief officers (2)
District council elected members (2)
NHS partners (11) comprising:
Public and patient experience will feed into theICPthrough its engagement activities and its citizens panel, which will inform all the work of the partnership.
Thematic case studies
The thematic case studies demonstrate the potential ofICPsto develop and drive forward partnership approaches in their areas. We hope these case studies may provide some inspiration for areas as they consider the opportunities to improve outcomes and experiences that can arise from partnership approaches.
People experiencing extreme social exclusion, including homelessness and rough sleeping, have significantly poorer health outcomes and die much earlier lower life expectancy than the general population. The mean age at death was 45.9 years for males and 41.6 years for females who were homeless in 2020. These groups are often less able or willing to access health care in the community, and therefore make greater use of urgent and acute health care services. This includes attending, and being admitted to, hospital many times more than the general population, often staying for longer, but also self-discharging or being discharged to the street. Readmissions are common.
Local health, care and housing ‘systems’ often fail to come together to provide appropriate homes, care and support at the right time, to prevent a return to homelessness following a hospital visit, and further health crises.
To overcome this problem, Brighton and Hove Council working with UHSFT (acute trust), SCFT (community trust), SPFT (mental health trust), introduced the Out-of-Hospital Care Model (OOHCM). This includes ‘Step Down from Hospital’ accommodation of 5 new units of 24 hour supported accommodation with clinical in-reach, on site care services and resettlement and reconnection support.
This provision fills a gap in Brighton and Hove’s already well-developed health and care system for people experiencing homelessness, which includes a specialist ‘inclusion health’ GP practice (Arch Health CIC), a community nurse team and a mental health team, and a specialist ‘Pathway’ hospital team. Working with housing and support services, including Brighton’s Street Outreach Service, these services come together to support people to stay healthy and well in the community, and are now also able to support the safe and timely discharge of people who need to use the hospital.
Individual challenges faced:
Solutions and ways of working:
RADARis a partnership between the local acute hospitals and the local mental health NHS provider and the Greater Manchester Mental Health NHS Foundation (GMMH) who operate the Chapman-Barker Unit.
Alcohol problems are becoming a major public health concern, with alcohol admissions an increasing burden on acute hospitals. TheRADARpathway at the Chapman-Barker Unit, was introduced to address this problem.RADARhas 4 main aims: reducing the burden on acute trusts, improving clinical outcomes for service users, providing improved experience for service users in a therapeutic setting and demonstrating cost-effectiveness. In accordance with these aims, the service focused on specific subgroups of alcohol related admissions such as those who frequently present to acute hospitals.
TheRADARpathway transfers acute presentations from 11 A&Es in Greater Manchester to a specialist in-patient detoxication facility, which is run by the Chapman Barker Unit. This service admits patients 24/7 a day, 365 days a year. The Chapman Barker Unit identified 10 beds and a specialist detox programme, combining the benefits of a 5 to 7-day detoxification with the delivery of a range of psychological interventions, including physical and mental health care and support and a strong focus on assertive aftercare. TheRADARpathway is extremely cost-effective and beneficial for service-users. An independent academic ofRADARhas shown that 50% of unplanned admissions maintained not drinking at a 4 week follow up.
Individual challenges faced:
Solutions and ways of working:
Improving population health and increasing life expectancy is a key priority in West Yorkshire (WY), theICSaims to: improve physical and mental health outcomes; reduce health inequalities; understand the causes of ill health and wellbeing and identify opportunities to work together to tackle these. West Yorkshire Health and Care Partnership’s Improving Population Health Programme (IPHP) has formed a partnership agreement with the West Yorkshire Violence Reduction Unit (VRU), which brings together health, law enforcement, local government, education, voluntary and community services and others to understand how and tackle root causes of violent crime.
Working collaboratively has resulted in the 2 systems (IPHP andVRU) coming together and forming the Adversity Trauma Resilience (ATR) Programme. Extensive engagement has been undertaken with system leaders, networks, and boards, including Health and Wellbeing boards, Safeguarding Networks,ICSprogramme boards, Children’s Boards, and local medical councils to increase collaborative and partnership working, resulting in the development of a formal governance structure, network and multiple workstreams. It was decided that theVRUand Health and Care Partnership (HCP) have overall governance and responsibility.
The ATR programme has currently over 300 members including people with lived experience. The programme covers all sectors, organisations and everyone that lives and/or works in West Yorkshire. Partners developed shared common commitments that all partners across the system should work to prevent trauma and adversity and mitigate harm and improve the wellbeing of our population, with a particular concern for those most vulnerable, involved in violence, exploitation and facing multiple difficulties, complex needs, and childhood trauma. To deliver on this commitment, West YorkshireVRUand Health and Care Partnership have put in place) the following joint programmes: West Yorkshire Adversity, Trauma and Resilience programme; A&E Navigator and Community Links Program; Pilot for Trauma and Adversity Navigators in A&E; Public Health reducing Violence Network; Night-time Economy workstream and ensuring women and girls are safe healthy and free form violence, and exploitation.
West Yorkshire developed a community action collective, to ensure continued engagement and involvement with workforce across all sectors including theVCSEand people with lived experience. They developed theWYATR training collaborative to ensure a workforce that is therapeutic, skilled, confident, trauma informed and responsive, where every interaction matters.
Individual challenges faced:
Solutions and ways of working:
The Voluntary Community and Social Enterprise (VCSEsector plays a key role inICSs, including theICBandICP, as well as place-based partnerships and neighbourhoods. Norfolk and Waveney believe theVCSEsector is a vital cornerstone of a progressive health and care system and should be embedded as an essential part of how the system operates at all levels.
Norfolk and Waveney formally established theVCSEassembly in 2021, to provide aVCSEengagement forum across Norfolk and Waveney (N&W), with a focus on health inequalities and prevention, with connection at neighbourhood, place, and system level. To provide a mechanism to support collaborative design of services and the capability to respond to emerging needs and to increase influence and participation ofVCSEorganisations and groups in the design and delivery of health and care services within theICS.
N&Wappointed an assembly chair which works with partners to progress the model and engagement mechanism. Whilst developing theVCSEAssembly,N&Wassembly steering group is always mindful that systems are diverse, thus, one size does not fit all and that stakeholders should be able to contribute. TheN&WAssembly Chair is a member of the interim integrated partnership and subject to the legislation will have a formal role on the integrated care partnership.
The Assembly continues to be progressed in line with the developments being made in ourICSand recognises engagement mechanisms at a system level (such as the links to our existing thematicVCSEforums, on Children and Young People, older people, and mental health) and is supporting the progress around place and neighbourhood connections.
Annex C: The Health and Care Bill
Clause 26 of the Health and Care Bill proposes to amend the Local Government and Public Involvement in Health Act 2007 so that the integrated care board and all upper-tier local authorities that fall within the area of the integrated care board must establish an integrated care partnership. This will be a joint committee of these bodies made under the new section inserted in the Act. The partnership must include members appointed by the integrated care board and each relevant local authority. The integrated care partnership may determine its own procedures and appoint other members.
The integrated care partnership will have a statutory duty to prepare the integrated care strategy. The strategy must detail how the assessed needs of an area will be met by either the integrated care board, NHS England, or the local authorities. To aid this, local authorities must share their joint strategic needs assessments, developed by their health and wellbeing board with the integrated care partnership(s) that cover the area of the local authority. The integrated care partnership must consider revising its integrated care strategy whenever it receives a new joint strategic needs assessment.
The strategy must consider how NHS bodies and local authorities could work together to meet these needs using section 75 of the NHS Act 2006, using agreements to pool budgets or lead commissioning arrangements between local authorities and NHS bodies. The strategy may also state how health-related services (defined as services that may influence the health of individuals but are not health services or social care services) could be more closely integrated.
In preparing this strategy, the integrated care partnership must have regard to the NHS mandate and guidance published by the Secretary of State, and it must involve the local Healthwatch and people who live or work in the integrated care partnership’s area.
The integrated care strategy must be published and shared with each responsible local authority, and the relevant integrated care board in that area.
Health and wellbeing boards in response to an integrated care strategy, must prepare a ‘joint local health and wellbeing strategy’ that sets out how the local authorities, integrated care board and NHS England will meet population needs in that area. AnICB, in the preparation of its joint-forward plan must also reference how the plan implements any relevant joint local health and wellbeing strategies to which theICBis required to have regard.
Local authorities and integrated care boards must have regard to the joint strategic needs assessment, the integrated care strategy, and the joint local health and wellbeing strategy when exercising their functions and NHS England must have also regard to them when exercising their functions related to the provision of health services in the area.
Health and Wellbeing Boards
The Health and Care Bill does not make any substantial changes to the establishment, functions or duties of Health and Wellbeing Boards.The Bill does require local authorities to share Joint Strategic Needs Assessments, prepared by the Health and Wellbeing Boards with the integrated care partnerships that overlap with the area of the local authority.
Upon receipt of an integrated care strategy, the Health and Wellbeing Board must prepare a ‘joint local health and wellbeing strategy’ that sets out how the local authorities, integrated care board and NHS England will meet population needs in that area. However, if the Health and Wellbeing Board does not need to prepare a new joint local health and wellbeing strategy if, having considered the integrated care strategy, they consider that their existing joint local health and wellbeing strategy is sufficient.
Health and wellbeing boards were established by Section 194 of the Health and Social Care Act 2012, by requiring each Upper Tier Local Authority to create a health and wellbeing board for its area, as a committee of the local authority and setting out the required membership.
Health and wellbeing boards have a duty to promote integration between commissioners of NHS, public health, and social care services for the advancement of the health and wellbeing of the local population. A health and wellbeing board must provide advice, assistance, or other support in order to encourage partnership arrangements such as the developing of agreements to pool budgets or make lead commissioning arrangements under section 75 of the NHS Act.
Health and wellbeing board are also responsible for preparing joint strategic needs assessments and joint local health and wellbeing strategies, and the Health and Social Care Act 2012 (under section 196) allows local authorities to delegate any functions exercisable by the local authority to the health and wellbeing board that it established.