This study seeks to investigate how Integrated Care Systems have developed since July 2022, with a specific focus on how they have managed and overcome pressures associated with the planning, coordination and commissioning of health and care services. Understanding these systems and their key pressure points will allow wider system partners to steer improvement across regions through best practices and partnerships across both short and long-term pressures.
The Findings and Discussions can be found below. You can locate a full pdf version of the report here.
Findings and Discussions
New structures and managing the change
The introduction of ICSs represented the largest legislative change in England for both the health and care sectors in a decade. This change was felt across all ICS leaders interviewed.
The change was perceived by many as the formalisation of previous practice, with the introduction of a statutory framework. One ICS leader described the change as being perceived as a “lift and shift exercise” as the Health and Care Bill 2022 made its way through Parliament.
This perception was quickly debunked as all ICS leaders described significant change within their respective systems, mainly owing to the required governance and accountability changes, but in particular, the creation and divide between an ICB and ICP. Both structures required significant reformation of internal practice at a fast pace to meet their core requirements, namely the ICB continuing to deliver commissioned NHS and care services and the ICP delivering an Integrated Care Strategy, which was due to be returned to Government in December 2022, to help inform the direction of the ICB. This has been set against a context of statutory duties, including deploying initiatives to improve population health and reprimand health inequalities.
Before their statutory introduction, across the country ICSs were already operating as informal partnerships using soft powers and influence to achieve their objectives. The maturity of these informal partnerships, as well as the previous relationships and structures which existed, have dictated how significant the size and speed of the change have been as ICSs have moved from CCGs. This contrast can be seen between the two following ICS leaders:
“It really does feel like a new organisation that has had to pick up a number of legacy issues.”
“We are building on fairly firm foundations… We have had a long track record of partnership through the era of the STPs. In our ICS we had an effective health and care partnership which was the predecessor body of our ICP.”
Establishing a hierarchy of control governed by accountable bodies within the context of a new statutory framework is no small task. It has required a significant change in ways of working. However, these new ways of working have generated an immense amount of positivity, with the desire to drive meaningful positive change at the core of every ICS we interviewed. There was a recognition that despite longstanding goals to integrate health and social care services, there is limited evidence to suggest this has been achieved. Consequently, there is a newfound sense of optimism and opportunity within each ICS with a recognition that ‘more of the same’ is not an option. As two ICS leaders outlined:
“The ICB wants to add value rather than just repeat what we might normally do in an NHS type organisation which has traditionally worked with NHS partners.”
“There is a huge amount of engagement happening across our system. It will be pointless for us, as an Integrated Care System, to replicate, reproduce, or do the same thing again.”
A recognised barrier to driving the integration agenda forward has been the limited, or omissive, engagement with the adult social care sector. The ICB leaders we spoke to outlined their proactive steps to ensure the voice of adult social care was heard at both the ICB and ICP. The extent to which the sector was being engaged and how the sector was engaged differed significantly between ICS.
If the ICS has a strong Care Association, this often acted as the primary vehicle for engagement as they are perceived to be a singular voice which could speak representatively on behalf of the local care providers within their membership. However, this representation is typically isolated at the ICP level. At an ICB level, the adult social care sector was often referenced as being represented by the local authorities. The strength of a local authority’s ability to represent the adult social care sector divided ICS leader perspectives.
There was a strong acknowledgement of the challenges associated with ensuring meaningful representation of the adult social care sector, which was often cited because of the sector’s diversity. As one ICS leader referenced:
“I think we have got a good foundation, but I think there is probably more we could. I suppose a challenge would be there are hundreds of providers in the area and therefore it’s quite difficult to have one voice for them.”
Despite the varying levels of representation within the governance structure of the ICS, every ICS leader recognised the importance of ensuring the voice of the adult social care sector was heard at all levels of the ICS. This has led to a variety of initiatives being employed. As the ICS leader from Kent and Medway described:
“We introduced a ‘Together We Can’ symposium where we brought together partners from across the ICS to really think about how we develop our Integrated Care Strategy. I think that’s given us a really good platform to hear what the key issues are and to reinvigorate the commitment in Kent and Medway to working together as a system to deliver on some of our challenges, but also make sure we can identify the right shared outcomes to support our ambitions.”
The Integrated Care Strategy was noted as a key catalyst for prompting and promoting rigorous engagement with the adult social care sector. There was a desire amongst those ICS leaders who discussed their strategy to use the learning from engaging with the sector as part of the development of their strategy to move beyond ad hoc engagement and move towards capturing meaningful feedback continuously.
Identifying and overcoming the pressure points
The introduction of ICSs has not come without its challenges. The key pressure elucidated during the interviews was that of finances and funding. These were both internal, as well as external.
From an internal perspective, ICS leaders described the reality that despite the introduction of ICSs as new systems, historic financial pressures were carried through from previous structures, not least those pressures of deficits and debt inherited from acute trusts and CCGs.
The Government has exacerbated these historic pressures by introducing a requirement for ICSs to reduce their operating costs by 30% within a year. All ICS leaders referenced this as a primary source of concern which has affected the balance between addressing short and long-term pressures. This is against a backdrop of meeting new statutory duties, namely improving population health and reducing health inequalities. As one ICS leader described, “We have been tested early and tested hard.”
This balancing act, poised between the operational and financial pressure of the day-to-day running and the statutory functions of ICSs, has created a reality where there is concern amongst ICS leaders that the short-term pressures will undermine the longer-term purpose of ICSs. This balancing act is only made more challenging by the legislative framework in which ICS leaders are currently operating. This was something highlighted by the majority of ICS leaders. As two ICS leaders outlined:
“The things that are barriers [to integration] are the politically led parts. You have the Care Act and statutory NHS frameworks. These do not speak to each other.”
“The Health and Care Act probably made it more difficult [to integrate health and social care] because it placed more statutory responsibilities on the NHS and did not support integration.”
There was a clear desire for ICSs to have more autonomy in how they will meet central targets, with a particular movement away from short-termism towards longer-term strategic planning backed by ringfenced and sustainable funding packages. It was clear that ICS leaders felt there was not enough money in the system, and the way the funding comes down to the NHS and then to the local authorities under the Better Care Fund creates challenges and does not resemble an efficient system.
ICS leaders appreciated the cost pressures faced by the adult social care sector as a key priority and pressure point across the health and social care continuum. There was ultimately concern that people were not able to receive the right care, at the right time in the right place. Blame was apportioned to central government with reference made to the years of austerity and how this has resulted in local authority funding being cut in relative terms. This has in turn affected the financial viability of many care providers, which slowed progress in creating a sustainable system that can foster meaningful integration. This has meant ICS leaders have had to remain pragmatic and creative in finding solutions to aid care providers:
“We all know that we are not necessarily going to get more money into the sector, but actually, we have got to do something different with the resources we already have, and we are going to have to challenge ourselves to make those resources go further.”
A strong sentiment was made regarding garnering a greater understanding of respective markets and ensuring capacity for the right care services. Several ICS leaders cited that there was either a “threadbare” market or a market operating at “overcapacity.”
The implications of cost challenges for the care sector were most explicitly discussed within the context of the current workforce challenges, against a wider sentiment around fee rates from local authorities residing below the cost of care. All ICS leaders acknowledged that the social care market has a real issue with recruitment and retention, at present. It was cited that care providers will regularly report workforce shortages as they are losing staff to the NHS, Amazon, Aldi and other big employers who have strong roots in local areas and can pay staff a better salary than adult social care providers can currently offer. This nuance was caveated that the cause of the issue is central Government underfunding and parity with the NHS. One ICS leader stated:
“We recognise that there isn’t the same level of funding available for social care and the social care [workforce] plan doesn’t have that line of resource attached.”
These financial and workforce challenges were cited as being intertwined with the success of the system as a whole. Particular reference was made to the whole-system issue of pressures in social care worsening pressures in urgent and emergency care which cyclically has a knock-on effect on the pressures being faced by the social care sector. These were worsened through the Covid-19 pandemic and have continued to peak through the Winter seasons. To combat this, ICS leaders employed strategies to ensure these pressure points were remedied or diminished. The West Yorkshire ICS leader stated that:
“Both the local NHS and social care teams worked together in the hospital to try and mobilise people in anticipation to come out of the hospital. We have our in-house team, which is rated Outstanding by the CQC, which the council funds and will support anybody for six weeks in coming out of the hospital in their home for free.”
The Priorities and Ambitions
To truly operationalise the integration between system partners then, ICS leaders recognised that there were immediate priorities that they must address at a system level, to achieve what previous attempts at integration could not, but these needed to be balanced against longer-term and aspirational priorities and ambitions.
The immediate priority for all ICS leaders we spoke to was ensuring safe and quality care was delivered across the ICS. There was a recognition that ICSs must prioritise their own understanding of their local care market; they must look to account for the full diversity of their adult social care market with an awareness of the intricacies, and specialisms, that the market holds. With a full understanding of their capabilities, they can utilise this sector to their full capacity when implementing their localised strategy.
Recognising that every ICS is unique, there was a variance in approaches to ensuring the right care was being delivered. Multiple ICS leaders raised the prioritisation of the “Home First” initiative, with the end goal of avoiding unnecessary admissions into hospitals or care homes when they can receive the level of support needed in a capacity that still keeps them independent.
This sentiment was balanced against the need for a plural and diverse market induced as a result of the growing demand and complexity of health issues faced by an ageing population. “Home-First” initiatives do not necessarily reflect that ICSs should endeavour to avoid admissions into both health and care, but to ensure that the correct level of care is provided to the individual in a place they identify as home. Building integrated community health teams, in partnership with the care sector, plays a significant role in this and avoiding unnecessary hospital admissions, as evidenced by the Leicester, Leicestershire and Rutland ICS Leader:
“We’ve got a geriatrician car…rather than an emergency ambulance being dispatched immediately if it’s non-life threatening…the geriatrician’s car goes to the care home…. we’re preventing around 100 emergency admissions a month using that model… patients love it, ‘cause it’s within what they call home.”
Moving beyond prioritising an understanding of local care markets, there was a universal recognition that there was insufficient money in the system. ICS leaders noted the financial challenges faced by different organisations, and that there is a priority for systems to adopt measures that would encourage appropriate resource allocation. This would allow sufficient exploration of innovative ways to use the funding available within the health and social care sectors to resource system partners effectively and improve individual experiences and outcomes. By integrating funding, ICSs can streamline the operational barriers between partners, ensuring those experience a streamlined, integrated service that meets their needs. Multiple ICS leaders envisioned this priority through the frequent uses of pooled budgeting and joint commissioning of services to meet people’s needs efficiently:
[When referring to pooled budgeting and joint commissioning] “That will make a huge difference in terms of outcomes for individuals, but also relieve pressure on some of the statutory resources from both the social care and NHS perspective as well.”
“We are taking individuals from the point of assessment through to the point of safe placement in the community with an integrated, single managerial approach.”
The ambition to do more within the constraints of the current funding envelope was balanced against the desire to move away from short terms funds. There was a desire for the Government to help unlock ICSs’ ability to develop sustainable, long-term solutions instead. Two ICS leaders acknowledged that national Government initiatives, designed to support systems address issues, would have been better utilised if the systems themselves were given autonomy to utilise the funds more effectively:
“We need the Government and the Department of Health and Social Care to delegate responsibility to ICSs; give us the money as a lump sum, not slithers through the BCF, D2A or Winter Pressures.”
“When we’re trying to sort these things out [Winter Pressures] and you’ve got some short-term funding that comes in… actually we want to be more proactive around planning around how we could those resources at a much earlier point.”
Another priority outlined by ICS leaders was the use of data and digitisation. Digital transformation is a vital ambition that ICSs must have in order to enable them to successfully meet their core objectives, as ‘the digitalisation of health provision underpins many of the changes envisaged for the NHS and is depicted as central to the enhancement of patient care’ (Knight A; Burdet T, 2021). When ICSs support partners to digitalise their systems, and ensure that they are interoperable with one another, they unlock a wealth of data that can evidence and inform key strategic decisions at the system level.
One ICS leader recognised that data is “a game changer actually in terms of how we work”, and another highlighted that “a single source of truth is a big priority” for the operationalisation of their system. Access to all-encompassing data at system level improves the efficiency and continuity of integrated care. Two of the ICS leaders we interviewed, which were both at different stages of this data journey, recognised this need:
“We do not have a one-system means of reporting. We have Capacity Tracker but it omits issues. We need to put more around it.”
“Having a single version of the truth at quite a granular level that everyone accepts means you can then much more quickly move the conversation onto what are we going to do about that and get those people to the right place for the care they need next.”
The ICS leaders we spoke to acknowledged how advancing digital systems within their locality can unlock new ways for system partners to work together, specifically in terms of the health and social care workforce. Approaches like this would allow individuals to receive the same quality care, but in a more streamlined approach that consults multiple factions within both health and social care, without putting additional pressure on the workforce. The ICS leaders interviewed referred to the introduction of “virtual wards” with “integrated teams” monitoring the services.
However, all ICSs acknowledged that support mechanisms through digital technology and integrated systems alone are not enough and that a key priority reflected by ICS leaders was to support the care sector with the ongoing systemic workforce pressures.
ICS leaders underlined the need for a multi-faceted approach to workforce development, including career opportunities, skills development, and recruitment strategies to strengthen the social care sector.
There was a deep recognition of the need to stabilise and improve the social care workforce in the short and long term. A handful of the ICS leaders highlighted ambitions to expand their current target audiences for recruitment campaigns to include more pools of individuals which could resource the workforce, as outlined by one ICS leader:
“We are beginning to think about how can we connect people who are in long-term unemployment back into the care sector and… those who are of different age groups or potentially even people who might be veterans or have long-term conditions.”
Kent and Medway ICS highlighted the use and development of recruitment tools which has had a positive system influence on the social care workforce:
“In Kent, through partners in Kent County Council, they adopted the CareFriends app in 2021 but also funded the Kent Care App… we’ve got over 8000 licenses that are funded through the Council… that’s enabled us to also work together around developing the Kent and Medway workforce strategy.”
In the longer term, ICS leaders raised the ambition of professionalising the social care workforce, with a focus on creating pathways for individuals to develop and build long-term professions in these fields. Similarly, one ICS leader noted the positive reception that was felt by institutions offering several training programs designed to improve skills and knowledge within the workforce such as Infection Protection Control, falls training, apprenticeship levy, and their management training which is offered system-wide.
Where do we go next?
With the first year of ICSs now completed, it begs the question, what’s next? As highlighted already, there are areas of operational success but acute pressures that will continue to hinder efforts of integration if not resolved. This section will look to analyse the support ICSs need to integrate themselves in the years further to come under three categories: shared learning, representation, and accountability.
Although ICSs were building on, in essence, foundations that the previous CCGs had been bound by, the amalgamation of various groups into the newly established ICS still required significant groundwork. Throughout the interviews, when asked about wider support, all but three ICS leaders noted the benefit of shared learning. The promotion of shared learning can be primarily seen to benefit operational developments within an ICS. Particularly how it could improve a wider understanding of how a system could improve on its transition from a group of CCGs to an ICS:
“Other ICSs…are building a capital programme and I think they’ve been able to flex the rules better than we’ve been able to do here… Can we learn from this? They’re operating with the same framework, but they’re able to flex the rules more, you know. Can we change the culture of how we do things?”
More nuanced operational shared learning was discussed, and a clear theme was a desire to learn from others. Amongst some of the ICS leaders, there was an appreciation that as new entities in year one, ICSs do not have a complete comprehension of their adult social care market and therefore require external support to increase this understanding. Two ICS leaders outlined their view that the sharing of best practices and learning from other systems would be of benefit to them:
“External support of sharing best practice examples from others… I am interested to see what good might look like in other systems in terms of how do we make reporting not just acute health-focused, how do we capture social care.”
“To share innovation from other parts of the country, but also working with partners in the private sector or beyond, internationally even, in terms of research and innovation vision.”
Shared practice can be delivered in various forms. As already outlined, successful case studies of what is working well are viewed as a helpful tool that can guide an ICS, or benchmark to ascertain if a proposed policy would work.
A third form of shared learning that was discussed was external input from other organisations. Two ICS leaders perceived it as a tool to validate travel direction and align local and national objectives:
“It is about having your insight and support when setting objectives across health and social care when we are looking at priorities.”
“Create a shared, better understanding of the common set of challenges, but also offering some of the opportunities as well.”
As showcased, there is a clear desire to learn from others to increase success measures. However, wider, and external support is not solely isolated to the delivery of shared learning. Direct representation of care representatives within the governance structures of an ICS could be a tool to aid greater integration between health and social care. One ICS leader recognised the benefit of having national representatives around the table, on topics which require a greater understanding of the functionality of the adult social care sector:
“We need you [Care England] in the room around fee setting.”
Outside of specific topics in which external organisations could provide valuable insight, there was recognition of the media’s role in the public perception of adult social care. As noted by one ICS leader:
“I don’t think the narrative in the media is educated enough about what the real issues are in adult social care. They constantly talk about how the cost of social care tools, and they don’t talk about the fact that there is no money in the system now for people in it… I would like Care England to speak about how important it is for local authorities to be funded.”
With the population ageing and the demand for care increasing, there will be to be a greater reliance on adult social care. However, the hegemonic discourse portrayed in the public domain does not consistently portray the sector as a cornerstone of societal protection and an integral part of our economy. Having external support and representation within the system level of an ICS can help overcome cultural barriers and public perceptions that have impacted the care sector’s development. Another ICS leader built upon this view:
“I think there is something about how visible you [Care England] can be to help work with ICBs to get them to understand what the challenges are of the care providers, and what opportunities you think there are within that which help health just as much as any other part of the system.”
Representative bodies are made up of a diverse range of organisations and therefore have diverse networks and forums in place that ICSs can utilise. The benefit of engaging and working with national bodies can provide ICSs with the opportunity to engage with these networks and forums to further refine their policies and engagement with the care sector. One ICS leader outlined that:
“We would be foolish not to capitalise on the experience that your organisation [Care England] and other networks have. So, I think we need to find a way of tapping into existing networks, forums and representative organisations where possible.”
More knowledge can be shared across ICSs through external organisations, enabling shared learning and promoting good practice. Finally, when considering wider representatives within the adult social care sector, it should be considered how those networks can be used to support local and regional lobbying. As one ICS leader quoted:
“Care England might help us by lobbying or advocating for balanced funding for social care in the context of workforce development.”
The workforce challenges adult social care providers are currently facing is one that is widely recognised by many ICSs. Yet, there is still no long-term social care workforce plan that would create parity with the NHS. ICSs, therefore, recognise that working with representatives and colleagues could pave the way for localised approaches to further support and integrate the health and social care sector further.
Finally, it is important to highlight the importance of accountability and how external support can increase an ICSs’ accountability to ensure it meets the needs of the entire health and social care sector, rather than the former. Adult social care providers are often concerned that health and social care policies are first and foremost directed at the healthcare sector, with social care being an afterthought. Whilst this culture is not true across each ICS, care providers nonetheless can feel excluded from the governance structure of an ICS. The right accountability measures can help keep systems aligned with the needs of the adult social care sector. As highlighted by one ICS:
“I think it’s an opportunity for you [Care England] to reach out to ICBs with the challenges but also what are the opportunities. That would be a really good, positive place to be. Also engaging with NHS England and NHS Confederation as well on what some of those joint opportunities look like.”
Accountability would enable more dynamic development of more considerate policies that benefit both health and care. Another ICS leader built on this motion:
“I think there are certain debates and discussions which need to happen with our national leaders and opinion formers and that is something I think we could do together.”
System leadership is also important when considering the remit of accountability. Within an ICS, several leadership roles have varying functions and responsibilities. As highlighted previously, knowledge sharing is always needed. Therefore, system leaders should be seeking support from non-healthcare partners. As one ICS leader outlines:
“Where support would be helpful is system leadership as this does require different skills and it’s a different way of working.”
Holding leaders to account should seek to highlight knowledge gaps that will help ICS leaders improve their understanding of the social care sector. It will also open the door to further opportunities and shared learning, as different ways of working can lead to elements of what has worked well in social care being transferred to health and vice versa.
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