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 Introduction and Bibliography can be found below. You can locate a full pdf version of the report here.
Integration is a broad term; according to the Department of Health and Social Care, it is defined as the planning, commissioning, and delivery of coordinated, joined-up and seamless services to support people to live healthy, independent and dignified lives and which improves outcomes for the population as a whole (Department of Health and Social Care, 2022).
Integration strives to deliver better outcomes, experiences, and use of resources across health and care institutions. Integrated care is essential in improving care for people with long-term conditions who require ongoing care and support (World Health Organisation, 2016).
Attempts to integrate health and social care have been a national priority for a number of decades. In the last ten years, we have moved from Primary Care Trusts to CCGs and now to ICSs, all with a common intention of creating partnership organisations that come together to plan and pay for health and care services to improve the lives of people who live and work in local areas.
The integration agenda has been reinvigorated by the introduction of 42 ICSs through the Health and Care Act 2022. The Health and Care Act is based on the idea that collaboration between system partners, including hospitals, GPs, social care, and others, is needed to improve local services and make the best use of public money. ICSs are the cornerstone of this ambition.
Whilst ICSs have existed informally since 2016, they have had to operate informally until the introduction of the Health and Care Act last year. Most recently, the NHS was made up of 106 CCGs across England. CGGs represented clinically-led statutory NHS bodies responsible for the planning and commissioning of healthcare services for their local area. ICSs, in contrast, are geographically based partnerships that bring together providers and commissioners of NHS services with local authorities and other local partners to plan, coordinate and commission health and care services.
ICSs are made up of two constituent and statutory parts. The ICB has taken on the NHS planning functions previously held by CCGs, with authority over how the NHS budget for their area. Conversely, the ICP brings the NHS together with other key partners, including the adult social care sector, to develop strategies to improve the health and wellbeing of local populations.
The health and social care system faces enormous pressures, with significant vacancies across both sectors, record numbers of people waiting for routine hospital treatment, a growing number of people awaiting social care assessments and health inequalities and inequities widening (Care Quality Commission, 2022). This is against a backdrop of an ageing population and significant underfunding from central Government.
ICSs represent a real opportunity to foster tangible change and overcome historic barriers impeding achieving meaningful integration, thereby alleviating the current pressures and driving positive outcomes. For this hope to be actualised, ICSs must forge equal partnerships across system partners which will subsequently improve the range and quality of support provided.
National reports have been commissioned and produced to provide an independent review of ICSs, most significantly the Hewitt Review, which examined how the oversight and governance of ICSs can best enable them to succeed. Wider reports, such as the Fuller stocktake report, have also reviewed what is working well, why it’s working well and how we can accelerate the implementation of integrated primary care.
This report aims to provide an alternative and novel insight into how ICSs have progressed over the last year, with a particular focus on the centrality of the adult social care sector in the success of ICSs.
To achieve this Care England interviewed eleven ICS leaders across ICBs and ICPs asking them to reflect on the progress made in the last year, what pressures have been faced, and how these have been overcome, all whilst looking through the lens of adult social care provision.
Methodology and methods
This report is based on a qualitative research project which used a framework analysis to analyse eleven semi-structured interviews concerning how ICSs 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.
A qualitative study was chosen as qualitative methods permit a deeper understanding of experience and meaning from the perspective of the participant (Hammarberg and de Lacy, 2016). Qualitative interviews permit an exploration of complex issues and values. This was particularly appropriate for the present study which has been shown to be multi-layered and complex.
A semi-structured interview is particularly appropriate for research seeking to explore detail concerning the lived experiences of respondents (Flick, 2008). The design allows the interviewer to remain true to the research objectives but allows the respondents to construct and portray information in their own words (Roulston, 2010). Furthermore, the design allows the researcher to probe for more information on answers of particular interest and seek clarification on answers which were unclear.
Sampling and recruitment
The target population was identified based on the following inclusion criteria: the respondent currently sits on the ICB or ICP and holds decision-making responsibility which informs the strategy and ambitions of the ICS. This project was deemed a minimal-risk project as it did not involve vulnerable participants, nor were there any foreseeable risks to the participants.
The targeted sample size decided on was ten participants with coverage across all seven NHS regions. The sample size selected was to ensure the local variation between ICS was recognised and accounted for as robustly as possible. Whilst the challenges facing each ICS are not the same, as populations, pressures and resources vary widely between areas, we wanted to explore what was working well and what was not both locally and nationally.
The respondents were sourced through pre-existing connections available to the researchers. Since the inception of ICSs, Care England has conducted an array of work with ICS leaders. This research project formed a continuation of this programme of work. Accordingly, participants were recruited within the research team’s formal network who met the inclusion criteria.
An overview of the research project was sent to prospective participants, alongside an Information Sheet which explained the nature of the interview. If interested, the respondent contacted the researcher. No immediate time pressure was placed on respondents to allow sufficient time to consider the information (Wilson, Draper and Ives, 2008). Respondents were selected on a first-come-first-serve basis. Prior to the interview, the participant was presented with a Consent Form and given appropriate time for completion to ensure informed consent.
The final sample reached eleven participants which covered six of the seven NHS regions.
Virtual interviews were conducted via Microsoft Teams at a date and time convenient to respondents in May and June 2023. Whilst face-to-face interviews would have been preferable, virtual interviews still allowed the researcher to recognise visual cues which can help build rapport and interpret responses (Novick, 2008).
This research study assumed a diachronic topic guide (Weiss, 1995). The research question possesses a temporal dimension as how to ICSs have developed since July 2022. By nature, this represents the accumulation of information, decisions, and behaviours over time. The Topic Guide was prepared to be appropriate for participants who sat within either the ICB or ICP. All questions were formulated as open questions to allow the participant to answer the questions subjectively.
The first topic sought to explore the participant’s perceptions of the current pressures and tensions within their ICS. Accordingly, attention was given to how the transition from a CCG to an ICS has been managed, what pressures have arisen or carried through to the ICS, the barriers which have previously and are currently impeding integration, and a reflection on the ICSs priorities within its first year.
The second topic examined the role of adult social care within the ICS, particularly reflecting on the governance structure of the ICS and how the adult social care sector was represented.
The third topic looked to undercover how Care England could support the ICS and wider ICS leaders in meeting their ambitions as well as driving the integration agenda forward at a national level. This topic also looked to explore what is currently working well in the system and how this good practice could be brought to bear at a national level.
The final topic explored the future of the participant’s ICS, predominantly looking at how they plan to drive change and move towards a truly integrated system which recognises the significance of the adult social care sector.
Data collection and transcription
The interviews were recorded using an audio recording device. Although audio recording devices denote limitations such as their intrusive nature (Weiss, 1995), their use was deemed necessary to permit verbatim transcription thereby allowing the participant’s comments to be quoted word-for-word. Permission to record the interview was sought with all three participants in the Consent Form. Transcription was performed by the research team to allow for immersion within the data. Following transcription, the transcripts were emailed to the participants to confirm if they were happy with the accuracy. The audio files were stored on a password-protected private computer and managed in line with the UK’s Data Protection Act.
The data was analysed using a framework analysis. Framework analysis is a matrix-based approach which involves creating codes based on the content of the data and then clustering the codes into categories (Dixon-Woods, 2011). Central to the analysis is the iterative process of moving between stages which enables the researcher to develop a conceptual framework (Ritchie and Spencer, 1994). A framework analysis was appropriate for this study as it enabled the researcher to capture different aspects of the phenomena under investigation and analyse the relationships methodically using interconnected stages.
As with all forms of data analysis, analysis is influenced by the characteristics of the analyst (Galdas, 2017). Accordingly, this project benefited from multiple researchers who were able to corroborate findings.
Following transcription, open coding took place, whereby transcripts are read line-by-line and the content, whether literal or implicit, was noted. The codes referred to beliefs, emotions, observations, and behaviours (Gale et al., 2013). This stage was completed with printed versions of the transcripts.
The following stage consisted of developing the analytical framework. Following the open coding of two transcripts, the codes were compared and grouped into categories, see Excerpt 1. This process formed the analytical framework that was applied to the remaining transcripts.
Excerpt 1 – Example of grouped coding
After the application of the framework to the transcripts the data was charted into a framework matrix. A table was used, Excerpt 2, to summarise the data from each category established by the analytical framework. The codes for each category were presented using verbatim words and phrases thereby pertaining to the participant’s original message.
Excerpt 2 – Example of framework matrix