Integrated Care Systems: Why? Why? Why?

It is so easy for large complex organisations and systems to lose sight of why they exist. This is especially true when many different stakeholders and partners are involved often with a different understanding of the challenges and issues.

The Government’s recent ‘Integration and Innovation’ White paper[1] and subsequent proposed legislation, aims to establish Integrated Care Systems as statutory entities with the triple aim to “support better health and wellbeing for everyone, better quality of health services for all, and sustainable use of NHS resources.” It proposes to do this through both “integration within the NHS to remove some of the cumbersome boundaries to collaboration and to make working together an organising principle” and “greater collaboration between NHS and local government, as well as wider delivery partners, to deliver improved outcomes to health and wellbeing for local people.”

A key starting point therefore for any ICS and associated ‘places ‘, is for senior leaders and stakeholders to clarify and refine the ICS purpose in their particular context. As has been often said, “when you’ve seen one ICS, you’ve seen one ICS.” Helpfully national policy guidance appears to be permissive – allowing local flexibility whilst establishing a national design framework. Thus, the interpretation of the purposes which will be set out in legislation, is a matter for local articulation. The history and partners making up an ICS will shape the starting ambition, constraints, and capacity.

Furthermore, the local authorities and NHS organisations in the ICS are all statutory organisations with their own sovereignty around decision-making albeit all operating under the White Paper’s proposed ‘duty to collaborate’.  Relationships and shared ownership will be critical to creating a high performing overall integrated care system in any particular geography.

Without clarity of purpose people can often feel like its change for change’s sake. Drawing from Simon Sinek[2], we have found a ‘golden cycle’ process which explores ‘why – how – what’ helps to facilitate the development of a shared understanding of purpose. This is a fundamental shared building block, without which any design process is inherently flawed and likely to be subject to frequent change and challenge.

It also is clear that the different purposes operate on different timescales and are of particular interest to different stakeholders. Local authority Health and Wellbeing boards will focus on population health and wellbeing and tacking inequalities and the causes of inequality. These are complex multi-factorial ‘wicked issues’ which take many years to address. On the other hand, NHS providers and local patients, will be focused on waiting times, patient pathways and quality of care. Whilst ICS Boards will also have the resource position in clear sight – after all, loss of financial control is probably the main ‘P45’ issue for accountable officers in the NHS.

Building shared understanding and clarity of purpose is a critical building block but it won’t be easy. Given the inherent tensions within the purposes of ICSs, they will also need to be carefully designed. Convening system partners around core purpose(s) and ‘shared meaning’ together is a key first step.

More useful information on ICS can be found on the Kings Fund website at https://www.kingsfund.org.uk/publications/integrated-care-systems-explained

[1] Integration and Innovation: working together to improve health and social care for all.  Presented to Parliament by the Secretary of State for Health and Social Care by Command of Her Majesty. February 2021

[2] Simon Sinek, Start with Why, 2009