What does integrated care mean for rural communities?

Public spending on health care is driven by the needs of the population, the resources available and national priorities. Health services are facing unprecedented financial and operational pressures, with many NHS organisations in deficit and key performance standards missed. At the same time, some people require support from both health and social care services and there are longstanding calls for them to be integrated – putting patients at the centre of how their care is organised and saving money by cutting down on emergency hospital admissions and delayed discharges. Integrated Care Systems (ICSs) are bringing together NHS organisations and Local Authorities to work in partnership to improve health and care in their area. NHS England has acknowledged that transitioning to ICSs is ‘complex’, requires a ‘staged implementation’ and they make take several years to fully form. What are ICSs, how are they developing, and what do they mean for rural residents? Jessica Sellick investigates.  ………………………………………………………………………………………………..

Health and social care services in England have traditionally been funded, administered and accessed separately – with health provided for free at the point of use through the National Health Service (NHS) and social care through means-testing carried out by Local Authorities. Successive Governments have sought to better integrate health and social care by focusing on providing care as close to the patient as possible (i.e., in their home or community rather than in hospital). This move towards integration has led to the creation of Health and Wellbeing Boards, the Better Care Fund and Sustainability and Transformation Partnerships (STPs). 

Integration is now a central goal of the NHS – referenced in both the Five Year Forward View (October 2014) and the Long Term Plan (January 2019). In September 2019 the NHS set out legislative proposals for a new NHS Bill to implement the Long Term Plan and enable parts of the NHS to work with partners more easily. The Bill would replace the current NHS procurement framework which is seen by some health commissioners and providers as a barrier to integrating care at scale. Integrated Care Systems (ICSs) are one of the emerging models of integrated health and social care. 

What is an Integrated Care System (ICS)? The NHS Long Term Plan contains an ambition that every part of the country should be an ICS by 2021. An ICS ‘brings together local organisations to redesign care and improve population health, creating shared leadership and action…They are a pragmatic and practical way of delivering the ‘triple integration’ of primary and specialist care, physical and mental health services, and health within social care’.  This emphasis on ‘working together’ is not new and the origins of ICSs can be traced back to 2016 and the establishment of Sustainability and Transformation Partnerships (STPs). STPs are five-year plans covering all aspects of NHS spending in England. STP leaders generally come from clinical commissioning groups (CCGs), NHS trusts or foundation trusts or local government. There are 42 STP areas – with their geographical footprints varying from 300,000 to 2.8 million people.  The Long Term Plan envisages that by April 2021 ICSs will cover the whole country, growing out of the current network of STPs. 

NHS England and NHS Improvement have highlighted three areas at which decisions will be made within ICSs: 

  1. Neighbourhoods (populations circa 30,000 to 50,000 people) – served by groups of GP practices working with NHS community services, social care and other providers to deliver more coordinated and proactive services, including through Primary Care Networks (PCNs). 
  2. Places (populations circa 250,000 to 500,000 people) – served by a set of health and care providers in a town or district, connecting PCNs to broader services, including those provided by Local Authorities, community hospitals and voluntary organisations. 
  3. Systems (populations circa 1 million to 3 million people) – all health and care partners in different sectors come together to set the strategic direction and to develop economies of scale. 

According to research by the King’s Fund, ICS leaders have suggested that 70-90% of work within an ICS should occur at the place and neighbourhood levels, with the remainder carried out at the system level. 

There are two other forms of integrated care: (a) Integrated Care Partnerships (ICPs)– these are alliances of NHS providers that work together to deliver care by agreeing to collaborate rather than compete; and (b) Accountable Care Organisations (ACOs) – these are established when commissioners award a long-term contract to a single organisation to provide a range of health services to a defined population following competitive procurement. There are a number of important differences between ICSs, ICPs and ACOs. For example, ICSs are characterised by ‘integration by collaboration’ whereas ICPs as ‘integration by contract’; ICSs involve an ‘alliance agreement’ by the bodies involved whereas ICPs require a single contract held by a single body.   

How many ICS are there? In line with STPs, the size and geographical footprint of ICSs is expected to vary from area to area. Since 2018, 14 areas have been designated as an ICS. They are: (1) South Yorkshire and Bassetlaw, (2) Frimley Health and Care, (3) Dorset, (4) Bedfordshire, Luton and Milton Keynes, (5) Nottinghamshire, (6) Lancashire and South Cumbria, (7) Buckinghamshire, Oxfordshire and Berkshire West, (8) Greater Manchester, (9) Surrey Heartlands, (10) Gloucestershire, (11) West Yorkshire and Harrogate, (12) Suffolk and North East Essex, (13) The North East and North Cumbria, and (14) South East London. These areas cover rural and urban geographies; different population sizes (ranging from 528,000 in Gloucestershire to 2.7 million in West Yorkshire and Harrogate); and different system complexities (with 2 areas having devolution agreements in place: Greater Manchester and Surrey). One-third of England’s population is now covered by a developing ICS. 

NHS England and NHS Improvement’s regional teams will work with ICSs to agree system-wide objectives and performance against these objectives. 

What will ICSs do? Every ICS will need to have: 

  • A partnership board, drawn from commissioners, trusts, PCNs, Local Authorities, voluntary and community sector organisations and other partners. 
  • A non-executive chair (locally appointed but subject to approval by NHS England and NHS Improvement) and arrangements for involving non-executive members of boards/governing bodies. 
  • Clinical and management capacity drawn from constituent organisations to enable them to implement system-wide changes. 
  • Full engagement with primary care – including through a named accountable clinical director for each PCN. 
  • A greater emphasis by the Care Quality Commission (CQC) on partnership working and system-wide quality in its regulatory activity. 
  • All providers within an ICS will be required to contribute to ICS goals and performance – including in relation to (a) population health and (b) system objectives. 
  • Clinical leadership aligned around ICSs to create clear accountability to the ICS – with cancer alliances, clinical senates and other clinical advisory bodies coterminous with one or more ICS. 

ICSs are expected to incorporate learning from existing initiatives including the 50 vanguards that tested and refined new care models. 

From a clinical perspective ICSs may reduce barriers between services and competition between providers leading to improved patient care. Clinical input is central to the development of ICSs and ensuring that the views of health and care staff and their representative bodies are actively sought as ICSs develop may help to address some of the barriers that the health and care systems face (e.g. recruitment and retention of staff, funding, resources etc.)  

From a local government perspective, ICSs will have a key role to play in working with Councils at ‘place’ level with commissioners making shared decisions with providers on how to use resources, design services and improve population health. This means every ICS is expected to have streamlined commissioning arrangements to enable a single set of decisions to be made at a system level. As part of this CCGs are expected to become leaner and more strategic and support providers to partner with local government and other bodies on population health, service redesign and Long Term Plan implementation. Ultimately ICSs are expected to replace STPs by 2021. 

 From a patient perspective, ICSs will have a new accountability and performance framework which will measure the extent to which the local health service and its partners are genuinely providing joined up, personalised and anticipatory care. 

In September 2018, the King’s Fund published a review of ICSs during their first year. They found most ICSs were making progress in developing their capabilities to work as systems, and organisations were working more collaboratively to manage finances and performance in a way that was not happening previously. There were some early signs of progress in delivering service changes, particularly in relation to strengthening primary care, developing integrated care teams and reviewing how specialist services are delivered. 

A British Medical Association (BMA) briefing on ICSs has also identified some common themes across the 14 ICSs established to date: 

  • ICSs have a specific focus on enhancing the role and scope of primary and community care services. This is revolving around the development of Primary Care Networks (PCNs) and Multi-Disciplinary Teams (MDTs) . NHS England sees PCNs are central to the provision of at-scale primary care – encompassing GP surgeries, community and mental health trusts, pharmacies and voluntary and community sector organisations. 
  • ICSs are prioritising improving the overall health of their population to prevent ill-health – this includes looking at the wider determinants of health and the use of social prescribing.  
  • The current and future workforce has been highlighted as a major issue – with some ICSs prioritising the use of new clinical roles to support their work. 
  • ICSs are focusing on better use of data, technology and innovation to improve care and support prevention – this is centred on improving IT interoperability and the sharing of patient records.
  • Several ICSs are exploring possible service reconfiguration – including centralising specialisms at certain sites and/or trust mergers. Any service reconfiguration should be led by clinicians, based on clinical evidence, rather than driven by financial pressures. 
  • Clinical Commissioning Groups (CCGs) are changing as ICSs are developing – with a single CCG covering an ICS, although in some areas ICSs are not coterminous with CCG boundaries. Commissioning is also changing, with providers increasingly taking responsibility for some day-to-day functions rather than CCGs. 
  • ICSs will be taking collective responsibility for the resources and financial performance for the whole system – this will include arrangements for risk sharing and decision making on how services will be paid for.  
  • The move to system-wide working is changing regulation – with NHS England suggesting ICSs will be subject to a new form of regulation that focuses less on the performance of individual organisations and more on the system. 

How will they develop? NHS England has produced a ‘maturity matrix’ [pages 9-11] for ICSs. This outlines the core characteristics of systems as they develop and is intended to provide a consistent framework for all regions and systems across the country. There are four stages a system is expected to follow: emerging, developing, maturing and thriving.  For a system to be formally named an ICS it is expected to meet the attributes of a maturing ICS. The matrix cover: (1) system leadership, partnerships and change capability; (2) system architecture and strong financial management and planning; (3)  integrated care models; (4) track record of delivery; (5) coherent and defined population; (6) oversight; (7) finance; (8) planning; and (9) support.  

NHS England describes the matrix as a ‘journey rather than a series of binary checklists’ in recognising that systems will not develop across all domains at the same pace. 

What do they mean for rural communities? Integrated health and care is pertinent to rural communities, which experience poorer access to services than their urban counterparts. The way the health system is currently organised and funded is based upon economies of scale. While ICSs aim to provide patients with equal access to its services at the same level of quality, how will they take account of different types of rural and coastal populations at a neighbourhood, place and system level?  

A briefing published by the Nuffield Trust in November 2019 looked at why the different models of integrated care that have emerged so far had not produced the expected results of reduced hospital admissions. They identified a number of reasons why this may be happening: 

  • The model may be poorly designed, targeting the wrong population, not listening to patient preferences and/or containing a large number of complex work streams. 
  • The model experiences difficulty when it reaches the real world i.e., getting multidisciplinary teams to work well, effectively involving primary care, and the likelihood of uncovering undiagnosed pathology are all issues that have caused problems.
  • The expectations of those designing the models about the outcomes that are likely, and the speed that they can be achieved, are sometimes higher than can be achieved in the often short periods allowed for evaluation. 

NHS England’s maturity matrix for the development of ICSs sets out how a thriving ICS should have a  meaningful geographic footprint that respects patient flows; be contiguous with local authority boundaries (or have clear arrangements for working across local authority boundaries; and cover an existing STP of sufficient scale (1 million population or more). With one-third of the population now covered by an ICS and 70-90% of the work expected to happen at place and neighbourhood levels, how will ICSs listen to, and act on, insights from rural residents and patients? Where will their voices be in the development of local plans and allocation of resources?

Currently there is no clear statutory basis for the development of ICSs leading to concerns around their accountability and oversight. Clinicians, local government officers, Elected Members and the public are unsure how to challenge the direction of travel or decisions taken within an ICS. In 2019, Luton Council withdrew its support from the Bedfordshire, Luton and Milton Keynes ICS; Nottingham City Council temporarily suspended its involvement in the Nottinghamshire ICS; and in Berkshire West neither the South Central Ambulance Trust nor Local Authorities were participating in their ICS. Concerns about a lack of transparency and democratic oversight in the ICS planning process were cited. Research conducted on delivering integrated mental health support for older people in South Australia, for example, identified three structural barriers to integration: (1) fragmentation of Governmental responsibility, (2) funding shortfalls, and (3) the centralisation and standardisation of service delivery. Where do the flexible, informal and self-sufficient relationships that typically underpin integration in rural communities fit within an ICS? 

To date, the experience of local government and the NHS working together has been variable. Legislation can remove obstacles to integration, but it does not necessarily lead people and organisations to collaborate more effectively. Should legislation specify the level of involvement of Local Authorities, or other non-NHS bodies, in ICS arrangements? What will be the future of existing forums for promoting joint working, such as Health and Wellbeing Boards? Greater sharing of responsibilities across health and care may mean that regulation needs to change. Some of this is already happening, with the Care Quality Commission now reviewing local systems, as well as individual providers. Legislation can help avoid legal uncertainty – for example, clarifying what might happen if the decision of an ICS conflicted with the statutory duties of its member organisations. However there is concern that while ICSs are intended to overcome and remove existing organisational barriers; the models that are developing often appear dominated by NHS Trusts – how can they ensure the plans they are drawing up involve primary care [GPs], public health and social care [Local Authorities]? Evidence from Switzerland and Italy, where local hospitals were converted into health centres [as part of attempts to coordinate health and social care resources within and closer to rural communities], highlighted the importance of (i) creating a new legal entity or specific organisational unit to focus managerial attention on the need to coordinate health; and (ii) having enough internal resources to support the professional development of staff.  

Cuts to Local Authority funding have already stretched budgets in the areas of public health and social care. At the same time many NHS Trusts are in deficit. How will ICSs deliver system-wide change when the capacity of services it seeks to integrate are already under so much pressure? For me this underlines the need to have a dialogue about how much it costs to meet health and social care needs in rural areas (for children, young people and adults) and how to pay for integration (before provision collapses).

In November 2019 the Local Government Association (LGA) and the Social Care Institute for Excellence (SCIE) published a joint resource to support local systems to integrate. The document prioritised 15 actions, drawn from the UK and what works from international research. A number of core principals underpin these actions – here integration is not an end goal but a means of achieving the goal of better, joined up care; and should support the building of community capacity for prevention, early intervention and place based care and support.  In Herefordshire and Worcestershire, for example, it is difficult to deliver acute care because of the rurality of the area and the distance patients have to travel. The STP is looking at how acute specialist clinicians can work with community teams outside of hospitals, including providing advice and guidance to neighbourhood teams. In designing neighbourhood teams in Worcestershire the STP/ICS went to see the Buurtzorg Nederland and the Norrtaelje model in Sweden to learn how they could empower clinicians to ensure care is patient centred. 

Many STPs are not yet in a position to become ICSs – and may not be for some time. For change cannot happen overnight– and needs to be married with some realism about the scale, complexity and resources needed to truly deliver integration. If ICSs are the future of the NHS – if they are intended to lead to stronger health and care systems across the country – how can we ensure systems think rurally? 

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Jessica is a senior research fellow at The National Centre for Rural Health and Care (NCRHC). The NCRHC is a Community Interest Company, national in scope with a Headquarters in Lincolnshire, that focuses on four principal activities: data, research, technology and workforce. 

Jessica is also a researcher/project manager at Rose Regeneration. Her current work includes helping public sector bodies to measure social value; evaluating an employability programme; and reviewing a project that supports parents committed to recovering from, drugs and/or alcohol addictions.

She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. Website: http://roseregeneration.co.uk/https://www.ncrhc.org/ Blog: http://ruralwords.co.uk/ Twitter: @RoseRegen