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How feasible is the switch from sustainability and transformation plans (STPs) to integrated care systems (ICSs)? Valeria Fiore investigates
The NHS long-term plan – published in January – described how health and care organisations should join forces and work more closely together, taking collective responsibility for their populations’ health. The plan asked all NHS organisations and their affiliates currently operating as STPs to become ICSs by April 2021.
ICSs are systems based on collaboration between NHS organisations, local authorities and the third sector, all working towards the shared goal of improving the health of their population, according to NHS England.
However, the long-term plan gives little detail on how STPs should make this transition.
Some experts, including leading healthcare think-tanks, also believe the health and social care systems will look quite different from one another by April 2021.
The current system dates back to 1991, when the then health secretary Ken Clarke introduced the NHS internal market, with different bodies for providers and commissioners, a move designed to encourage competition in the healthcare sector.
NHS organisations have now experienced more than two decades working in a competitive environment. However, for the past few years, the NHS has favoured a focus on integration, a gear shift that can be traced back to the publication of the Five-Year Forward View.
Launched in October 2014, the Forward View made the case for better integration of health and social care services according to a patient’s needs bringing together ‘primary and specialist care, physical and mental health services, and health with social care’.
‘The speed of transition will vary’
The face of health and social care will change considerably over the next few years to meet the long-term plan’s requirement for ‘triple integration’, bringing together ‘primary and specialist care, physical and mental health services, and health with social care’.
The long-term plan confirmed there will be fewer CCGs, of which there are currently more than 190. In the future there will typically be one per ICS, with ICSs expected to grow out of the current network of STPs.
The plan gave an overview of the characteristics ICSs will have, which include a partnership board with representatives from the commissioning, provider, primary care network, local authority, voluntary and community sectors.
As part of the NHS planning guidance published in December 2015, 44 STPs were announced. Since then, 14 of these have been chosen to become ICSs in two waves, launched by NHS England.
Different parts of the country have reached varying levels of integration since STPs were introduced. Senior fellow at The Nuffield Trust Natasha Curry thinks that we will continue to see a level of variation even after April 2021, by which point NHS England aims for ICSs to cover the entire country.
‘The speed at which this transition will happen will vary from place to place and depend on the starting point of the locality,’ she says. ‘When it comes to the target date – April 2021 – we are not going to see the whole country covered by uniform ICSs. Even if they are all known by that label, they are going to look different inside and represent different stages of development.’
The King’s Fund chief executive Richard Murray agrees. ‘I’m sure that up until 2021 and beyond we’re going to see a lot of variation across the country. The STPs that were furthest ahead are likely to remain ahead, while other parts of the country will be slower behind,’ he says.
‘No single formula’
Since STPs were introduced, they have been working towards delivering more joined-up care. NHS England says that it will build on the progress already made by STPs and support them in their transition to ICSs, but it’s not yet clear what this process will entail.
‘At the moment, there’s no single formula for what ICSs should look like. In the long-term plan there are only a few key features about ICSs, what they’ll look like, what they’ll do. I think that’s still an evolution,’ Mr Murray says.
Some STPs have become ICSs through devolution – for instance, the Greater Manchester and Surrey Heartlands partnerships – which means they can make decisions locally in response to their population’s needs.
Elsewhere, organisations that are part of an ICS have agreed to work with a combined budget, making collective decisions on how their finances should be spent to benefit the local population, such as in the case of Dorset ICS.
‘The process by which an STP becomes an ICS is not outlined in the long-term plan as there is no nationally prescribed, one- size-fits-all model,’ says Cambridgeshire and Peterborough interim STP accountable officer Roland Sinker.
‘However, we are well positioned to evolve into an ICS as we have demonstrated joined-up approaches to planning, such as establishing an STP board in September 2017 and being one of the first STPs in our region to hold STP board meetings in public from November 2018.’
The lack of central guidance doesn’t necessarily mean it will be difficult for STPs to become ICSs. ‘There are different ways of creating ICSs – that’s because they are systems that should reflect local arrangements and context,’ says West Yorkshire and Harrogate Health and Care Partnership ICS lead Rob Webster.
NHS England said it will work with NHS Improvement, local government, and voluntary and community sectors to share best practice and help STPs make the transition to ICSs.
Although help is available, some think that making the transition within the two-year period is still an ambitious target.
‘It looks tough to me, but we are hopeful that STPs have been maturing towards ICS status. Developing relationships and trust in the context of the current regulatory, financial and operational environment takes time,’ Mr Webster says.
‘Becoming an ICS brings additional freedom and flexibility managing the delivery of local services, and provides better co-ordinated and more joined-up care for patients. We have worked hard on this for nearly three years and have the benefit of exceptional leaders across the partnership in all sectors.’
GP and clinical lead at Nottingham and Nottinghamshire ICS Dr Nicole Atkinson thinks the transition from STPs to ICSs ‘is not going to be an overnight journey’ and that it will take a number of years to work through.
‘It’s going to be a considerable challenge but I think it will motivate people. The challenges that our health and social care system is facing now make the case for integration and transformation a number one priority,’ she says.
According to Surrey Heartlands ICS lead Dr Claire Fuller, STPs will be helped in their transition to ICS status by the level of knowledge already available around the country.
‘All parts of the country are at different stages, but the amount of learning that is available will really accelerate change and the transition from STPs to ICSs,’ she says.
Health experts believe that good relationships between the different partners are also a key feature of a solid ICS. According to Dr Atkinson, ‘it’s critical to spend time building relationships and trust. That takes time, but once it’s embedded, it allows a lot of this work to happen, and people don’t tend to resist the change, they want to be part of it.’
‘The biggest risk is loss of accountability’
Accountability has been a controversial issue for ICSs. The King’s Fund traces the origins of the term ‘accountable care’ to the US, following President Obama’s healthcare reforms.
In the UK, the term was initially used in two contexts: accountable care systems (ACSs) and accountable care organisations (ACOs). The legitimacy of the latter was criticised and examined through two judicial reviews last year.
Campaigners and trade unions including the BMA feared that ACOs lacked clarity and, indeed, accountability, and could favour the privatisation of the NHS as private companies could bid for an ACO contract.
ACSs were later rebranded as ICSs as part of NHS England’s Refreshing NHS Plans for 2018/19.
However, despite the name change, it is still unclear who will be held accountable in an ICS.
NHS England hopes to tackle this through the introduction of a new ICS accountability and performance framework to ‘consolidate the current amalgam of local accountability arrangements and provide a consistent and comparable set of performance measures’.
However, this framework hasn’t been released yet.‘There is a question of where that accountability is going to sit,’ says Ms Curry. ‘At the moment, we have a split between commissioning and providing, and the commissioners clearly have a role to hold those providers to account.
‘In an ICS, I am not sure it’s clear that we’ve got somebody saying I’m going to hold you to account for this. It’s not to say it can’t happen, but it hasn’t yet been articulated clearly.
‘The biggest risk is the loss of accountability. In local government, there is a very clear democratic accountability. They are held to account by the electorate. Within health, we don’t have that. At the moment, commissioners fulfil that function, and maybe they still will, but it is not completely clear.’
In the case of Nottingham and Nottinghamshire ICS, this lack of clarity resulted in Nottingham City Council’s decision to suspend its collaboration with the ICS in November 2018, following concerns that the body lacked ‘democratic oversight’.
However, the council decided to rejoin the ICS at April’s executive board meeting due to the ICS agreeing to several changes to its governance in response to the council’s concerns.
NHS England suggested in the long-term plan that ‘legislative change would support more rapid progress’, helping organisations work in a more integrated way. This is because individual organisations have been used to working autonomously, which could add a new layer of challenges in the transition towards integrated care.
‘Obsession with structure can be unhelpful’
In order to support the effective running of ICSs, NHS England suggested in the long-term plan that Parliament should allow trusts and CCGs to make joint decisions by giving NHS foundation trusts ‘the power to create joint committees with others’.
This would allow them to create ‘joint commissioner/provider committees in every ICS, which could operate as a transparent and publicly accountable partnership board’.
‘I think the legislative change and clarity on the accountability framework would help,’ says Ms Curry. ‘There are talks about ICSs working as a system and organisations working together towards common goals, but the ICSs themselves are not going to be statutory bodies.’
Allowing ICSs to become statutory bodies could be counterproductive, according to Mr Webster. ‘ICSs are systems made up of organisations. They are the servant of the organisations, not their master.
‘They are supported by governance arrangements that allow joint decision-making where required. The more we consider ICSs as organisations, the more likely we are to damage relationships and the pace of improvement. Our obsession with structure in the NHS can be unhelpful.’
There is agreement among clinicians and policymakers that integration is the way forward. It is not likely, however, that the health and social care sector will see any change to legislation to favour integration any time soon, as other more pressing issues – such as Brexit – are likely to push it into the background.
STPs will have to continue to work with the information that is available to them while they wait for NHS bosses to release further details – including the new ICS accountability and performance framework – on how local systems should achieve ICS status by April 2021.
It seems the exact nature of the transition is very much a work in progress.