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As the first wave of Integrated Care Systems are given new financial flexibilities, the scale of what is being attempted should not be underestimated.
Our members within the NHS Confederation have been clear for some time that joined-up, patient-centred health and care services are the future of the NHS and must be supported to flourish.
The move to Integrated Care Systems (ICSs) is an attempt at reorganising health and care services unlike anything before, not least because there is no legislation to mandate a particular form for them and because they challenge some of the long-standing foundations on which the NHS has been run.
Local leaders are being asked to rearrange the system and change the way they behave within it. They have to become more collaborative – no easy task in a system which encourages organisations to focus on their own performance rather than that of the systems as a whole and where leaders are expected to meet targets set by regulators who will continue to monitor individual organisations. It is a contradiction that needs to be reconciled if effective collaboration is to flourish.
In most cases, the 10 areas where we are seeing the first ICSs emerge – which range from rural Dorset to Greater Manchester and cover one in six people in England – have been able to move at greater pace because they have developed firm relationships long before STPs and ICSs were initiated.
The trust they have built up over years has enabled them to work more effectively together and to have the necessary conversations about financial risk sharing and reorganising services.
There is obvious logic in giving the areas deemed most ready the chance to push ahead, but we should not overstate what has been achieved thus far – some are at a very early stage in this journey and no-one is anywhere near being a mature integrated system, if such a state is possible given the current legal framework. As such we need to acknowledge the challenges facing them and the importance of spreading the learning across the system.
One of the new ICS leaders reflecting on the absence of any statutory basis, observed that they were in effect ‘a collection of like-minded individuals’, who lead individual organisations which remain responsible to their own boards and individual regulators.
While strong relationships have allowed them to agree a shared vision and commitments, including financial risk sharing, his fear was that a continued lack of any statutory framework would be a barrier for the initial 10 and an even greater barrier for others, where the strength of relationships was weaker.
Delivering this change requires strong leadership and political support. The worry must be that emerging systems may not have fully taken on board the scale of what is being attempted.
They will also have to deal with unfriendly forces who wrongly see what is being attempted as a means to privatisation.
In reality, this is nonsense – if anything the danger is for a statutory takeover which sees a variety of alternative providers – from voluntary, community and independent sectors – being left out of local conversations and thereby excluded from the integrated care systems that develop.
We must guard against replacing a system that does not collaborate well at all with one that only collaborates and engages with other statutory or public sector bodies. We can create a seamless (and integrated) supply chain with different organisations who bring the diverse solutions we need to create the new models of care which put patients at the centre.
All this can seem daunting for but there is room for optimism.
Data shows the rise in emergency admissions slowing in some advanced STP/ICS and vanguard areas, as well as initiatives starting harness technology, empower staff, patients and communities, and connect services around the needs of patients.
Equally as promising is evidence which shows emerging partnerships comprising hospitals, primary, community and social care. All this should give us hope for the future of joined-up care. The move in many places to focus on planning and delivering services for localities serving populations of around 50,000 people is another positive step, with the prospect that services will coalesce around the needs of the people they serve. That must always be the new priority.
Niall Dickson is chief executive of NHS Confederation