Seventh Report - Integrated Care Systems: autonomy and accountability

It is clear that Integrated Care Systems offer a new way of working across health and social care. They encourage collaboration with a range of partners and a focus on what matters to their local populations. This fundamental premise needs to be balanced within a national service, funded by taxpayers and accountable to Parliament. It is therefore right that DHSC and NHS England set some of the priorities that ICSs should be working towards.

However, if ICSs are to realise the ambitions that have been set for them, and move beyond collaboration towards true integration, it is vital that DHSC and NHS England do not dictate how ICSs should deliver those outcomes. NHS England will also need to be conscious of its organisational culture and make concerted efforts to not revert to overly restrictive ways of working.

Targets for ICSs set by DHSC and NHS England should be based on outcomes. There may be times when greater prescription around how targets are achieved is needed, but we believe this should be done sparingly.

We welcome the clear references to local priorities within NHS England guidance for ICSs and DHSC’s proposed shared outcomes framework. We hope that, in the years to come, this focus on local priorities will be maintained. However, we share the NAO’s concern about the tension between local needs-based strategies and a national standardised service. Experience shows that locally determined priorities may become the poorer relation to priorities driven nationally.

DHSC should explain the mechanisms that will ensure that progress is made against local priorities. It should set out how this compares to mechanisms used to measure progress against national priorities, alongside an assessment of whether this balance will support ICSs to meet their four main objectives.

DHSC should publish, as soon as possible, the proposed shared outcomes framework and more information about how and when ICSs should expect it to be implemented.

Unfortunately, there is a clear risk that short-term, acute pressures will dominate ICS capacity, resources and leadership headspace, limiting the true flexibility of ICSs. Active effort from DHSC and NHS England is needed to ensure ICSs retain the space they need to focus on matters like public health and prevention. This will be especially necessary at this early stage of development for ICSs but should be maintained as ICSs evolve.

NHS England should provide an update on whether they intend to refresh their 2019 Long-Term Plan and, if so, when. Any update to NHS England’s Long-Term Plan must put prevention and long-term transformation at its heart, empowering ICSs to pursue these priorities and giving them the confidence that they have the necessary backing from the Government and NHS England. This should also apply to the Government’s pending Major Condition’s Strategy. (Paragraph 37) Integrated Care Systems: autonomy and accountability 25

Improving outcomes in population health and healthcare is one of the four core purposes of ICSs. Despite this, there is no mandated representation for public health professionals on Integrated Care Boards. Without that voice of expertise driving the public health agenda on ICBs, we are sceptical that ICSs will succeed in addressing longer-term priorities and fear that the move to ICSs will, once again, result in a sickness service, not a health service for the future.

To guarantee a continual focus on the prevention agenda, all Integrated Care Boards should ensure they include a public health representative, such as a public health director or public health lead. In 12 months, DHSC should conduct a review to understand the extent to which this is happening. If necessary, further steps should be taken to mandate the inclusion of a public health representative so the focus on prevention is not lost.

The four key purposes of ICSs are all dependent on taking a long-term approach. In order to fulfil them, ICSs need to be supported to make long-term decisions and have as much certainty as they can about upcoming funding.

We welcome the Minister’s comments about giving ICSs information about the funding that will be available to them further in advance. DHSC must set out how it intends to do this, and any decision to give that information must be made in plenty of time to support ICS preparations for winter 2023/24.

System leadership is different to organisational leadership and ICS leaders, as well as leaders at other levels, need support to develop skills to make the most of the opportunities and to ensure ICSs do not become too NHS centric. Systems need leaders that will work collaboratively and not be tied to the existing institutional instinct in healthcare to look upwards rather than outwards.

The Government and NHS England should set up and fund an ICS leadership development programme, specifically targeted at supporting leaders of and within ICSs to develop the skills required to be successful system leaders (Paragraph 48) Accountability

We share the concern expressed by the NAO about the lack of clarity around what ICSs are expected to deliver within their core purposes. While we are conscious of, and agree with, the need to avoid micromanaging ICSs, we believe that DHSC needs to provide additional clarity about what exactly ICSs are expected to deliver. Only then can the public, and parliamentarians, begin to assess the success of ICSs.

Following engagement with ICSs and being conscious of the space required for local priorities, DHSC and NHS England should issue guidance with additional detail on what ICSs are expected to achieve within each of the four core purposes. As we have said previously, the focus here should be on outcomes and not dictating to ICSs how they achieve the goals.

Members of Parliament should be supported to directly hold their local ICSs to account for the service they provide to constituents, without having to rely on an assessment provided by local health and care leaders. We believe this is an integral 26 Integrated Care Systems: autonomy and accountability part of the role of an MP. We therefore welcome the Secretary of State’s desire to empower parliamentary colleagues to hold their local ICSs to account through transparency on ICB performance data.

The Secretary of State should set out further detail about how he intends to empower MPs to hold their local ICSs to account and what performance measures he envisages being available to support this.

Partnership working is fundamental to the design of ICSs and will be the make-or- break factor in their success. As we have discussed, the monitoring and evaluation of NHS priorities and structures is well established but it is unclear how partnership working will be monitored. It is also unclear how ICSs will be held accountable for partnership working, particularly if problems arise.

NHS England should provide more clarity about what ICSs should expect in terms of the monitoring of partnership working and how this will be assessed in ICB annual assessments.

DHSC, working with ICSs, should clearly set out what action could be taken, be that by the CQC, NHS England or others, to resolve issues of poor partnership working, in particular with adult social care.

We have heard a range of compelling arguments for particular professions to have greater representation on Integrated Care Boards and are sympathetic to the concerns that have been raised with us about the exclusion of expertise. However, we are also sympathetic to the Government’s intention to give ICSs flexibility when determining which professions are most relevant to their local needs. Our concern is that it is unclear how the Government will monitor and evaluate whether its approach is the correct one. If data is not held centrally on how many, for example, public health experts or social care providers or clinicians, are on ICBs and no assessment is made of the adequacy of the representation, it is not possible to understand whether the Government’s flexible approach is yielding the results it intends. It will also not be clear whether there are any patterns of under-representation.

DHSC should centrally gather information relating to the membership of ICBs, including the specific role of members and their area of expertise, by 1 October 2023.

Once the data is gathered, DHSC should review it with a view to understanding whether the policy of keeping mandated representation to a minimum is producing the intended results and whether any specialties are especially under-represented. They should report the outcome of this work, and whether any further mandating is required, to the House.

The core purposes of ICSs, and the importance of addressing local needs, will not be met without good patient and carer involvement. ICSs cannot truly deliver for their local area without considering the needs of that area from the patient or carer’s perspective. (Paragraph 81) Integrated Care Systems: autonomy and accountability 27

Given the new expectations that have been placed on Healthwatch organisations across the country, we believe this is a good opportunity to consider their funding and commissioning arrangements.

DHSC should therefore review the funding and commissioning arrangements for Healthwatch, with a view to ensuring they are fit for purpose within the context of new ICSs, and support Healthwatch to have a clear voice. The outcome of this review should be reported to the House.

Given that the CQC will have the legal powers to conduct assessments from April 2023, it is concerning that there are still outstanding questions that the Government needs to provide clarity on. This is particularly around any priorities DHSC may have for the assessments, and whether the CQC will be expected to provide ratings. This absence of information limits the CQC’s ability to prepare for these assessments and lengthens the time it will take for them to refine their approach to system assessment.

DHSC should urgently provide the CQC with its decision on ratings and any priorities it would like the CQC to focus on. It should also communicate to ICSs what methods will be used to address any areas of concern that assessments might raise. ICSs should be given fair notice about this, and the CQC may need time to incorporate this into their approach, so it is imperative that this clarity is provided before the bulk of the CQC’s assessment work begins.

DHSC and NHS England should review existing regulatory assessments for ICSs with a view to ensuring there is as little duplication as possible. We recommend this work is done alongside the Department for Levelling Up, Housing and Communities given their role in local authority assurance. (Paragraph 94) 28 Integrated Care Systems: autonomy and accountability