Clarity needed on ICS governance

by Emma Knowles

23 April 2021


Integrated care is not delivered by boards. It happens around the patient and at service level. But governance structures are important in creating the right environment in which integrated care can be provided. And it may be an obvious point, but a new focus on population health will only work if there is enough funding for health and social care.

The HFMA backs the move to establish integrated care systems (ICSs) as statutory organisations, as set out by the Department of Health and Social Care in its white paper Integration and innovation: working together to improve health and social care for all (see an HFMA summary) . Covid-19 has shown how well health and care organisations can work together when traditional barriers are removed. Putting ICSs onto a more formal footing gives us the best chance of delivering services to patients that are not hindered by where budgets are held or who has organisational responsibility.

We agree that the focus must remain on establishing the right environment and culture for integrated care. But governance and structures need to support this endeavour and there is still a lot of detail needed to understand how the whole model holds together.

We made this point in our evidence to the Commons Health and Social Care Committee’s inquiry into the white paper, which the committee published this week. For example, the two-tier approach – with a statutory ICS body taking on overall system leadership, supported by a statutory ICS health and care partnership – risks adding complexity and bureaucracy to the system and does not address the conflict between system and organisational statutory duties.

The collaboration seen during the Covid response has been fantastic, with providers supporting each other through mutual aid. But to an extent, this was facilitated by a temporary financial regime that, for the first six months, funded all NHS providers to break even. As we move back to more traditional financial flows – albeit based on a new proposals for aligned payment and incentive contracts – we need to ensure there is no conflict between system and organisational statutory duties.

The overall quantum of funding will be key to this. Insufficient money in the global healthcare pot will undermine moves to integrated care, potentially creating tensions between systems and their constituent organisations. Some downward pressure on resources is right to encourage the delivery of value. But funding levels also need to recognise the pressures facing the NHS before the pandemic – including significant staff shortages – and the very real costs of continuing to recover services in a Covid context and tackling the significant backlog of care.

We also need to underline that integrated care is about much more than health services. Tackling the wider determinants of health has to involve a much broader partnership of local government, third sector and other public services. We have some concerns that establishing the system leadership role as an explicit NHS body will send out the wrong message to local authority and other partners. Perhaps the biggest issue though is that these organisations also need to be appropriately funded.

Social care funding, in particular, needs to be reviewed and revamped – meeting long standing promises to fix what is widely recognised as a service in crisis. The continued underfunding of social care means true system working cannot be achieved.

Integration of care services will not be achieved overnight and it is good that we are taking the first steps. The overall goals of the white paper are widely supported. What we need now is clarity on how the proposals can be made to work in practice and funding that gives the proposals the best chance of success.