System clarity

by Lee Outhwaite

05 May 2021

The creation of integrated care systems is about more than moving functions from existing bodies to new ones. There will be major changes to roles and the way services are designed and run. More discussion is needed about these changes.

The NHS is now embarked on a grand planning exercise involving a series of returns to NHS England and NHS Improvement.  It may be useful to see this planning approach through the lens of three distinct timeframes: very short-term; short-term; and medium-term. 

Inevitably the service needs to work on all three of these planning time horizons concurrently. And, while there is an inevitable inclination to concentrate on the short-term demands, we must not lose sight of the more medium-term goals. 

We can’t think about this in a sequential way, but perhaps we do need a language to describe where our focus is and which specific timeframe we are addressing with any work we undertake. The three time horizons give a different emphasis for finance, operations and the quality agenda/domains, as outlined, below


    Very short-term

    • 21/22 H1 block funding and associated planning requirements


    • Underlying position and mobilisation of the efficiency programmes


    • Working differently in terms of provider collaboration at place and scale, strategic intent and ICS development


    Very short-term

    • Elective recovery
    • Mental health investment standard
    • Primary care investment
    • Covid third wave, potentially in August


    • Dealing with the Covid-19 legacy, longer waiting and building back better
    • Care integration and reducing the delivery of fragmented services


    • Plans to tackle health inequality and socially determined disease
    • Ensuring we can deliver services through self-care or primary care and step down to lower cost care contexts
    • Putting prevention centre stage
    • Tackling social isolation and inclusion


    Very short-term

    • Harm associated with long waits
    • More routine post Covid-19 access to services


    • Building capability around wider quality indicators than those currently used within the NHS or system


    • Using a wider outcomes framework to monitor broader quality delivery
    • Closer integration between public health and NHS care monitoring


The move to integrated care systems is specifically intended to help us to deliver the medium-term agenda – providing a collaborative model without many of the obstacles of the previous system. The proposed legislation is relatively light on the detail. It sticks fairly closely to the transfer of functions, for example from clinical commissioning groups to the ICS NHS bodies. But the detailed reasons why we are doing this are important:

  • there is a growing understanding and belief that the current statutory provision structures in the NHS will not deliver integrated care in an optimal way, especially given increasing prevalence of frailty and chronic disease.
  • we are acknowledging that provider collaboratives may be better placed than existing commissioning structures to manage demand. They will need to change and optimise pathways of care. This will change the historic role of providers that has been in place since the purchaser/provider split.
  • we want to partner more closely with local government to ensure we are tackling socially determined disease and the broader issue of health inequalities.

These factors are a key part of the central rationale for ICS development and need to be reiterated at each point of the implementation of the ICSs. And they need to be at the centre of the supporting guidance accompanying new legislation, if not at the heart of the legislation itself.

Three further points are probably important in the context of the next steps for ICS development. 

First, how will the provider collaboratives embrace primary care networks, primary care and general practitioners to deliver the care integration aim. Primary care is fundamental to the delivery of more integrated care.

Second, if provider collaboratives are to take the central role in demand management and pathway design that has been talked about – leading on how services should be put together to deliver the desired outcomes – there are questions that need answering. Perhaps fundamentally, how does this work in the context of specialist and direct commissioning. Getting the split right between what is provided at place- and system-level and across multiple systems will be challenging.

And third, if we are to partner more closely with local government on the wider health and wellbeing agenda, how do we expand the use of pooled budgets? This will take the NHS and its partners into areas it has only really tested the water of to date with section 75 agreements. And yet we will need to do this maintaining separate governance arrangements, identities and relative roles.

There is a good deal of work going on at the moment. But it would be helpful if there was more clarity and discussion on the purpose behind some of the changes. Specifically, there is a need to better define what the roles of provision will be once the ICSs are statutorily established from April next year. We may have set out in the right direction, but we need to start identifying more of the milestones that will deliver on the medium-term goals.

Lee Outhwaite is a member of the HFMA System Finance Special Interest Group