Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by deputy editor Dave West.

This week’s The Integrator newsletter is an interview with Dominic Hardy, the NHS England director who took over responsibility earlier this year for covering England with integrated care systems by April 2021, in addition to his previous role of primary care delivery.

The NHS’ best-known pipeline of recent times is the foundation trust pipeline, running from 2004 until 2016 – involving some difficult asks which dozens of trusts never managed to pass. Another model was the pipeline to clinical commissioning group authorisation. This saw all CCGs approved to operate by an April 2013 drop dead date, but many left with “conditions” and “directions” limiting their autonomy, sometimes staying in place long past 2013.

The pipeline for sustainability and transformation partnerships to become integrated care systems is much closer to the CCG model. Under the NHS long-term plan, all areas will pass by the April 2021 target date; but, after this, they will be assigned varying levels of maturity and autonomy, as decided by NHSE.

Mr Hardy does not reject this comparison: “We already work with the ICSs on the basis that they continue to mature [after they become ICS]. So essentially this isn’t going to be a pass [or] fail, hit the bar [or] don’t hit the bar.

“We want to work with the systems that we’ve got so they build all the characteristics of what a mature [ICS] looks like, and to be able to get to that point over the next couple of years.”

He moderates slightly, however: “In a way we don’t want to shift the bar downwards – we’ve got some clear expectations about what an effective ICS is and does.”

One of the nagging worries about ICSs outside NHSE and within is – like other pipelines and structural initiatives before them – they might change organisational badges but not actually improve health or care.

The policy seeks to overcome this by trying to judge STPs and ICSs, as Mr Hardy puts it, by “focusing on the five key service redesign challenges that chapter one of the NHS long-term plan sets out”. The aim is “to get the integration part of it right and build collaborative partnerships to be able to make that stick”.

NHSE can therefore argue ICSs are there to accelerate service improvements, not as an end in themselves.

But being an ICS is not in fact as simple as (or perhaps as difficult as) integrating care in several major service areas.

Elite club

And, despite there being a few ICS “diagnostic” services on offer via management consultants, the requirements to pass and become an ICS are highly opaque.

Unlike CCG authorisation, there are no must-dos set out in secondary legislation, nor long public documents detailing the evidence required.

For STPs keen to become an ICS, as a leader of one such system described it at a recent event for those wanting to take forward integration, it seems to be an “elite club” whose early members are themselves hothousing what it means to be an ICS as they go along – and “no one can tell us what’s required”. The truth, arguably, is to sit tight and play the waiting game until 2021; although presumably this would be missing the point.

I asked Mr Hardy – whose full title is director of primary care and system transformation – what the most important characteristic was for determining whether a system made the grade.

“It would be easy to cherry pick one or two – the challenge is to do a number of things really well: To have the leadership in place that can really prioritise those care models… To be able to build critical mass among clinical teams across sectors [and] across health and social [care].

“But also to then do that on a sustainable basis – how do you grow your own leaders? We’ve seen Surrey Heartlands develop an academy to have an ongoing pipeline of leaders who are prepared to take forward key bits of improvement work.

“I don’t think it’s one characteristic or another – almost by definition it’s a system so people are going to have to have a range of capabilities.”

What are the most difficult parts?

“It will vary by system but building the infrastructure that you need at each level – neighbourhood, place, and system – and sustaining the strength at each of those, is going to be a challenge for most.”

In particular, he highlights building primary care networks. This is the other side of Mr Hardy’s job; it has been a big focus of most if not all ICSs, and is the subject of much heavy lifting and lively debate across England right now.

PCNs were difficult, he said, “because [systems have] different starting points… there is fantastic work going on all around the country but there are parts… where people will start from a lower base”.

Mr Hardy diplomatically suggests that working together, service improvement, integrated care and population health were “something that a lot of general practice has done over many years but has suffered by having immense workload pressures”. Another way of seeing it is that some of the asks are completely novel for lots of practices.

Horses for courses

It’s clear to me that, while the LTP gave a little more definition to ICS and a pipeline target date of April 2021, it did not come with the integration cookie-cutter which is feared by some, and hoped for by others who yearn for consolidation and simplification.

“Horses for courses” has been an overriding principle since Simon Stevens joined NHS England. Across several of the big detailed questions about what an ICS is or should be, there are still no easy answers on offer.

The NHS long-term plan carefully said a “typical” ICS should be covered by only one CCG, implying a swathe of commissioning group mergers. And we are seeing many areas now coming forward proposing cross-system CCG mergers. Prominent ICSs with quite a few CCGs – Greater Manchester, West Yorkshire and Harrogate, and South Yorkshire and Bassetlaw for example – are not so far among them, however.

Mr Hardy confirms a single CCG per ICS was “a direction of travel” but adds: “What I want to avoid is a distraction exercise where people decide they’re going to merge CCGs just because that’s the next thing to do.

“It always needs to be for a purpose… But we did signal really clearly in the LTP that over time, that’s where we think people should get to, unless there are particular conditions pertaining in a patch which means it’s not quite the right thing.” It’s a fine line to walk.

NHSE has also said, but not specifically required, that ICSs should cover a population of one million or more – a condition not met by seven of the existing ICSs, nor by eight STPs. Again there remains flexibility: ”Over time we’d expect a shift to systems of more than one million, but clearly there are systems that function really effectively as genuine systems at a level below that.

“Again where they’re getting impact we need to back them. Given the choice between putting energy into making improvements and fiddling with architecture, I know what choice I’d make.”

I also asked whether, ideally, ICSs should hold public board meetings, with published board papers – something a handful are now doing, and which was highlighted by Nottingham and Nottinghamshire ICS when Nottingham City Council agreed to rejoin it. Mr Hardy praises the “spirit of engaging” here, but does not endorse this particular method.

Local chief executives trying to make sense of integration policy often ask whether their STP or ICS is meant to be taking over assurance or performance management, in the model of strategic health authorities. Some systems are moving into this space but others really don’t want to.

Mr Hardy indicates it is something good STPs or ICSs should be doing, but when pressed on whether this meant they would be becoming more of an outpost of NHSE/I, he adds: ”It will vary depending on the circumstances. That’s why we’ve said to our regional teams we want to get behind you, but equally we want you to enable systems to understand where they are right now and to be able to create the right conditions so they do get to that place.”

And the seven new NHS England and Improvement regional directors and their teams are likely to play a big part in decisions about STPs and ICSs on their patch in the coming months. The RDs have shown little of their hand so far but there are early signs some may be shaping the leadership of their more difficult STPs.

Leadership where we find it

System working under the Stevens’ approach makes no claim at all to be a “stable, transparent and rules-based” game, to contrast with an Andrew Lansley Equity and Excellence phrase.

In this fuzzy world, leadership and individual leaders have even greater influence.

There’s been plenty of change to STPs’ assigned leaders since they started work in early 2016; but there’s been even more turnover lately, following the LTP and as people gear up for the next phase.

I will do the sums properly soon, but I think STPs and ICSs are moving towards executive leaders who can run them more or less full-time, on a day-to-day basis, and are typically from a commissioning background, away from incumbent trust chief executives who do not give this time commitment, and have sometimes lacked a wholehearted belief in the project too.

Mr Stevens has stressed regularly in the past that he will “back energy and leadership where we find it” – coming from different types of organisations in different parts of England – rather than supporting any particular type of organisation, background or model. The policy to date on this issue, and Mr Hardy’s comments on it, stick close to this approach.

But Mr Hardy indicates that NHSE does expect a firming up of system leadership: “These are definitely serious jobs. We have put our backing behind ICSs as the vehicle to get integrated care to happen and deliver on the LTP, so we want people to do those roles who are really serious leaders, with experience of dealing with complex system challenges, and being able to deliver improvement across different organisations.

“We can still expect a range of people and backgrounds to come forward to do that. Just as we’ve got at the moment in the ICSs that have made progress over the last couple of years.” He cited Rob Webster in West Yorkshire, Sir Andrew Cash in South Yorkshire and Glenn Douglas in Kent as successful system leaders who have come from trusts (although only Mr Webster is still a provider chief, at South West Yorkshire Partnership Foundation Trust, in addition to being a successful and committed ICS leader).

Pressed on whether being an STP or ICS leader is now a full-time role, Mr Hardy adds: “It’s the capabilities of the leaders who come forward that really matters – their philosophy, their values, the way they want to work in an integrated way across the system matters hugely.

“The fact we’ve nailed our colours to the mast and said getting to ICS status really matters, and there’s a serious leadership job to do in systems that aren’t yet there, gives a fairly hefty clue about what we think about the nature of these roles.”

HSJ’s Integrated Care Summit 2019 will discuss ICS and much more, on 19-20 September in Manchester. It is open to senior leaders in relevant roles and sectors.