Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by integration senior correspondent, Sharon Brennan

With sustainability and transformation partnerships needing to convert into integrated care systems in the next 15 months, HSJ has had another look at how the leadership of these is developing.

There are some overt signs that leadership is bedding in. All but two systems have a chair (37), or are in the process of recruiting one (three). And although a slow shift, leadership of these systems has remained stable in 74 per cent of STPs/ICSs in the last six months.

While this is only a five percentage point increase in the number of systems that had the same leader in place in July 2019, it is a big drop compared to leadership turnover of 70 per cent in the early days of STPs.

But as some of the pieces of governance fall into place, new ones emerge, especially about how integrated care partnerships fit into an ICS.

ICPs are even more nebulous entities than STPs. They are roughly defined as groups of providers working together in a local patch to redesign and deliver vertical pathways.

They are being developed in part to make the footprint of an ICS more manageable. When we surveyed ICSs/STPs we found that 23 of them are now looking to set up a total of 84 ICPs between them. Mostly they seem aligned to ‘place’ geography, although it is not yet clear if their population sizes will match NHS England’s description of ‘place’ as covering 150,000 to 500,000 people.

To confuse matters, they not “integrated care providers” as defined by the formal contract developed by national leaders in recent years. That is proving unpopular as most areas are uninterested in going through the complexities of tendering the contract when they believe a more informal partnership approach will deliver what they are looking for.

Among those I’ve talked with about these informal ICPs, there seems a general consensus that their development is positive but there is very little direction from the centre as to how they should operate.

One source told me that a real barrier could be who leads them – some are mooting a person employed by a clinical commissioning group who has the commissioning experience.

However, with our recent analysis showing that an accountable officer of a CCG is currently the most popular choice for leading an ICS, that could intensify concerns about whether this new landscape is actually bringing about real change.

One senior leader in an STP/ICS warned that identifying “the CCG with the ICS by having the same leader can be seen as maintaining the provider/commissioner split, when they are meant to break down that split”. This would be true twice over, if they also led the ICPs.

Alternatively, I’ve been told relationships between trusts could be a “barrier” for ICP development if they are to be led by a senior trust leader. It is tough for trusts to overcome the embedded instinct to compete, rather than collaborate, and this would be harder still if a lead provider model is adopted in which one trust takes on the risk and farms out parts of the contract to others.

There is also a growing risk that by encouraging partnerships between statutory organisations it becomes harder to see how to meaningfully involve the voluntary and independent sector - the latter clearly exposing the thorny issue of how to maintain patient choice in a world of agreed partnerships.

One source that has been working closely with these emergent systems also warned that if ICPs are led by trust chief execs, leadership within an ICS will end up very middle-heavy if the strategic commissioners do not attract bigger names to lead them.

However, improving leadership balance within an ICS is where we may see some real change in 2020.

To a degree, the combination of CCG role and STP leader is helping to boost the perception and glamour of the role. One person told me that the recent appointment of Wilf Williams to lead Kent and Medway’s merging eight CCGs, and most likely its STP too, suggests these roles are starting to attract bigger names. “He seems well respected and I couldn’t imagine him returning from Australia to head up a single CCG,” I was told.

The future leaders’ programme, now in its third year, is also beginning to produce a different style of provider leader – “They are no longer the big beasts, and more interested in collaboration than looking at their own organisations at any costs”, the same source said.

To date most ICPs are in the very earliest stages - there is currently a commitment amongst provider organisations to work together. In the future a move to a clearer form of governance and contract negotiation will be likely, but before then getting the structure, purpose and leadership of ICPs right will be essential to their success.