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

Luton council’s decision to pull out of one of the original integrated care systems raises the question of how, and in what form, councils are going to be involved in ICS as their national spread ramps up.

It’s a question which divides opinion.

In my last Integrator, I pointed out how the NHS long-term plan has downgraded ambitions for local government’s role in ICS, saying the NHS “will have a key role in working with local authorities at ‘place’ level” rather than at the higher “system” level, as has been attempted so far. 

Paul Burstow, the former care minister and long-time social care campaigner, is now chair of the Hertfordshire and West Essex sustainability and transformation partnership, so has one interesting perspective on these things.

He told me in a recent interview: “It would be a mistake to not see local government as having a chair at the strategic table of ICS development.”

He continued: “To position them as part of place but not in that strategic conversation is to misunderstand local government’s role as legitimising quite a lot of what we are trying to do at the population health level.”

The patch’s outgoing STP executive lead, Deborah Fielding, agreed, saying it would be “foolish” not to include councils in governance strategy as the area’s “population health strategy is so much based on the social determinants of health and the really key things that only councils can contribute to”.

But this is not a view shared by all.

In fact, the commissioning boss of one of England’s most important health systems made the point to me that the workings and accoutabilities of the NHS and local government are too incompatible for integration to be viable at the higher “system” level.

The NHS is answerable to national, upward-facing targets and regulations, and ultimately to the Department of Health and Social Care. In contrast, councils are led by councillors, who are elected by the public and often oppose changes they don’t think are in their public’s interest, making democratic considerations and calculations. 

The distinction between “system” and “place” in this context is that the former typically spans several top-tier local councils – making it particularly difficult to square their various and separate interests – while “place” often matches up to a single authority, making for a smoother relationship.

The view of this particular commissioning chief, who works across quite a few clinical commissioning groups, was they would not look to resolve the incompatibility of local government and the NHS across their whole system, but instead focus on developing place-based health and social care relationships within council boundaries.

This is the tack Bedfordshire, Milton Keynes and Luton ICS now has to take with Luton Council. The authority is happy to continue its established relationship with its corresponding CCG, but will no longer take part in wider ICS decisions, partly because of political disagreement with the new way of working.

(Both Luton Council and Nottingham City Council, which suspended involvement in its area’s ICS last year, are Labour councils; and therefore could have been coloured by the myth of ICS backdoor privatisation.)

Whether NHS England has a preference between the two approaches – or indeed is much bothered about the relationship with local government at all – is an interesting question.

There are some big developments coming up that will shape ICS/council relationships locally, and will bring into clearer focus what the centre is looking for.

An NHS England/NHS Improvement implementation paper is due soon which should give clearer details on how ICS are expected to develop, including when and how their partnership boards must be set up.

These boards can include councils but, perhaps mindful of the 2016 debacle when STPs were drafted and NHS England had to try to stop councils from releasing them, regulators have recognised they cannot force local authorities to take part.

Alongside this, we are expecting a consultation on potential NHS legislation which might offer routes to formalise ICS structures. This would likely have to exclude local authorities and could exacerbate the view that councils have little real role in ICS decisions and the NHS more widely.

It could also highlight the diverging approach to procurement between the two. While the NHS is now keen to circumvent the tendering process where possible, councils are largely wedded to routinely requiring suppliers to compete for contracts.

Finally is the better care fund, a long-standing bone of contention between councils and the NHS. BCF allocations and goals for 2019-20 are well overdue, and tension remains about the NHS’ demands in return for its money flowing to the BCF.

A national review into how the BCF operates has been ongoing for many months and its findings – which could easily stir up NHS/council relations further – are keenly awaited.