The Integrator: ICBs in limbo and under pressure

Nearly two weeks on from the announcement of seismic cuts to integrated care boards, there’s barely a squeak on key details such as which functions should be targeted and which should be spared, or how the reductions are to be apportioned around the country. 

Clearly, there was no plan in place, and a fortnight isn’t long to determine such existential questions. But nor is the little over six months left before ICBs are – in theory, at least – meant to deliver those cuts. Which involve drawing up organisation plans, consulting on them, and managing HR processes for a huge number of job changes and exits. 

With this comes the likelihood ICBs will have to backpedal on crucial work, work government will be relying on to implement its upcoming 10-Year Plan, expected in May or June, when ICBs will presumably be well into the cuts process.

On the chopping block

Dame Patricia Hewitt, former Labour health secretary and chair of Norfolk and Waveney ICB, expressed the depth of the pain of many ICB leaders, telling HSJ she fears they “will struggle to fulfil their statutory functions” after the restructures. 

These legally required tasks (which are essential to patients, and system flow), include Continuing Healthcare assessments, safeguarding, and managing the care packages of patients with very complex needs). These add up to a big chunk of ICBs’ staffing.

Mergers of functions and leadership with neighbours – and potentially formal mergers, too – are likely if ICBs are going to have a fighting chance of continuing statutory functions.

But in turn, the prospect of centralisation raises big questions of whether local partnerships, place and neighbourhood work, central to the public service reform and prevention which many see as ICBs’ core purpose – can be protected.

Sarah Walter, ICS Network director at the NHS Confederation, tells me: “There is a real risk that this will lead to cuts in some areas that are anticipated as an important function for 10-Year Health Plan implementation.

“For example, place-based arrangements and support for developing neighbourhood working capacity, which I think are at the heart of delivering that local neighbourhood health model.”

Many systems have dug in on developing neighbourhood teams over the past year or so, building them up from local work over many years. But maturity varies significantly – many areas have little by way of formal arrangements or substantive services. While the national guidance sounds straightforward and familiar, actually delivering it is a world away. There is still much work to do, and for ICBs there will be decreasing headspace to do it.

Recent history from the last round of cuts, which ICBs are still reeling from, shows these most subsidiary levels are often the natural target when push comes to shove.

“In the absence of anyone having said, ‘We’re going to remove some of the huge number of statutory duties that ICBs need to be delivering’ – which don’t cover things like neighbourhood health – it becomes very, very difficult,” adds Ms Walter. 

Fork in the road

Among the burning ruins, some are looking for the least bad way out. Tom Shakespeare, managing director at Brent Integrated Care Partnership in North West London, told me the cuts could – if approached in the right way – be an opportunity for place. 

“There’s a choice here now. We could either be distracted and subsumed into this, or we could see it as an opportunity to build something different,” he says. 

The ICP’s “Brent health matters” programme focuses on community outreach and population health management to tackle its high levels of deprivation and complexity, working with GPs, public health and mental health. The area’s emerging integrated neighbourhood teams are built off the back of this work. 

While nascent INTs help make place-based work “business as usual”, adds Mr Shakespeare, an “investment in change capacity” is also needed “because it’s not going to happen on its own”.

This includes business intelligence support for population health, workforce development and training, and support from providers to tackle inequalities in existing services provision, which will be needed from somewhere if ICBs are no longer going to have the capacity.

Although trusts have also been told to cut 50 per cent of corporate costs, an emerging shift in power towards providers could provide a natural home, Mr Shakespeare argues.

An increasing adoption of lead provider contracting and development of vertically integrated providers is anticipated. It could help fill the leadership and resource void around place and INTs.

Some working in the community are much more wary of large trusts, especially acutes, and may look instead to joint working with councils, or developing existing large-scale primary care providers.

But Mr Shakespeare says providers and place could work “much more effectively together”, for example because they can naturally draw organisational frontline teams together.

“If what comes out of this is a recognition of place and providers being the engine of change, there is an opportunity for us to be much smarter with the resources that we’ve got and whatever resource is left.”

Provider collaboratives are usually limited to a single sector – such as acutes and mental health – but opening this up to more vertical cross-sector and place-based working is likely the natural next step. They will need to develop trust and overcome resistance with place-based partners, not least primary care, but successes in pockets of the country suggest it can be done. 

“The risk is that we could lose a significant portion of the ICB resource that supports place, but I say we should be doubling down on our collective commitment to place,” adds Mr Shakespeare.