The Integrator: The five lessons from the second year of ICSs

There’s a lot of rich detail in our survey of integrated care board leaders published today, showing where ICBs are at in 2024, what they’re doing and how, and what might help them achieve it.

It’s well worth a look at their detailed responses covering: how they’ve made an impact so far; what their plans are; and their views on the biggest barriers/enablers.

Here are five lessons I think can be taken from the results:

1. It’s a myth that ICBs are doing nothing about prevention and communities. Asked about their biggest improvements to services so far, there were numerous mentions of reducing inequalities, community development, population health management, secondary prevention initiatives, and links with local government.

Examples include cardiovascular prevention “interventions in primary care, community assets and digital,” which are improving outcomes; hubs in farmers markets to reach homeless and excluded people in rural areas; “community development workers aligned to neighbourhood areas”; and support/development to help VCSEs thrive “in the competitive commissioning environment”.

Has this demolished historic walls between the NHS and other spheres? No. Does it extend as far as shifting significant resources into non-NHS services or even into upstream care? So far, there’s little evidence of it, although half of ICB leaders claimed they’d increase VCSE spending in 2024–25, and nearly 60 per cent said they’d delegate significant budget to “place”. 

2. Nothwithstanding the above, three NHS crises — finance, performance and workforce — dominate the big decisions. Drastic system spending controls are already widespread, and these will now be tightening further and spreading nationwide. Counterproductive and painful decisions, like the 32 per cent who expected cuts to substantive clinical staff, are also likely to be multiplying as 2024-25 budgets are settled.

The most common theme cited in ICBs’ biggest successes so far, mentioned by 14 respondents, was work to bolster urgent and emergency care. The next were efforts on NHS retention and recruitment.

One ICB CEO spoke volumes when, declining to respond to the survey, they said it was “out of touch with our reality” to even discuss service improvement and staff retention, while in the grip of deficits and ICB staffing cuts.

3. These are old, NHS-focused problems. But ICBs are using new levers and tools against them. In finance, this system approach involves open-book scrutiny, whether on budgets or productivity measures, and “triple lock” signing off on spending.

In UEC it means — in two examples — “integrated pathways that include urgent community response, virtual wards, frailty hubs and acute illness hubs” and “reducing patients waiting for discharge through joint working with the council, focusing on increasing homecare reablement”.

ICB leaders also say they’re getting dividends from system leadership and management. On finances in particular, one cites “proactive finance director liaison and cooperation focused on savings and productivity”; another CEO reports: “Increased empathy, understanding and transparency is helping, but also a recognition that if we don’t live within our means, we will never be able to protect transformation funding and improve in the longer term.”

4. More contentiously, many systems are also leaning heavily on consolidation across providers, by which I mean “combining several things” with the aim of becoming more effective — normally while also removing costs.

Some argue this is the preserve of larger ICBs and was encouraged by my questions. But a large majority, including many in smaller systems, say they’re planning more shared staff, back-office/support teams, and waiting lists.

Several leaders said their biggest achievements so far included trust mergers, groups or collaboratives. Forty-one per cent plan more of this, and 75 per cent want it to be accelerated nationally.

But where is the line — and what’s the right balance — between integration, collaboration, consolidation, and merger? Many others, particularly in smaller providers, will disagree that continuing to weld them together is the answer. The issue will continue to spark fierce debate.

5. There’s surprisingly strong support for some contentious policies: dropping data sharing restrictions; further reform of clinical training, including an NHS “tie” post-qualification; further clipping of foundation trusts’ wings; restricting access to accident and emergency (presumably allied to a very different emergency care model); and reducing public consultation.

If the respondents are right, a minister willing to spend political capital on those policies could make some headway without burning cash and get ICB leaders behind the cause. There are signs, too, of emerging plans for longer-term service reform, with common subjects including: children’s services, mental health, autism and ADHD, frailty, and digital access.

Just as telling, though, are the policy issues that split opinion.

On GP reform, the national contract is, as ever, seen as a barrier, but there’s no majority for tearing it up. Nearly all ICB leaders say they have or will be creating “integrated neighbourhood teams”, but only half support these ICB-designed INTs replacing primary care networks, presumably favouring more continuity and less disruption. 

Just under half think removing NHS England regions, with ICBs taking on full performance management of trusts, would be helpful; 36 per cent say it is unhelpful.

NHSE is clear this is not its current path, as underlined in its new assessment framework, which nudges ICBs to focus on their “unique contribution” and do less marking of providers’ homework. It appears to be the direction that seems to be preferred by Wes Streeting too.

Asking ICBs to focus squarely on prevention and reforming primary and community care might appeal to many, not least many ICBs. But their interactions with secondary care providers — including challenges and disagreement — will remain key to achieving their aims, as the findings above make clear.