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

With the new year, in case you needed reminding, the clock ticks a little louder as we move towards the national integrated care system deadline of April 2021.

Fifteen months does not sound far off when you consider how many unknowns remain about what is expected from an ICS. And, if you make some basic assumptions of what’s required, how far some areas still have to go.

For many leaders I’ve spoken to over the last three months, the finances remain the hardest thing to square.

It has never been clear quite how a system steps up from working in “shadow” form to becoming a fully fledged ICS.

NHS England and NHS Improvement expect an ICS to have accepted a single control target for its health economy. However, to date only Dorset ICS has gambled all of its sustainability funding on meeting the collective control total.

All other systems, even those that have been accepted as fully fledged ICS such as Surrey Heartlands and Bedfordshire, Luton and Milton Keynes, have resisted pooling all their SF — keeping much of it linked only to individual providers’ financial targets.

This means that if one organisation fails to manage its finances, it doesn’t bring the rest down with it — but also, in principle, that the whole system sacrifices a (small) amount of extra transformation funding.

It shows how hard it is to get organisations to act collectively when doing so risks destabilising real-world income and activity.

Similarly, ICS leaders are raising questions about their responsibility for financial issues they feel they cannot resolve at a local level, and would not necessarily wish to.

Meanwhile, in systems with multiple clinical commissioning groups, some CCGs want reassurance that their five-year funding allocations as already issued will all be spent on their population, even as they come together across a wider patch.

Some parts of England are happy to work towards a system control total at “place” level — of populations between 150,000 and 500,000 — but are much less keen to do so across their wider ICS, especially where other “places” within have entrenched financial problems.

Others are concerned about the lack of clarity from the centre about how it wants “strategic” commissioning to be carried out in the future. 

“The system is too vague as to who is expected to do the commissioning of services, and there are too many different models being developed across different systems,” said one commissioner. “I don’t think NHSE knows what they want either.”

For systems with large financial gaps within them which are not going to be turned around in 15 months, it makes it very hard for them to gamble all on a system control total they know will be nigh impossible to reach.

Mid and South Essex Sustainability and Transformation Partnership said, at the halfway point of 2019-20, it expected to end the year £32m adrift of its planned control total. Similarly, Devon STP is forecasting to be £63.7m in deficit by year end, a £50.3m variance to plan.

Both were part of the “success regime” initiative for troubled health economies in 2015. MSE STP has said it will not become an ICS until April 2021, but Devon is hoping to go earlier than that.

If systems are expected to speed up their ICS development, they will need more direction on what it means to work to a system control total, among other key questions defining an ICS.

A national ICS guidance paper — previously expected late last year and now, hopefully, arriving in coming weeks — might bring a bit more clarity.

It was pushed back by the general election: So, too, it seems, was the finalisation of local systems’ five-year plans; and the national implementation programme for the NHS long-term plan.

The delays caused by the political upheaval, and the arrival of a government with a decent majority, could now be used to push back the 2021 ICS deadline — I wouldn’t be at all surprised if this was the case.

And without that delay, there’s high risk that the systems wrestling the most with these difficult financial decisions may become an ICS in name only.