With the long-term plan imminent, Niall Dickson discusses the challenges facing STPs/ICSs and ways to address them, especially through increased freedom for local systems

Joined up

As NHS leaders await the arrival of the long-term plan, we expect this new strategy to signal “make or break time” for local systems working in health and social care.

We know there is support for system working as an approach: when we recently surveyed leaders of NHS commissioner and provider organisations, six in 10 (61 per cent) of the 64 healthcare leaders who responded told us they agree sustainability and transformation partnerships and integrated care systems represent the right approach for partnership working between the NHS and local government.

But we also know systems are hard to establish: the vast majority of NHS leaders (86 per cent) told us only “moderate” or “a little” progress had been made implementing the vision of the Five Year Forward View in their area.


Our survey results show that achieving a breakthrough in the quality of system working must be a joint endeavour between local and national leaders where everyone has a part to play. The journey is far from complete and there are deficits both locally and nationally that need to be addressed.

Our survey highlighted poor levels of public engagement in STPs and ICSs, a need to do more to ensure local government and the independent and voluntary sectors are fully involved in local systems, and to improve accountability arrangements.

These are not simple challenges and NHS leaders, along with their counterparts in local government, are being expected to address them while also dealing with their “day jobs” (in other words running hospitals, commissioning organisations and local government services). To do so is no mean feat, and we need to remove every obstacle from their path in order to support them as best we can.

Large numbers of reporting requirements that focus at the organisational level can hinder this progress, as can overly specified financial control requirements. We are, therefore, pleased to see indications that some of these existing requirements may be reviewed in the coming months.

Both the NHS and social care are facing enormous challenges. Increasing numbers of people rely on these services and funding is not keeping pace with demand.

Our survey highlighted a need to do more to ensure local government and the independent and voluntary sectors are fully involved in local systems, and to improve accountability arrangements

The 3.4 per cent annual increase in the money for the NHS that the prime minister announced earlier this year is welcome, but economists have calculated that a minimum of 4 per cent is required to drive improvement.

Social care services have not received a similar funding uplift and these services are becoming increasingly unstable.

Meanwhile, the challenges that local systems face – such as growing multimorbidity, increasing numbers of frail elderly people and the effects of deprivation – do not relate naturally to existing organisational or sectoral boundaries.

Leaders need to be able to work together across these boundaries to design solutions that make most efficient use of the facilities, resources and staffing structures in local areas.

So far, we have tended to talk about the need for this kind of devolution at a service level, but to hold back from taking the risks required to give it the best chance of succeeding.

This is understandable: every person working in every part of the health and social care system – including at the arm’s length bodies and regulators – does so with the goal of the best possible services for patients and service users in mind.

Support local systems

But if the current way of answering these questions is not delivering the results we need, we need to ask ourselves whether our caution – which comes from a desire to avoid big bang changes and the risks associated with them – is becoming part of the problem.

We are, therefore, calling on the long-term plan to support local system working by:

  • Making support for effective local leadership and relationships a priority;
  • Focussing attention on the key factors that will allow local improvements to health and social care services;
  • Shifting the focus of regulation from performance management to improvement support;
  • Supporting local systems to strengthen ownership in their communities of the long-term plan vision.

We recognise that we are calling for increased freedom for local systems at a time when the health and social care service faces significant challenges – and that this may feel counterintuitive.

This request for greater freedom comes with a quid pro quo. For this to work, local leaders will need to work harder to implement these new ways of working and embed local accountability mechanisms

But if the logic of the Five Year Forward View and the STP/ICS movement is that the serious systemic problems facing the service will only be addressed via close partnership working at a local level, we feel it is important the entire NHS puts every effort into making these local approaches successful.

Otherwise, we risk stifling potential solutions through fear of the scale of the challenge.

This request for greater freedom comes with a quid pro quo. For this to work, local leaders will need to fulfil their part of the deal and drive forward the implementation of these new ways of working, while working harder to embed local accountability mechanisms.

With the right support and accountabilities in place, we consider these highly experienced and committed senior staff are the people with the greatest chance of delivering the right changes for local communities. In the absence of any other solutions, it is now time to let our local leaders lead.