INTEGRATED CAR E SYS TEMS
Patients and clinicians will no doubt be delighted by the removal of bureaucracy and competition and wish for the action of locking in the gains made during the painful and challenging year for healthcare during the pandemic.
Integrated Care System Development
The development of ICSs is the latest set of policy measures designed to encourage closer partnership working between local NHS organisations, local authorities, voluntary sector organisations and others. In future, the partnerships will have greater collective responsibility for managing NHS resources and performance and for changing the way care is delivered. Some insight into the state of play can be gained by reviewing London’s developments. They have five ICSs which have been in place for around five years, during which joint working and relationships and understanding have developed. A report setting out how NHS England and NHS Improvement5
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the way forward identified four underlying elements which will underpin frameworks for care in all areas: l ICSs, bringing together commissioners and providers of NHS services with local authorities and other partners to collectively plan and improve health and care.
l Place-based partnerships between local organisations that contribute to health and wellbeing in smaller areas within an ICS – for most areas (but not all) ‘places’ will be based on local authority boundaries.
l Provider collaboratives, bringing together NHS Trusts and Foundation Trusts within places and across ICSs to work more closely with each other. The form these will take and their function remains to be seen, with further guidance expected in early 2021.
l The national and regional bodies, including NHS England and NHS Improvement, the Care Quality Commission (CQC) and the Department of Health and Social Care, which will increasingly work through systems rather than individual organisations.
These will build on work at the level of local neighbourhoods, where primary care networks (PCNs) will join up primary and community services.
The London context London is unique in terms of its population and the challenges it faces. Nearly nine million people live in Greater London. Among its diverse population of whom a third were born outside the UK, 300 languages are spoken and there is a high degree of deprivation. There are stark health inequalities, which has prompted the Mayor
to produce a health inequalities strategy,6 which focuses on five key areas. Healthy Children – helping every London child to have a healthy start in life by supporting parents and carers, early years settings and schools. Healthy Minds – supporting Londoners to feel comfortable talking about mental health, reducing stigma and encouraging people across the city to work together to reduce suicide.
Healthy Places – working towards London having healthier streets and the best air quality of any major global city, ensuring all Londoners can access good-quality green space, tackling income inequality and poverty, creating healthy workplaces, improving housing availability, quality and affordability, and addressing homelessness and rough sleeping. Healthy Communities – making sure all Londoners have the opportunity to participate in community life, empowering people to improve their own and their communities’ health and wellbeing. Healthy Living – helping Londoners to be physically active, making sure they have access to healthy food, and reducing the use of, or harms caused by, tobacco, illicit drugs, alcohol and gambling. At a sub-regional level, London set up five different ICSs. They were initially reviewed by the King’s Fund7
who found, in 2017,
that across all the ISCs there were: l Common ambitions across the systems to give greater priority to prevention and early intervention and to strengthen and redesign primary care and community services, as well as plans to reconfigure hospital services.
l Some proposals to reduce the use of hospitals and cut bed numbers were not credible on the scale proposed, particularly in the context of predicted population growth.
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l Plans to close the expected financial gap were also questionable, with a lack of detail on how this would be achieved and unrealistic expectations regarding efficiency savings.
l Much more needed to be done to engage with partners in local government and other sectors and to involve patients and staff in the work of STPs.
Since those beginnings, there has been change, development and more joint learning and working. Since that time, greater focus on clinical priorities has emerged with expectations identified as: l New community-based approaches to managing long-term conditions.
l New approaches to minimise hospital stays, e.g. through discharge models that maintain reductions in delayed transfers of care.
l Building on the shift to online delivery seen during the pandemic – ‘virtual by default unless good reasons not to be’ for primary care, outpatients and diagnostics.
l Further consolidation of specialist services and sharing of clinical support services such as pharmacy and pathology.
l An enhanced focus on tackling health inequalities.
There is encouraging evidence also that clinical groups both in acute care and the primary care networks are forming and making significant changes to the old ways of working, now that competition has gone and collaboration is the new by-word. Each of the ICSs is a bit different in its approach and collaboration with local authorities is working at a different pace in each of them, but moving forward, none-the-less. Public and patient involvement is also increasing although a comment is made that it is difficult to assess how inclusive of different
APRIL 2021
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