The evolving role of county authorities in Integrated Care Systems

The NHS and local authorities in England are facing immediate and immense pressures as we head into winter. Systems are handling intense demands in managing recovery from Covid against a backdrop of a cost-of-living crisis, rising demand across services, profound workforce challenges and funding restraints.

These pressures and the pandemic itself have highlighted the importance of collaborative working between health and social care services. Be it discharge pathways, population health management or their roles as anchor institutions for communities, the mutual dependencies between councils and local NHS services are in sharper focus than ever before. The formal introduction of Integrated Care Systems (ICSs) in July 2022 offers a path forward for driving greater collaboration between councils, the NHS and the voluntary, community and social enterprise sector.

Given the significance of the changes that ICSs bring for their members, the County Councils Network (CCN) asked IMPOWER to review the emerging role of county authorities within these systems and provide a stocktake on progress. We were delighted to accept. As a company we are acutely aware of not only the challenges that organisations face in working together but also the inspiring results that can be achieved when they overcome these barriers.

ICSs have been considered extensively from the perspective of the NHS. However, we believe that this report is the first to consider these systems from the perspective of councils, whose role is central to the integration agenda. While the statutory basis for ICSs is now fixed, how they operate in practice will continue to evolve over the next few years. Our research covers three key themes which will be crucial to that evolution: governance, strategic delivery planning and culture. We hope that the findings and recommendations in this report are useful to councils, their NHS colleagues and central government, as partners in ICSs continue to grapple with shared challenges to provide the best outcomes for their citizens.

RECOMMENDATIONS

Strategic policy recommendations

1. DHSC and NHSE need to fundamentally review the level of centrally mandated activity and targets in policies and funding requirements, particularly in shared policy areas, to ensure that they are consistent with the principle of locally-driven strategies.

2. In further developing integration policy, DHSC and NHSE should review mechanisms to strengthen local, rather than national, lines of accountability, for example through further devolution deals.

3. The role and future of “Place” needs to be refined locally by ICBs and local government, with clear delegation plans that support the principle of subsidiarity – that issues should be tackled at the lowest level possible to handle their resolution. This is particularly important for ICSs with multiple LA partners.

4. Council and local NHS leaders should agree a small number of specific and achievable inclusive ambitions ahead of the next financial year, through their ICP. This should build partner confidence in Integrated Care Systems’ ability to deliver real change.

Expenditure and outcomes

5. ICBs and LAs should report together annually on ‘out of hospital’ health and related expenditure. NHSE should also report annually on out of hospital expenditure, by spending type. This will enable local benchmarking and is already occurring nationally in Scotland.

6. DHSC/NHSE should agree, in consultation with local government, a small number of proportionate metrics to track performance of services at the margin of integration nationally. These should be quality assured for consistency. ICBs and LAs should agree and report on their own local metrics for local priorities.

Governance

7. ICBs should make clear arrangements for oversight of major decisions with local authorities, as a minimum covering budget allocations and significant service reconfiguration. This is needed to protect council partner members from conflicts of interest in their roles on ICBs and LAs and is particularly necessary for councils sharing ICSs with multiple other councils. It is also needed to ensure that decisions have sufficient political input.

8. DHSC and NHSE should review ICS boundaries after a year of the legislation coming into force. In particular, for councils spread over multiple ICSs some arrangements will become less and less workable over time.

9. LA Scrutiny Committees should set out their expectations to ICBs, considering joint sessions where they share an ICS with other councils. ICBs should be clear on the information that they will provide to local scrutiny committees. Each LA and ICS will need to agree its own arrangements, but scrutiny should be proportionate, co-ordinated and useful. There may, for instance, be occasions when it is appropriate for scrutiny committees to meet with NHS and LA colleagues simultaneously to discuss shared issues.

10. NHSE and its regional teams should be clear on the role of LA feedback in ICB chairs’ appraisals. The ICB chair role carries significant power in ICSs and can only be changed with the Secretary of State for DHSC’s approval. As such, LAs should be able to provide feedback on the work of the chair.

11. ICB chairs should review ICB membership annually, drawing on experience from other boards. We found no reason for membership to remain static and that lone council voices on ICBs felt overlooked in discussions which could undermine their input. For LAs working with multiple other councils, a lack of local representation is felt to be particularly problematic. Decisions on political representation were often taken based on outdated central government guidance and this should reasonably be revisited.

12. DHSC should review the statutory requirements of Health and Wellbeing Boards and ICPs to allow for pragmatic working arrangements that minimise duplication. In the interim, where possible, LAs should agree clear divisions of responsibility between ICPs and HWBs, as well as rationalisation of their roles to minimise duplication.

Strategic Delivery Planning

13. ICPs should agree a small set of achievable priorities for partners in ICSs for 2023-24. Trying to do too much initially when decision-making and delivery are yet to be tested is a significant risk to long-term system engagement. Focussing on a narrower set of aims will generate confidence in the ability of system partners to deliver meaningful change and create a virtuous cycle for further action. In each case the “positive externalities” that integrated approaches will bring should be quantified for each partner. What this could mean in practice is set out separately.

14. ICPs should agree in advance with ICBs and LAs how they are expected to demonstrate “regard” to the IC Strategy. One option would be to ensure that the chair of the ICP is a full member of the ICB. There is a risk of disengagement with the ICP if strategies are not seen to drive real change, particularly in budget setting. For the NHS, IC Strategies should act as a local counter-balance to demands on ICBs from NHSE and DHSC.

15. DHSC and DLUHC should clarify the future approach to pooled funding and grant allocation between councils and ICBs. Recent evidence, such as the ASC Digital Transformation Fund and £500m for hospital discharge, suggests that central government funding for ASC services may be routed through ICBs rather than going to LAs or pooled funds such as the BCF. This undermines the principle of partnership working between the NHS and councils.

16. ICB chairs should review ICB agendas and ensure these are appropriate and sufficiently focussed on the long term. ICB time should meaningfully focus on non-operational, strategic and transformational issues that take advantage of the expert skills and knowledge of attendees. Core NHS operational issues should be delegated to sub-committees where necessary.

17. ICBs should define the geography, role and medium term future of place-based partnerships including delegation, in agreement with LAs. Formal delegation may not be appropriate, however certainty over medium-term arrangements will support planning and this is particularly important for councils sharing their ICS with multiple other councils.

Culture

18. ICBs and ICPs should carry out proportionate board development exercises. There is clear value in these and where we found examples in our research, they were welcome, however these need to be proportionate. Our research indicates that there would also be particular value in improving NHS partners’ understanding of councils’ resources and responsibilities.

19. LAs and NHS/ICB partners should focus organisational development at the management level. This level appears to be a key point of tension across boundaries and local leaders need to develop a vision with shared values and priorities. Core to this is building trust between the different organisations.

20. Councillors should agree parameters with ICB chairs for regular engagement outside of formal governance arrangements. This should enable an exchange of views on LA and NHS priorities as well as how to manage these in the local political environment. It is also essential to developing the trust required for effective partnership working. ICB chairs and ICP chairs should make information available that explains their work to local politicians, enabling councillors and MPs to be able to justify and explain the work of these bodies to their various constituents.