What ICBs need to do

06 February 2023

How ICBs can succeed in 'the mother of all storms'

Principal consultant Fenella McVey reflects on how integrated care boards are finding the time and resources to focus on prevention and the wider determinants of health while also coping with unprecedented challenge.

Integrated care boards (ICBs) have been described as having been born into the ‘mother of all storms’: political and economic instability, a cost-of-living crisis, a lingering pandemic, record waiting lists, record staff shortages and strikes, budgets eroded by inflation and threatened by further cuts, and a multiplicity of NHS England (NHSE) targets focused on near-term operational improvements, with few if any addressing the ICS aims.

Given the extent of immediate pressures, six months in, how have ICBs approached addressing inequalities and improving population health outcomes?

Integrated care board success factors

In our work supporting a range of ICBs, we have observed the following success factors:

For ICB boards:

  • Make time: start modelling future behaviours now
  • Accelerate learning: board boot camp

For ICB organisations:

  • Don’t overcomplicate – keep things simple
  • Don’t overextend or duplicate activities (best) done elsewhere
  • Address bottlenecks: streamline governance and ensure it supports new (system) ways of working

Make time: start modelling future behaviours now

In the pursuit of ‘earned autonomy’, many are prioritising meeting financial and operational targets in the first year so that they may have greater freedom for innovative and longer term thinking in future years. While there are obvious merits to this approach, it has led to tensions with partner members and non-executive directors.

Some local authority partner members have started to disengage as they see ICB board agenda dominated with acute health care issues, with scant or no time for community care or wider determinants of health. Relationships are further strained when the dominant (sometime only) topic on which NHS colleagues seek to engage with the local authority is hospital discharge. Similarly, some non-executive directors have felt frustrated by what they see as ‘the same old NHS’ agenda.

Other ICBs recognise that the operational situation and requirements are unlikely to be less demanding next year, and they need to start modelling their future self. This means ensuring ICB priorities and, correspondingly, the board agenda, seek balance between acute health, mental health, community care and the wider determinants of health and that budget and resource allocation starts immediately, if incrementally, to prioritise prevention over treatment.

Accelerating learning: board bootcamp

Boards typically develop over time, through shared experiences. As new entities, many ICBs are seeking to accelerate this process through board development programmes, including board boot camps, in which boards are presented with a series of challenging scenarios in compressed time, based on real issues. Accelerated learning is enhanced by mid-meeting self-assessments against the characteristics of highly effective boards. System thinking and system understanding can be further enhanced by discussing scenarios from the perspective of another board member.

Don’t overcomplicate/ keep things simple

In pursuit of ‘getting things right,’ it is easy to bite off more than one can chew and/ or over-complicate. As time has proven, across many walks of life, keeping it simple can be a great short-cut to success. We have observed two examples of this: one in data analysis and one in collaborative working.

Data analysis: in their pursuit of complex, AI-supported, population health management, some systems are missing quick wins from insights from relatively simple data analysis. For example, a simple analysis of appointment data typically reveals that a high proportion of secondary care appointments are one-off referrals with no follow-ups and a fraction of a percent of the population require multiple health and care home visits a day, which can equate to over 500 appointments a year per person. How much time could be saved if most of the one-off appointments with no follow-up referral were referred to an alternative practitioner, e.g. a physiotherapist? For those with complex needs, how might a multi-disciplinary team, drawn from across health and care providers, save on appointments and improve the patient experience by covering multiple needs in each visit?

Collaborative working: preparing for joint working with partners can suffer from the ‘hole in the bucket’ syndrome. It is easy to ‘over-prepare’ by seeking to establish a common language, align policies, align systems, etc. While these things might be helpful in the longer term, they are not necessary and several systems found that they became a barrier. Cutting to the chase and focusing on the shared benefit/ risk mitigation saved a lot of time and was more effective.

Don’t overextend/ duplicate what is (best) done elsewhere

Some ICBs are still operating in command-and-control ways, which can be very time-consuming, as well as not being in line with the principles of system working, subsidiarity and proportionate oversight. Other ICBs are focusing on their role as a ‘system convenor’, which is enabling them to find time to be more strategic. It also helps ensure that existing system infrastructure is used and helps avoid setting up new entities which duplicate what local authorities, VCSEs or NHS trusts/ foundation trusts already have in place. One example of this is the new ICB quality and outcomes committees, where key to establishing the right focus was establishing relationships with trust committees to assure their role and not duplicate it. They have also been successful where they have started to look at outcome measures, particularly population health datasets, and have sought to have more proactive public health and resident/patient involvement.

Some ICBs are benefitting from effective use of non-executive time. Some systems have a chairs group, where the ICB chair convenes a meeting with chairs of NHS trusts/ foundation trusts, sometimes also including chairs of other system partners, to help identify shared objectives and build relationships. Some have set up stakeholder management, where executives and non-executives have assigned system relationships to maintain and build. Interestingly, the highest impact often comes not from moving someone from neutral to champion but from moving a key stakeholder from negative to neutral.

Address bottlenecks: streamline governance and ensure it supports new (system) ways of working

Some ICSs are finding themselves slowed down by out-of-date, unclear, and/or cluttered governance. For example, schemes of reservation and delegation (SoRDs) that are out of sync with the organisational structure charts and/ or terms of reference, leaving it unclear where decisions are taken. A local authority described time being taken up discussing the same topic across multiple meetings, delayed decisions and frustrated system partners. ICBs should take the opportunity now to review and streamline their governance before processes and behaviours become entrenched.

Over the past two years, GGI has worked directly with well over a third of the 42 ICBs, supporting on strategy, governance and board and system development. If you would like to discuss how your ICB could increase its efficiency and effectiveness, please get in touch.

Prepared by GGI Development and Research LLP for the Good Governance Institute.

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