ICS design – good governance will be key

The Integrated Care Systems: Design Framework gives local leaders space to implement positive change – but success will depend on courage, collective action and strong support.

The publication of the Integrated Care Systems: Design Framework by NHS England takes the country a step further towards healthcare reform. Importantly, it provides a lot of space for local leaders to take hold of implementation in a positive way.

Adopting the right mindset, so that system reform is seen as developmental, as part of local stewardship responsibilities for health and care, rather than about following central diktat, could make these reforms excitingly different.

But this will require local leaders to be brave, to act collectively and to be well supported by practical tools and resources. These will need to embody the principles and the precision of good governance – something that has been explored in the GGI ICS series of webinars and now needs to be put into practice.

There are also clear limits to local agency. As expected, the design framework sets out how the NHS, local authority and other partner organisations in ICSs will be expected to operate from April 2022. It provides welcome functional detail, absent from the White Paper published back in February, particularly around timescales and structural relationships and governance arrangements.

Systems, structures and processes

In terms of structural governance, the guidance details the standard form of a statutory ICS.

ICS partnership

• The ICS partnership will be a joint committee of both the ICS NHS body, each local authority with public health responsibilities within the place of the ICS and some VCSE organisations.

• The ICS partnership will lead on aligning ambition, purpose and strategy across partners and will be responsible for creating the integrated care strategy for the ICS.

ICS NHS body

• The ICS NHS body - with a focus on planning, allocating resources and ensuring the delivery of services in place to meet the outcomes of the population. The governance of these bodies will need to afford flexibility to operate in a way that reflects the local context through place-based partnerships and provider collaboratives.

• The NHS body will develop a plan to deliver on the ICS strategy set by the ICS partnership.

• It will have a unitary board made up of executives, partner members and independent non-executive directors.

• Ultimately the NHS body will be responsible for the ICS addressing health inequalities, enhancing productivity and supporting social and economic development.

However strong relationships may seem already at system level, getting these arrangements to work effectively will demand tough organisational development and require trusted support.

The guidance also goes beyond statutory requirements to identify some initial success criteria. These emphasise elements of good governance around culture, inclusivity, consensus, communication and engagement, which have been overlooked in the past.

Engagement

It is good to see the design framework insisting that embedded engagement with people and communities is essential to success, alongside the expected emphasis on a core financial framework. This has to be right to deliver local legitimacy as a determinant and an outcome of local change.

But this will be tough to land with integrity as part of local governance arrangements. Connecting disparate voices into the heart of governance in a meaningful way is another huge developmental challenge left to local leaders to deliver. This requires engagement with local communities to be much more visible now in the way systems are developed.

Flexibility

ICSs appear to have been given scope to design placed-based partnerships tailored to meet local needs, for which the guidance suggests potential models. Each ICS will be unique; there will be many models, not one.

But this is very much a national reform, attempting to square away life beyond the pandemic and set a tone for the next election. It would be naive not to see the political intent, especially given the timing of the speech from the Secretary of State about creating the best healthcare system in the world. This should not deflect leaders from pursuing local innovation and ownership, however.

Culture

The cultural shift which the guidance promotes is about moving from competition to collaboration, about agility and pace in decision-making, about working in partnership at place level and about transformation.

The reality is that local leaders face the prospect of carrying the burden of reform at a time when they are having to address many years of accumulated backlog in demand and hold together a hard-pressed workforce.

The big questions to address locally will be about capacity building and deployment of skills, as well as growing a collective mindset and risk appetite, which is focused on achieving local reform with its own character.

As Professor Sir Muir Gray said at the recent NHS Confed conference: “This is a cultural revolution, not a structural reorganisation… we need to rewire the way people think.”

It's time to flip the script.

Illuminations

• Good governance is about more than just processes and structures. It is about people and culture and the ICS guidance opens the door to local good governance provided the right mindset and capacity are devoted to it now.

• Systems will need a lot of practical support to take the opportunities in the interests of local populations.

• GGI is already gathering together the resources and tools which will help.

The timescales are challenging, there is a lot to be done. GGI is here to help navigate this important journey towards integrated care. No one is better placed to advise you. Find out more about how we can help.