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Still early days? The development of Integrated Care Systems

08 November 2024
Dr Marie Sanderson is a policy analyst and organisational economist based at the London School of Hygiene & Tropical Medicine, and is part of the PRU HSSC Management Team



Since 2015, health care policy in England has shifted away from a focus on competition, as a way to drive performance towards more collaborative and integrated ways of working. Integrated Care Systems are at the forefront of this shift, intended to ensure better collaboration between NHS organisations and other NHS partners such as Local Authorities, and the voluntary sector.

Formal responsibility for managing the NHS budget and working with local partners to plan and deliver integrated services sits with Integrated Care Boards (ICBs), while the wider Integrated Care Partnership (ICP) brings together the NHS, Local Authorities, and other key local partners to develop long term strategy around health and wellbeing.

This collaborative approach is based on the belief that when local partners can agree plans together, they can create better services to address local needs.

ICSs have four core responsibilities:

  • Improving population health and healthcare
  • Reducing health inequalities;
  • Enhancing productivity and value for money
  • Helping the NHS support wider social and economic development.

However, there is not much evidence about how this approach to decision making is working in practice.

Given the significant role that ICSs are now expected to play in NHS recovery it is important and timely to consider what we know so far.

Our recent study The Architecture of System Management (2022-2023), investigated how governance, accountability and decision-making arrangements are developing in ICSs, to support the achievement of system goals. Our research was based on case studies of three ICSs (out of the 42 in England) in 2022/23.

Important principles underlie ICS’s co-ordination of decision making between local partners:

  • Subsidiarity: decisions should be made closest to those they affect
  • Consensus: decisions should be agreed by everyone
  • Local freedom: ICSs should be able to structure decision making in a way that works for them locally
  • Best for system: partners should make decisions based on what is best for the system as a whole, not their individual organisations.

In addition, ICSs must try to co-ordinate partnership working with bodies which they do not have power to direct.

We found that, in our three case study ICSs, representatives of system partners were in favour of the collaborative approach. They agreed that they should put the interests of the system as a whole first when making decisions, and that making decisions together would lead to better decisions overall.

However, in practice the three ICSs were facing considerable challenges in deciding how decision making should be organised, and governance arrangements were still under development. Decision making arrangements were complex, and could be confusing, with significant duplication at times.

Importantly, it was not always clear who was responsible for making which decisions. Some interviewees were concerned that in practice the principle of subsidiarity was not being adhered to, and control over commissioning and resource allocation was not being given to local decision-making groups.

ICSs were facing very difficult decisions in the face of limited resources and increasing demand for care.

Taking such decisions together was made more difficult by the fact that individual organisations are still being performance managed for their financial performance separately, and it was not certain that this consensus approach would be sufficient to address these issues.

While Integrated Care Systems were only formally established in 2022, local system partners have been working together since 2017 when Sustainability and Transformation Partnerships were set up to support partnership working across local health economies. In spite of this, we found that collaborative decision making arrangements in ICSs are still under development.

It clearly isn’t easy to work together in this way, and questions remain about whether the collaborative ICS model will be able to address the considerable challenges facing systems.