July 2022 sees the formal establishment of the Integrated Care Systems (ICSs) created by the Health and Care Act 2022. These bodies will integrate health and social care in England, with the aim of providing more joined-up services tailored to local needs. However, questions remain about how ICSs will function at place-level, particularly in terms of decision making and accountability at place level. Here, Melissa Surgey outlines how ICSs will interact with pre-existing bodies, where the gaps are in the legislation, and how policymakers in Government and the NHS can start to fill them in.

• Much of the day-to-day work of ICSs will be done at place-level, generally taken to mean local authority boundaries.
• However, place is poorly defined in the Health and Care Act, with subsequent gaps in the decision making and accountability framework of ICSs.
• Policymakers in Government, the NHS, and regulators must provide more guidance in these areas, while continuing to allow ICSs the flexibility to deliver localised services.

The Health and Care Act 2022 came into effect on 1 July 2022, cementing almost a decade of national policy focus on the integration of health and social care into legislation in England.

Most recently, the English NHS model of integration has focused on joining up services at different geographical levels:

• System (1 – 3 million population) – responsible for setting strategic direction at a sub-regional level, and developing economies of scale
• Place (250,000 – 500,000 population) – typically aligned with local authority boundaries, and responsible for the majority of primary and secondary health care and social care planning and delivery
• Neighbourhood (30,000 – 50,000 population) – a footprint for the organisation of multi-disciplinary teams to deliver preventative population health initiatives and primary care

42 Integrated Care Systems (ICSs) have been established as the vehicle for coordinating health and care. Each ICS consists of a number of “places” where local NHS commissioners, providers, the local authority, the voluntary and community sector, and other public sector partners should work collaboratively to integrate health and care on a scale closer to local communities.

It is important to note that while ICSs and place-based partnerships are a mandated policy initiative, partnership working on different geographical footprints has existed both formally and informally for many decades pre-dating recent policy trends.

What’s changing?

A key part of the Health and Care Act 2022 is the creation of Integrated Care Boards (ICBs) as statutory bodies taking on the responsibilities previously carried out by NHS Clinical Commissioning Groups (CCGs). CCGs previously operated on a place footprint, holding the budget for the majority of local health services. Their responsibilities included the planning and purchasing of health services to meet the needs of the population they served, as well as the oversight and assurance of the quality and performance of these services.

A notable change arising from the Act is the abolition of CCGs at place level and the assumption of their budget and statutory responsibilities by ICBs on a bigger system footprint. The expectation is then that these budgets and responsibilities will be delegated back to place-based partnerships, respecting the subsidiarity of place as the most suitable unit for planning and delivering services for local communities.

While the Act sets out statutory responsibilities for health and care commissioning, the wider landscape in which commissioners operate – and the role they play in this – is overlooked, and a number of elements of how ICBs and places will operate in reality remain unclear.

Defining place

Place is generally considered as being co-terminus with local authority boundaries. However, how these boundaries intersect with the service user flows of different health and care services presents complexities that challenge the ability to neatly define a population and its services. System and place health and care leaders appear to be in general agreement that basing place on local authority boroughs resonates the most with the public. Nonetheless, there are unanswered questions about how joined-up care would be delivered seamlessly to people whose lives do not neatly align with arbitrary boundaries, especially those living on the periphery of these. The need to draw boundaries somewhere is essential to act as a unit of planning and delivery for health and care services, but policymakers and health and care leaders should be wary of underestimating the impact sociological, historical and political factors have on how partners and the public engage with place.

What should be done where?

Commissioning encompasses a wide range of responsibilities related to the planning and oversight of health and care services. A key role of ICSs is to decide what should be commissioned by the ICB and what should be delegated to places. Although all ICSs have created a “function and decisions map”, these are generally high level and do not provide detail of what services will be commissioned at what level and the rationale for this. More mature ICSs and places appear able to navigate this adequately in the interim through the strength of long-standing relationships between partners.

However, ICSs and places should be cautious about the lack of clarity there currently is about what will be done where and by who, and the practical consequences of this when navigating contentious issues or crisis situations.

Policymakers and NHS England must ensure decision-making pathways are in place across regional and place levels, even if a degree of ambiguity around the decisions being made remains.

Who is accountable?

Superimposing new partnership bodies over existing sovereign organisations – such as local authorities and NHS trusts – creates ambiguity around who is accountable for what in the new health and care system. Although the ICS Chief Executive and a “single accountable person” for each place are mandated roles, accountability mechanisms beyond this remain vague. In many ICSs, system issues arising are currently resolved by relying on the goodwill of existing relationships between partners. While relationships are undoubtedly important, ICSs and places struggle to clearly articulate any safety net underpinning these should they break down, or what recourse would be possible if a partner does not act in the wider system’s interest.

Given that ICBs and places have now taken on statutory responsibility for the planning and oversight of health and care services, it is imperative robust and practical accountability frameworks are established, while still building upon partnership working values and behaviours. There appears to be little appetite from local leaders for any further highly prescriptive national guidance, so allowing individual places and ICBs to develop these locally in line with some high-level universal principles may be the most amenable and practical approach to this.

ICSs and place-based partnerships are reporting positive developments in integrating health and care. In many cases, they are more formal embodiment of collaboration that has evolved over a number of years. During this time, it is understandable – and even advantageous – to maintain a degree of strategic ambiguity while partnerships are in their infancy. However, as these new bodies take on very real and important legal responsibilities that directly impact patient care, it is essential that the spirit of collaboration is held up by clear and robust processes explaining how the new system works in reality.