What is meant by integrated care?
The term ‘integrated care’ covers a number of different models of care, however what they all have in common is that there is a close collaboration between NHS organisations, local councils and other providers (charities, not-for-profits, private companies) for planning and delivery of healthcare.
Integrated care can cover NHS care, including community care, urgent and emergency care, primary care (GP surgeries), and hospital care, and council services, including social care and public health.
Previously, models of integrated care have been discussed using several different names including accountable care organisation (ACO), integrated care organisation (ICO) and integrated care system (ICS).
NHS England abandoned the term ‘accountable’ in 2017/18 and in the NHS Long-Term Plan published in January 2019 only uses the term integrated care system (ICS) as a broad term to cover integrated care development.
Who will be in charge of the ICS?
The ICSs proposed by NHS England in the Long-term Plan will be run by a “partnership board” comprised of commissioners, trusts and primary care, with a non-executive chair vetted by NHS England and NHS Improvement.
Each ICS will have a single clinical commissioning group in charge of commissioning/buying services.
Seven new joint regional teams have been set up which are separate to and above the ICS. These teams are there to support the development of the ICS and the partnership boards.
Will the public have a say in how an ICS is run?
An initial examination of how an ICS will be run indicates that the public will have little input to the running of an ICS and there will be a loss of accountability compared to the current system.
The partnership board that runs the ICS will not have a public voice on its board nor will they be public bodies.
There is also no public representation on the joint regional teams, reducing accountability still further. These teams are not public bodies and there is no requirement for them to publish their papers.
How many ICS are planned?
The plan is for approximately 42 ICS across England, each of which will evolve from the sustainability and transformation plan (STP) regions.
How advanced is ICS development?
ICS development was included in all the sustainability and transformation plans published in 2016. In June 2017, NHS England announced ten areas to develop the first ICSs. A further four were selected in May 2018. The NHS ten year long-term plan envisages all of England having ICSs by April 2021.
The most advanced area is Dudley CCG but development here has stalled due to difficulties with contract legislation.
How will organisations work together in the ICS?
The NHS long-term plan outlines two possible ways organisations will work together in an ICS:
- Either the ICS can be delivered through collaborative arrangements between different providers, including local ‘alliance’ contracts, or;
- one lead provider (a prime provider) can be given responsibility for the integration of services for a population. The lead provider or integrated care provider (ICP), will use the new ICP contract, which for the first time will allow the integration of a large number of services, including primary care.
What sort of organisations can have a contract in an ICS?
A contract within an ICS can be held by any type of organisation – NHS, charity, not-for-profit and private. Although the long-term plans notes: “we expect that ICP contracts would be held by public statutory providers”, there is nothing to prevent a private provider holding an ICP contract. There will also be plenty of sub-contracts that can be held by any type of organisation.
Will ICS encourage privatisation of the NHS?
The long-term plan does nothing to discourage private companies having contracts in the NHS but as already mentioned NHS England envisage that the ICP contracts will be held by a public body. Outside of the ICP contract, however, there will be plenty of sub-contracts available.
The long-term plan calls for an end to compulsory tendering of contracts, through making changes to the 2012 Health and Social Care Act; this compulsory tendering was considered to be one of the major drivers of private company involvement in the NHS. However, the long-term plan keeps open the possibility that a contract tender will be used should the commissioning organisation think it’s best for the situation:
“We propose to free up NHS commissioners to decide the circumstances in which they should use procurement, subject to a ‘best value’ test to secure the best outcomes for patients and the taxpayer.”
It is perfectly feasible, therefore, for private companies to continue to be awarded contracts within the NHS.
The Independent Healthcare Providers Network, a group made up of private providers of healthcare, has welcomed the long-term plan’s aim to develop ICSs as they believe the emphasis on working with local partners will include independent sector providers. As the organisation notes:
“To further promote more integrated models of care, we welcome the Plan’s emphasis on the NHS working with its local partners, including independent sector providers, to produce and implement plans that meet the needs of local people.”
Is new legislation needed for an ICS?
Due to the 2012 Health and Social Care Act collaboration between commissioners and providers in the NHS. At present, there are very few options if the NHS wants to create a new NHS integrated care provider (ICP) to deliver primary care and community services for the first time under a single ICP contract.
As part of the NHS long-term plan, NHS England has called upon the Government to amend legislation in the 2012 Act to allow providers, such as trusts and other organisations, to be able to collaborate.
The request includes introducing legal “shared duties” for clinical commissioning groups and NHS providers on outcomes and finance and allowing foundation trusts to create joint committees, thus allowing “the creation of a joint commissioner/provider committee in every integrated care system”.
How will ICS be funded?
In December 2018, NHS England announced that control totals (these are equivalent to a fixed budget) will be given to all current ICS and STP for 2019/20 based on ‘system operating’ plans developed by the ICS and STP. These control totals are the sum of the control totals given to the individual organisations that make up the ICS or STP.
At present, it is unclear in the long-term how funding will be organised for an ICS.
Previous discussion on the development of ICS and integrated care organisations has revolved around the ICS or ICO having a fixed budget to provide all its contracted services. The positives of this approach is that the ICS is encouraged to focus on improving population health to reduce costly treatments and hospital use. However, fixed-budgets can also encourage methods to reduce costs such as rationing and encouraging patients to seek private treatment outside the ICS.