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A year of integrated care systems: reviewing the journey so far

The development of integrated care systems (ICSs) represents a fundamental and far-reaching change in how the NHS works, both between different parts of the service and with external partners. The evidence reported here shows that progress is being made in most ICSs in improving health and care and developing the capability to work as a system. The challenge now is to build on the foundations that have been laid by removing the barriers we have identified and providing time and support to ICS leaders to take their work to the next stage of development.

Having willed the ends, national bodies must provide the means to enable ICSs to succeed. As this happens, the understandable desire to see change happen quickly needs to be married with realism about the scale and complexity of what is being attempted.

Where are we now?

  • ICSs vary widely in their size and complexity and have focused in their first year on building the foundations on which to improve health and care for their populations.
  • ICSs have used the freedoms they have been given to explore what it means to work as place-based systems, both within the NHS and between the NHS and local government.
  • ICS leaders have been learning about system working on the job, including the need to lead differently to deliver their ambitions.
  • Much of the work of ICSs to date has involved establishing the governance, collective leadership and staffing needed to work as systems, and engaging with stakeholders such as local authorities in their communities.
  • Early changes in service models include work to strengthen and integrate primary care and community services and to review how specialist services are delivered in some areas.
  • ICSs also report that they are working more collaboratively to manage finances and performance across the system in a way that was not happening previously.
  • Larger ICSs are working through neighbourhoods and places as well as across the whole system to improve health and care, building on the work of the new care models programme and related innovations, and emphasising the principle of subsidiarity.
  • ICSs that are furthest ahead in their work are those that were already working as systems and have given priority to strengthening relationships and trust between partner organisations and their leaders.
  • Some ICSs have found it more difficult than others to establish common cause among partner organisations, either because some NHS organisations have been unwilling to commit or because local authorities have yet to be fully engaged.
  • Regulators and national bodies have been slow to align how they work with ICSs, and this is particularly evident in the way in which regional teams of NHS England and NHS Improvement relate to NHS commissioners and providers.
  • There are continuing tensions between the statutory framework, which focuses on organisations and their roles and accountabilities, and the growing emphasis being placed on systems and partnership working.