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.
Controversy for the development of ICS has revolved around the presence of private companies on the boards' that control the ICS, the large size of the ICS, which reduces local input to healthcare, and the disruption involved in large-scale reorganisation.
Integrated care is a complicated area, this page aims to answer some common questions on this area.
The Health & Care Bill 2022 completed its passage through Parliament in May 2022 and Integrated Care Systems were made into statutory bodies. There have been amendments to the bill and updates can be found in The Lowdown, including the following articles:
Parliament finishes with the Health & Care Bill, but what does it look like now?
'Integrated care' set to be a system of austerity and crisis
More flaws exposed in ‘integrated care’
Signs of Life: a review of Integrated Care System websites
Still no real signs of life in “integrated care systems”
Integrated Care Q&A
Integrated care is a concept which encourages organisations to work together under a single plan. It can involve sharing budgets and merging functions, but it is not a new concept and many countries have been experimenting with it in their healthcare systems.
The NHS has been working on various forms of integration within certain geographical areas for many years. What is different now is that according to the NHS ten-year long-term plan released in January 2019, the development of integrated care is the top priority and integrated care systems (ICS) must be in place across England by 2021.
One source of confusion when discussing integrated care is the plethora of terms used, including accountable care organisation (ACO) and system (ACS), integrated care organisation (ICO), and multispeciality community partnership (MCP).
In the long-term plan, NHS England refers to integrated care systems as a catch-all term that covers a range of integrated care models that are in development.
The January 2019 NHS long-term plan had as a key component the formation of around 42 integrated care systems (ICS) across England. In this document NHS England use ICS as a more general term to cover several forms of integrated care.
All forms of ICS, according to NHS England, should involve NHS organisations, local authorities and other non-NHS organisations providing health and social care, working more closely together. By April 2021, England had been divided into 42 ICS areas of varying size and population levels.
The White Paper Integration and innovation: working together to improve health and social care for all, published in February 2021 contained proposals to establish ICSs as statutory bodies in all parts of England. Under the proposals, a statutory ICS would be led by two related entities – an integrated care board (ICB) and integrated care partnership (ICP). .
The ICB will be responsible for NHS strategic planning and allocation decisions, and accountable to NHS England for NHS spending and performance within its boundaries. It will be governed by a unitary board which will be directly accountable for NHS spend and performance. The board will include a chair, chief executive, representatives of NHS trusts, general practice and local authorities, and others. CCGs will be abolished, with their functions and most of their staff transferring into the ICB.
The ICB will produce a five-year plan (updated annually) for how NHS services will be delivered to meet local needs. The ICB must refer to the ICP’s integrated care strategy and work with the joint health and wellbeing strategies published by the health and wellbeing boards in their area. Additionally, each ICB must outline how it will ensure public involvement and consultation.
The Integrated care partnerships (ICPs) will be responsible for bringing together a wider set of system partners to promote partnership arrangements and develop a plan to address the broader health, public health and social care needs of the population. Membership of the Partnership Board will include representatives from the ICB, and others to be determined locally, such as local government, NHS organisations, social care providers, housing providers, independent sector providers, and local Healthwatch organisations. They will be responsible for developing an integrated care strategy, which sets out how the wider health needs of the local population will be met.
ICS areas are massive often covering over 1 million people, as a result NHS England expects these areas to be broken down into smaller units within which providers and commissioners will integrate care. It has proposed a three-tiered model of systems, places and neighbourhoods in its guidance on ICSs.
NHS providers will work together at scale through provider collaboratives, new partnerships operating across ICSs to improve services. Provider collaboratives, may involve voluntary and independent sector providers.
Primary Care Networks (PCNs)/Neighbourhoods (populations of around 30,000 to 50,000 people): served by groups of GP practices working with NHS community services, social care and other providers to deliver more co-ordinated and proactive services.
Place-based partnerships (populations of around 250,000 to 500,000 people): served by a set of health and care providers in a town or district, connecting PCNs to broader services, including those provided by local councils, community hospitals or voluntary organisations.
The white paper proposals are in the Health and care Bill 2022 which finished its passage through Parliament in May 2022. Originally scheduled for implementation in April 2022, ICSs will become statutory bodies from 1 July 2022.
How all providers will work together is still a work in progress. In November 2021, Claire Fuller, a GP and executive lead of Surrey Heartlands ICS, was appointed by NHS England to review and set out how ICSs and primary care networks should go about improving out of hospital care. The findings are to be set out by March 2022, before ICSs become statutory organisations.
The review is expected to examine and set out examples of good practice and successful service models, such as integration with community services, connections with urgent care, streaming urgent and non-urgent patients between clinics/practices, use of technology, and involvement of community pharmacy.
NHS trusts and foundation trusts will continue with their current duties, but will also be expected to collaborate to a much greater extent with other organisations. They will have representatives on the ICS Board (ICB) and form collaboratives with other providers in the ICS. There will be a new duty to collaborate with local partners and a shared duty to promote the triple aim of better health, better care and lower cost.
NHS Providers are expected to join provider collaboratives. These will vary in their scale and scope. Some will be ‘vertical’ collaboratives involving local acute, primary, community, social care and mental health providers coming together to integrate their services and others will be ‘horizontal’ collaboratives involving providers working together across a wide geography with other similar organisations. All NHS providers will need to join a provider collaborative, and individual providers may be involved in more than one.
Private providers will be expected to be part of provider collaboratives, but after much campaigning, no private company will be allowed to have a representative seat on an ICS board.
1. Why rush forward with integrated care systems (ICS) and integrated care providers (ICPs) when there is yet to be any real evidence that they will work? It is only 7 years since the last major re-organisation, which has been widely criticised.
2. If ICSs are given a fixed budget under their contract, what happens when they run out of money, who goes without care and how is this decided?
3. ICSs are destined to fail unless proper funding is restored, the same is also true of any other form of integration.
4. Does this version of integration really fit with the key principles of the NHS - e.g., How can we make sure that healthcare remains free at the point of use, when more of it will be provided in the community where means-tested social care already exists?
5. There are concerns that the current form of ICS development will reduce local input into decision-making. The Health & Care Bill 2022 that completed its passage through Parliament in May 2022 makes clear that each ICS will be able to establish its own constitution – opening up the probability of wide variation in the extent to which ICSs opt to devolve decision-making down to more local level.
The STP (sustainability and transformation partnerships) plans published in 2016 initiated the development of integrated care systems (ICS) across the country.
In January 2019, the new NHS long-term plan announced that by 2021 all of the NHS in England will be developed as integrated care systems (ICSs), with approximately 42 ICS. These ICS have developed out of the STP areas.
Although all of England has now been divided into 42 ICS areas of varying sizes. The passing of the Health & Care Bill 2021 in May 2022 means that ICS will have statutory status from 1 July 2022. It is still unclear, however, just how much integration has actually taken place.
Recruitment of chief executives for Integrated Care Boards (ICBs) has been slow and difficult. By November 2021 only 24 of the 42 chief executive positions had been confirmed and five systems in the Midlands had run a recruitment process, but failed to appoint a chief executive: Staffordshire and Stoke-on-Trent, the Black Country and West Birmingham, Coventry and Warwickshire, Shropshire, Telford and Wrekin, and Birmingham and Solihull. Many other regions have interim CEOs after failing to recruit, including Manchester.
In May 2022, an investigation by the HSJ found that most ICS had not appointed a procurement lead despite NHS England directing the new local bodies to have a dedicated director in place by April 2022. Only 12 of the 34 ICSs which responded to HSJ’s survey said they had appointed a dedicated procurement lead.
In the NHS long-term plan published in January 2019, NHS England talks of integrated care systems (ICS) being either delivered:
- locally through collaborative arrangements between different providers, including local ‘alliance’ contracts;
- or, with one lead provider given responsibility for the integration of services for a population. In this case a new Integrated Care Provider (ICP) contract will be used.
An ICP generally refers to a care model where healthcare is run under a single contract by a single organisation. The contract could be awarded following a competitive tendering process. This process is open to all organisations - NHS, for-profit private companies and third sector organisations.
Despite the long-term plan stating:
“We expect that ICP contracts would be held by public statutory providers.”
There was at the time no legislation that prevented an ICP contract being awarded to a private for-profit company. So an ICP contract could effectively hand over the legal responsibility for provision of universal healthcare in an area to a private company.
Furthermore, there is no limit on how much of an ICP’s work could be sliced off and profitably sub-contracted to private corporations.
Two judicial reviews were brought against NHS England in relation to the contract, but both were dismissed.
When the Health & Care Bill 2022 began its passage through Parliament campaigners highlighted the possibility of private providers having a seat on ICS boards and thus an influence over commissioning. In May 2021, it came to light that local managing director Julia Clarke was already listed as a member of the Partnership Board, the unitary Board which currently runs the ICS covering Bath and North East Somerset, Swindon and Wiltshire (BSW).
After vigorous campaigning by organisations and amendments tabled by the Labour Party for changes to the Health & Care Bill 2022 so that private companies could not have representatives on Integrated Care Boards, eventually in September 2021 Health Minister Edward Argar agreed to table a government amendment to the Health and Care Bill that would prevent private interests from being on any Integrated Care Board. This has now been confirmed in the published report of the First Sitting of the Bill Committee on September 7.
The final Health & Care Bill 2022 does not allow the participation of the private sector in commissioning services and the new procurement system will allow the NHS as preferred provider, and will not permit contracts to be awarded to private providers without a proper open and transparent process.
However, outside of the Health & Care Bill 2022, there has been a major push for the use of the private sector to help reduce waiting lists for both diagnostic tests and elective surgery. NHS England’s ‘Delivery Plan,’ to enable the recovery of acute services from the after-effects of the pandemic, mentions the need for reliance on the “capacity” of the private sector extensively.
Numerous amounts of guidance, such as that on virtual wards, have been issued by NHS England reminding NHS commissioners that the private sector is there to partner with.
It was not clear in the long-term plan, published in January 2019, how funding for integrated care systems will be organised. The Covid-19 pandemic disrupted the development of ICSs as funding was increased to cope with Covid pressures. By 2022, it was clear that funding for ICSs will be under a stricter regime than the previous two years. Each ICS has been allocated a budget and every ICS, including those that carried huge deficits going into the pandemic, will be told to deliver financial balance in 2022-23, according to draft guidance seen by HSJ.
Some ICS went into the pandemic with deficits of more than £100m, and are likely to struggle to reach a balanced position. The draft guidance Revenue Finance and Contracting Guidance for 2022/23, in early 2022 from NHS England says: “NHS England and NHS Improvement intend to use additional powers in the legislation to set a financial objective for each integrated care board [the local commissioning body] and its partner trusts to deliver a financially balanced system, namely a duty on break even.”
It is unclear what the consequences will be for an ICS that fails to meet the instructions to break-even and over-spends.
Sally Gainsbury, senior policy analyst at the Nuffield Trust, told HSJ that NHS funding over the next few years is roughly being brought back in line with what was planned prior to covid. She added: “This financial guidance is just an indication of how harsh the implications of effectively holding down spending growth to get back to the pre-pandemic plan will be. Coupled with a duty to break even, the financial settlement makes it likely we will not just see further squeezes on provider costs, but also pressure to hold down activity growth rates, which will be harder than ever to do given the backlog in care.”
In February 2021, the Department of Health and Social Care published the White Paper Integration and innovation: working together to improve health and social care for all, which sets out legislative proposals for a health and care bill. The white paper contained proposals to get rid of the competition rules introduced in the 2012 Health & Social Care Bill which led to an increase in outsourcing.
The proposals also include a range of measures intended to support integration and collaboration. At the heart of the changes is a proposal to establish ICSs as statutory bodies in all parts of England. Under the proposals, a statutory ICS would be led by two related entities operating at system level – an ‘ICS NHS body’ and an ‘ICS health and care partnership’ – together, these will be referred to as the ICS.
In May 2022 the Health & Care Bill 2021 had progressed through Parliament, with some amendments, and was given royal assent. ICSs will become statutory bodies from 1 July 2022.
Historical Background
Originally the government had intended to introduce primary legislation for integrated care, but it changed these plans after the 2017 election substantially weakened its Parliamentary position. Subsequently it has been trying to proceed by changing regulations (secondary legislation) - leaving many of the existing organisations and structures in place, however the legality of this approach has been challenged.
In order for an fully integrated care systems (ICS) to be put in place a new contract needed to be available for the commissioners to use. In August 2017, a draft integrated care provider (ICP) contract was published, designed to allow Clinical Commissioning Groups (CCGs) to choose to commission ICPs in their areas.
This contract publication was followed by a two month consultation on the draft contract. At this point it became clear that before the contract could be used, secondary legislation would be needed to amend the Health and Social Care Act 2012.
At the start of January 2018, the secondary legislation needed was expected to be put in place in February 2018 thereby allowing the first ICPs to start in April 2018. However, in January 2018 Sarah Wollaston MP chair of the Commons Health Committee wrote to Jeremy Hunt asking that any moves to implement ICPs be paused pending further consultation. Prior to this legal challenges to the setting up of ICPs had been filed. Both the letter and the legal challenges resulted in a delay to the legislation.
In late January 2018, Jeremy Hunt wrote to the chair of the Commons Health Committee saying that the ICP contract implementation would be paused allowing for more consultation. NHS England was forced to conduct further public consultation work on the ICP contract.
NHS England's consultation opened 3 August 2018 and closed 26 October 2018.
From the January 2019 NHS long-term plan, it is clear that there are still legislative issues surrounding the development of ICS and ICP. NHS England called upon the Government to amend legislation in the 2012 Health and Social Care 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, allowing “the creation of a joint commissioner/provider committee in every integrated care system”.
In other areas of the world, Accountable Care Organisations operate with a capitated or fixed annual budget that allows the providers to retain and share any savings made. It is unclear how budgeting for integrated care systems and integrated care providers will operate as yet, but a fixed budget is a possibility.
This type of approach has led to concerns that services will be rationed either because the budget provided is just not enough to provide all universal healthcare services or, and this is particularly pertinent if the contract holder is a private company, to produce savings to increase the amount of budget that the providers can retain as profit.
Rationing services also encourages people to seek private alternatives, which in turn reduces the budget spend under the integrated care system, potentially leading to higher ‘profits’.
In May 2022, draft guidance from NHS England included that every ICS, including those who went into the pandemic with huge deficits of over £100m, will be expected to deliver financial balance in 2022-23. From April 2022 ICS are expected to deliver services from within funding envelopes set at the start of the year, and to be held to account on this.
It is unclear what the consequences will be for an ICS that fails to deliver financial balance. For 2022-23 it has been reported in the HSJ that there are significant gaps between allocated and projected spending.
Sally Gainsbury, senior policy analyst at the Nuffield Trust, told HSJ that: “This financial guidance is just an indication of how harsh the implications of effectively holding down spending growth to get back to the pre-pandemic plan will be. Coupled with a duty to break even, the financial settlement makes it likely we will not just see further squeezes on provider costs, but also pressure to hold down activity growth rates, which will be harder than ever to do given the backlog in care.”
Two judicial reviews were brought against NHS England in relation to the development of the integrated care provider contract (a new contractual form allowing commissioners to award a long-term contract to a single organisation to provide a wide range of health and care services to a defined population), with campaigners arguing that this could lead to health and care services coming under the control of private companies. The two judicial reviews were both dismissed.
The legal challenges were as follows:
999 Call for the NHS
The campaign group 999 Call for the NHS, backed by law firm Leigh Day, lodged a judicial review in October 2017. This claims that the contract for accountable care organisations breaches the Health and Social Care Act 2012.
The papers claim that the formation of ACOs breaches section 115 and 116 of the 2012 Act, which relate to the price a commissioner pays for NHS services and regulations around the national tariff.
The campaigners’ case argues that under current legislation, prices paid for NHS services must reflect how many patients receive the care under that specific service, whereas the ACO contract allows commissioners to give providers a fixed budget for the population in the area.
The judicial review was given permission to proceed in late December 2017 and it was heard 24 April 2018.
The Judge Mr Justice Kerr ruled that the court did not find anything unlawful with the payment mechanism proposed by the ACO contract.
The judgement said that the objection in the case was a political objection to the payment mechanism and therefore it "is not a matter for the court.”
JR4NHS
The second application for a judicial review was lodged on 11 December 2017 by Dr Graham Winyard, Dr Colin Hutchinson, Allyson Pollock and Sue Richards, and Professor Stephen Hawking, under the campaign name JR4NHS.
The academics are working with Harrison Grant Solicitors and Nigel Pleming QC to argue that introducing new commercial, non-NHS bodies (ACOs) to run health and social care services without proper public consultation and without full Parliamentary scrutiny would be unlawful. They argue that the consultation procedure around the ACO contract was insufficient.
In early July 2018, the judge, Mr Justice Green, ruled that the policy was “lawful” however the health and social care secretary Jeremy Hunt was “under a duty” to consider criticism against ACOs when it goes to public consultation.
The High Court held that the policy falls within the “statutory powers of a clinical commissioning group” and is “not contrary to the ‘commissioner-provider split’ under the National Health Service Act 2006”.
The campaign has decided not to appeal the decision.
