Integrated Care Systems Design Framework

Introduction

This briefing summarises key points from the 56-page Integrated Care Service (ICS) Design Framework published on 16 June 2021.

  • The framework sets out NHS England and NHS Improvement’s (NHSEI) expectations for the next stage of system development.
  • It outlines the core features of integrated care systems (ICS) and the expectations/minimum standards for all systems.
  • The framework sets out that determination of structures should take place with local flexibility whilst adhering to core features applicable to all systems.
  • It provides indicative outputs expected in every ICS over the course of the transition period in 21/22.
  • The framework is heavily dependent on changes to primary legislation and parliamentary process which is yet to commence.

NHS England and NHS Improvement will provide further guidance as the year progresses.

It is important to note the proposed legislation has not yet been put before parliament. Systems cannot pre-empt the decision of Parliament on whether to approve a bill or how it is to be amended. While plans can be made, systems should not take decisions or enter into arrangements which presume any legislation is already in place or that it is inevitable it will become law, before the Parliamentary process has been completed.

Summary

The document begins to describe future ambitions for:

  • the functions of the ICS Partnership.
  • the functions of the ICS NHS body.
  • the governance and management arrangements that each ICS NHS body will need to establish.
  • the opportunity for partner organisations to work together as part of ICSs to agree and jointly deliver shared ambitions.
  • key elements of good practice that will be essential to the success of ICSs, including strong clinical and professional leadership, deep and embedded engagement with people and communities, and streamlined arrangements for maintaining accountability and oversight.
  • the key features of the financial framework that will underpin the future ambitions of systems, the roadmap to implement new arrangements for ICS NHS bodies by April 2022.

The ICS Partnership

Each ICS will have a Partnership at system level established by the NHS and local government as equal partners. The Partnership will operate as a forum to bring partners – local government, NHS and others – together across the ICS area to align purpose and ambitions with plans to integrate care and improve health and wellbeing outcomes for their population.

The partnership will be required to develop an Integrated Care Strategy (in addition to the ICS NHS Body Plan and Joint Health and Wellbeing Strategies prepared by local Health and Wellbeing Boards).

Terms of reference and rules of procedure which will be locally determined and subject to mutual agreement of local partners.

Membership must include local authorities in ICS area and local NHS, but wider membership for local determination.

The Chair is to be jointly selected by NHS and local authority and can be same chair as NHS ICS Board.

The partnerships will have a role in hearing lived experiences, building on existing engagement.

The ICS NHS body

This new organisation will lead on integrating NHS planning and provision. It will have a Unitary Board (the Board) and all clinical commissioning group (CCG) functions and duties will transfer to the ICS NHS body when they are established, along with all CCG assets and liabilities including their commissioning responsibilities and contracts.

The Board will be responsible for:

  • Developing a plan to meet the needs of the population, having regard to the strategies produced by the ICS Partnership and Health and Wellbeing Boards.
  • Allocating resources, ICS NHS Body remains accountable for resources, with freedom to delegate budgets/authority to place. There will be no nationally-set allocations.
  • Establish joint working arrangements with partners to embed collaboration.
  • Establish governance arrangements to support accountability between partner organisations.
  • Arrange the provision of health services, including contracts, personalised care (inc CHC and FNC).
  • Leading implementation of the People Plan to align ‘one workforce’.
  • Leading system-wide action on data and digital to connect health and care services, understand local priorities and track delivery.
  • Invest in community organisations and infrastructure, alongside councils and other partners.
  • Joint working on estates, supply chain, procurement and commercial strategies to maximise value for money.
  • Planning for and responding to incidents when such emergencies or issues arise.
  • Increase functions delegated by NHS England and Improvement, including further delegation of primary care functions and specialised services.

A statutory minimum membership for the ICS Body Board has been proposed and will include:

  • An independent chair
  • A minimum of two other independent non-executive directors
  • The ICS Chief Executive
  • The ICS Director of Finance
  • The ICS Director of Nursing
  • The ICS Medical Director

In addition membership should include a minimum of:

  • At least one member drawn from NHS Trusts and Foundation Trusts within the ICS area.
  • At least one member drawn from general practice within the ICS area.
  • At least one member drawn from local authorities with statutory social care responsibility within the ICS area.

People and culture

ICS NHS Board are expected to have specific responsibilities for delivering against the themes and actions set out in the NHS People Plan and the people priorities in operational planning guidance.

The responsibility of individual employers will remain.

An employment commitment remains in place for staff, below board level, transitioning into new ICS organisation.

Supplementary guidance and implementation support resources will be issued to ICSs to support the development of strategic people capabilities, including a people operating model.

Governance and management arrangements

In addition to the minimum requirements, ICS Boards will have the flexibility in how committees are established and deployed. The Board will be expected to –

  • establish a constitution and scheme of delegation.
  • meet in public and publish papers for the Board and its committees.

The Board may also:

  • appoint individuals who are not board members or staff of the ICS NHS body to be members of any committee it has established
  • establish joint committees with NHS Trusts/FTs to which they may delegate responsibilities (decision making) in accordance with those bodies’ schemes of delegation.

The ICS will have significant flexibility in how and where decisions and functions are undertaken, every ICS NHS body should maintain a ‘functions and decision map’ showing its arrangements with ICS partners to support good governance and dialogue with internal and external stakeholders.

Role of providers

As constituent members of the ICS Partnership, the ICS NHS body and place based partnerships, providers of NHS services will play a central role in establishing the priorities for change and improvement across their healthcare systems and delivering the solutions to achieving better outcomes.

Provider contracts are expected to evolve to support longer term, outcomes based agreements, with less transactional monitoring and greater dialogue on how shared objectives are achieved.

Clinical and professional leadership

Specific models for clinical and care professional leadership will be for ICSs to determine local. Further resources describing the features of an effective model will be issued by NHS England / Improvement. These features include:

  • effective structures and communication mechanisms to connect clinical and care professional leaders at each level of the system
  • a culture which systematically embraces shared learning, supporting its clinical and care professional leaders to collaborate and innovate with a wide range of partners, including patients and local communities
  • protected time, support and infrastructure for clinical and care professional leaders to carry out their system leadership roles
  • clearly defined and visible support for clinical and care profession leaders, including support to develop the leadership skills required to work effectively across organisational and professional boundaries
  • transparent approaches to identifying and recruiting leaders, which promote equity of opportunity and a professionally and demographically diverse talent pipeline which reflects that community it serves.

Working with people and communities

As part of the ICS-wide arrangements each ICS NHS body will be expected to build a range of engagement approaches into their activities at every level and to prioritise engaging with groups affected by inequalities.

Arrangements in a system or place should not just provide a mechanism for commentary on services but should be a source of genuine co-production and a key tool for supporting accountability and transparency of the system.

The seven principles for how ICSs should work with people and communities are:

  1. Use public engagement and insight to inform decision-making
  2. Redesign models of care and tackle system priorities in partnership with staff, people who use care and support and unpaid carers
  3. Work with Healthwatch and the voluntary, community and social enterprise sector as key transformation partners
  4. Understand the community’s experience and aspirations for health and care
  5. Reach out to excluded groups, especially those affected by inequalities
  6. Provide clear and accessible public information about vision, plans and progress to build understanding and trust
  7. Use community development approaches that empower people and communities, making connections to social action.

Accountability and oversight

The ICS NHS body will be a statutory organisation. The members of its unitary board will have collective and corporate accountability for the performance of this organisation and will be responsible for ensuring its functions are discharged.

NHS England and NHS Improvement through its regional teams, will agree the constitutions and plans of ICS NHS bodies and hold them to account for delivery through the chair and chief executive.

Providers of NHS services will continue to be accountable:

  • for quality, safety, use of resources and compliance with standards through the provider licence and CQC registration requirements
  • for delivery of any services or functions commissioned from or delegated to them, including by an NHS ICS body, under the terms of an agreed contract and/or scheme of delegation.

Where an executive of an NHS provider organisation sits on the board of an NHS ICS body, they will in their capacity as a member of that board also be accountable – collectively with other board members – for the performance of the ICS body and ensuring its functions are discharged.

NHS England and NHS Improvement will provide guidance to support ICS NHS bodies to manage conflicting roles and interests of board members.

Financial allocations and funding flows

NHS England and NHS Improvement will make financial allocations to each ICS NHS body for the performance of its functions.

Decisions about spending will be devolved to ICS NHS bodies. This will include the budgets for:

  • acute
  • community and mental health services
  • primary medical care services
  • running cost allowances for the ICS NHS body.

This may also include the allocations for a range of functions currently held by NHS England and NHS Improvement, including:

  • other primary care budgets
  • relevant specialised commissioning services suitable for commissioning at ICS level
  • a significant proportion of nationally held transformation funding and service development funding
  • the Financial Recovery Fund
  • funding for digital and data services.

Funding will continue to be linked to population need and there will not be a centrally set allocation to ‘place’ within the ICS.

Full capital allocations will be made to the ICS NHS body, based on:

  • the outcome of the 2022/23 capital settlement for operational capital, building on the arrangements initially implemented in 2020/21
  • capital budgets being a combination of system-level allocations, nationally allocated funds and other national programmes
  • the methodology being kept under review to ensure available capital is best allocated against need.

The ICS NHS body will have the freedom to set a delegated budget for place-based partnerships to support local financial decisions to spend ICS NHS resources. The ICS NHS body will engage local authority partners on the ICS NHS resources for the NHS services to be commissioned at place and support transparency on the spending made at place level.

Budget allocated to and managed within a place (under the agreed schemes of delegation) might include:

  • primary medical care
  • other primary care as delegated/transferred from NHS England and NHS Improvement – dental, pharmaceutical, ophthalmology services
  • community services
  • community mental health including IAPT
  • community diagnostics
  • intermediate care any services subject to Section 75 agreement with local authority
  • any acute or secondary care services that has been agreed should be commissioned at place-level.

Data and digital standards and requirements

From April 2022, systems will need to have smart digital and data foundations in place. Systems will locally determine the right way to develop these capabilities and to ensure they are available at system and place level, and across provider collaboratives.

ICS NHS bodies are expected to:

  • Have a renewed digital and data transformation plan that is embedded within the ICS NHS body plan and details the roadmap to achieve ‘What Good Looks Like’;
  • Have clear accountability for digital and data, with a named SRO with the appropriate expertise underpinned by governance arrangements that have clear oversight and responsibility for digital and data standards
  • Implement a shared care record, that allows information to follow the patient and flow across the ICS to ensure that clinical and care decisions are made with the fullest of information.
  • Enable a single co-ordinated offer of digital channels for citizens across the system and roll out remote monitoring technologies to help citizens manage their care at home.
  • Cultivate a cross-system intelligence function to support operational and strategic conversations, as well as building platforms to enable better clinical decisions.
  • Agree a plan for embedding population health management capabilities and ensuring these are supported by the necessary data and digital infrastructure, such as linked data and digital interventions.

Managing the transition to statutory ICSs

Accountability for managing the change process will be with the current ICS and CCG leadership, with increasing involvement of the new leaders (eg chair, chief executive and others at board level) who may be appointed on a shadow or designate basis, pending the legislation.

Each ICS should make initial arrangements to manage the transition and ensure that there is capacity in place ready for implementation of the new ICS body.

Plans should be agreed with regional NHS England and NHS Improvement teams. Each ICS should ensure that planning adequately addresses the implications of organisational development implications as operations evolve from the current into the future configuration.

The indicative outputs expected in every ICS over the course of the transition period in 2021/22 are on pages 51-52 of NHS England’s framework.