Annex

• Core functions –strategy and oversight/improvement: 
  • Define the overall strategy and outcomes systems will be accountable for delivering
  • Develop policy and commission services that are best done once nationally
  • Create an enabling environment for change and improvement
• Current challenges:
  • Overcoming culture of excessive regulatory complexity and micromanagement of delivery
  • Pull from politicians towards national political priorities 
  • Lack of proximity to the system
• How functions could be delivered:
  • Provide necessary resources for systems to deliver a set of defined outcomes
  • Focusing just on the things which should be done nationally and doing them once, well
  • Commission things that need to be done nationally, such as specific digital and highly-specialised services
  • Define the direction and outcomes that systems need to deliver while leaving sufficient room for local discretion to determine how to achieve them
  • Accountability arrangements based on trust and developing systems to develop capabilities, with some limited but effective mechanisms for intervening when things go wrong, for example where there are misalignments or governance issues, ensuring that priorities like prevention, health equity, and digital transformation are consistently pursued across the system
  • Foster and support cross-sector collaborations with the aim of fostering healthier, thriving communities

• Core functions – strategy and oversight/improvement:
  • Working closely with organisations to co-develop national policy and strategy to bridge the gap between national policy and local implementation
  • Delivering functions best done regionally, such as high-level strategic workforce planning
  • Oversight of the quality, financial, and operational performance of providers and ICBs within their region and supporting them to develop capabilities
• Risks: 
  • Duplication with national tier and ICBs
• How functions could be delivered:
  • Adopt a ‘team of teams’ approach, as in North East and Yorkshire
  • Assure delivery of NHS England strategy at the regional level
  • Agree an operating model with ICSs 
  • Oversight of NHS organisations focused on assuring delivery against integrated care strategies, intervening where needed and avoiding duplication
  • Identifying best practice, using this to support and enable improvement
  • Support organisations and systems to develop their capabilities for strategic commissioning, improvement and operational and clinical management
  • High-level strategic workforce planning, development, education and training 

Population footprint of around 1 million to 3 million people

• Core functions – strategy and oversight/improvement: 
  • Develop a system-wide strategy to deliver the four purposes 
  • Deliver structural transformation of health services by integrating services and delivering the three shifts
• Current challenges: 
  • Investment in the health service is not aligned with population health outcomes
• How functions could be delivered:
  • Work as an equal partnership with local authorities to transform public services
  • Creating the right environment to enable local decision-making at place
  • Delivery against a set of locally-defined outcomes, including through contract oversight
  • Support mutual accountability arrangements through peer support, peer review and improvement
  • Over time, make a decisive shift from contracting individual providers for activity (or services), towards contracting that drives collaboration to improve people’s health (or outcomes)
  • To support their estate management responsibilities, take on enhanced estate management capabilities and functions currently held by NHS Property Services, supporting co-location to transform services
  • Commission and develop neighbourhood health
  • Support medicines optimisation

Core functions:

• Set a system strategy based on an understanding of their population’s health needs, including the identification of underserved communities. 
• Effectively and strategically commission and contract services to improve population health, reduce inequalities and increase allocative efficiency through payer functions and resource allocations 
• Convene the system with a view to transforming services, including shifting towards prevention and care closer to home 
• Evaluating impact to ensure optimal, value-based resource use and improved outcomes

Current challenges:  

• Duplication of oversight role with NHS England’s
• Struggling to meet competing demands 
• Budget constraints 

How functions could be delivered: 

• Lead strategic commissioning and strategically invest in health outcomes
• Evaluate population needs with a focus on underserved communities, set population health outcomes, allocate resources, and monitor impact based on population data, forecasting and modelling. 
• Convene system partners to, over time, make a decisive shift from contracting individual providers for activity (or services) to contracting that drives collaboration to improve people’s health (or outcomes) 
• Use greater ability to coordinate and support co-location to transform services 
• Day-to-day contract management role to ensure delivery of outcomes that providers have been commissioned to achieve for their population, including more seamless, joined-up care for patients
• Increasingly devolving more recurrent delegated budgets to place-based partnerships, giving them increased autonomy to take risks 

Core functions:

• ICP partners collectively set and drive strategic direction of the ICS through delivery of the integrated care strategy 
• Act as a bridge between local NHS and wider political, economic and social development 

Current challenges:  

• They are tasked with delivering the longer-term strategic areas which require more advanced levels of partnership working, such as improving population health outcomes, reducing health inequalities and accelerating the scale and pace of change towards prevention and social and economic development, but lack levers to enact change 
• Lack of capacity and profile 

How functions could be delivered: 

• Convene public sector and wider partners to drive mission delivery 
• Promote a shared culture based on trust, mutual respect and transparency within a system, through inspiring leadership and professional humility, which recognises and values all partners’ contributions 
• Enable participation and co-production with the voluntary, community, and social enterprise (VCSE) sector, the public and patients as well as partners such as academia, local business and emergency services 

Core functions (specifically relating the health): 

• Align economic and social policies with health objectives 
• As part of ICSs, collaborate with NHS partners to address the wider determinants of health and shift from sickness to prevention

Current challenges:

• Focus on establishment and new structures
• Lack of clarity on what their statutory health duty entails
• Socio-economic context of local area driving focus
• Lack of awareness of NHS leaders of their role

How functions could be delivered:

• Align economic and social policies with health objectives both locally (such as in local growth plans and local industrial strategies) and across regional statutory strategies
• Support public service reform and prevention within places
• Use the Statutory Health Duty to hold the system to account in delivering health improvement and health inequalities, focusing on how they can work with broader partners on the wider determinants of health
• Becoming statutory partners of the ICB
• Some mayors (or a delegate) will be appointed to one or more relevant ICPs, with an expectation that they (or a delegate) be considered for the position of chair or co-chair
• Work closely with ICBs to set priorities and develop plans, with a focus on fostering partnership working to address the wider determinants of health

Core functions (specifically relating to health):

• Pursue inclusive growth with health at its centre
• Commission services that impact health and wellbeing, including housing, social care and public health

Current challenges:

• Budget constraints
• Navigating structural reform

How functions could be delivered: 

• Local accountability arrangements will change in the coming years as a result of the government’s devolution white paper. [iii] The move towards a standardized sub-regional model of leadership – including restructuring two-tier areas (county and district councils) into single-tier unitary authorities (covering populations of ~0.5 million) – provides an opportunity to align more closely with NHS bodies
• Use local democratic accountability to enhance accountability to local communities
• Support public service reform and prevention within places
• Development of the Joint Strategic Needs Assessment and consideration of wider evidence to inform system level decision through health and wellbeing boards (HWBs)
• Monitoring and driving place level integration through HWBs
• Support place board models by delegating functions and budgets to ‘place leads’

[iii] English Devolution White Paper

Core function – delivery: 

• Delivering high-quality and efficient care
• Delivering some strategic commissioning directly through delegation arrangements and provider collaboratives
• Develop clear anchor strategies
• Act as sector ‘voice’ and leader in system and place-based planning

Current challenges: 

• Recovering operational performance
• Shifting resources from the acute sector into the community and primary care

How functions could be delivered:

• Increasingly shifting funding away from acute, towards community and primary care services
• Ensuring provider resilience and appropriate infrastructure to drive this shift through provider collaboratives and/or at-scale primary care
• Greater cross-system transparency of service pressures beyond the acute sector
• Input into system-wide strategy and translate this into local strategies and plans
• Deliver high quality and efficient services 
• Trust boards to provide first line defence in ensuring high quality care within organisations
• Pathway to maturity with the possibility of moving to accountable care organisation models

Population footprint of around 250,000 to 500,000 people

Core functions (in terms of their relationship with health functions) – delivery: 

• The engine rooms of integrated care – integrating provision of different public services around people (‘total place’) 
• Acting as the support and strategy lead for neighbourhoods, providing the supporting infrastructure for budget and workforce pooling, and in some cases holding the governance function
• Translating the strategic goals of ICSs into local delivery for the benefit of local populations
• Convening local partners to collectively respond to the challenge of improving population health and quality of life with a ‘community first’ approach

Current challenges: 

• Finances challenging relationships 
• Streamlining the complex and overlapping nature of local accountability
• Lack of central support or commitment to place-based working

How functions could be delivered:

• Help facilitate, streamline and improve decision-making at system level, supporting greater progress towards distributed leadership models at system level
• Enabling participation and co-production in service delivery with the VCSE sector, the public and patients as well as partners such as academia, local business and emergency services
• NHS (including primary care) and local authority bodies within partnerships take on increasing responsibility over budgets delegated by ICBs, ensuring budgets are effectively pooled across NHS and local government via Section 75 agreements and the Better Care Fund 
• Aligning greater autonomy for revenue and capital expenditure with holistic investment in addressing inequalities, including where appropriate through strategic authorities
• Maintain a sustainable governance structure and workforce at place

Population footprint of around 30,000 to 50,000 people

Core function – delivery: 

• Delivery of a more proactive, personalised and holistic model of care
• Engagement and empowerment of individuals and communities, driven by a biopsychosocial approach
• Empowering the frontline with autonomy and risk in the right places, with infrastructure to allow them to deliver effectively

Current challenges: 

• NHS performance management which focuses on a bio-medical model, distorts incentives to undermine trust, discourage frontline autonomy, and encourage short-term focus on acute needs

How functions could be delivered:

• Transformation of service model, particularly to those with highest level of need, linked to other areas of public service reform 
• The right expertise and cross-system triage systems (managed through economies of scale) at the local footprint 
• Strong integration at place to unlock the provider infrastructure: pooled budgets, population health data, workforce planning and digital infrastructure – leaning on the expertise of local government
• Leverage community insight to design and deliver care, empowering citizens to manage their health and fostering community resilience
• Harness the expertise and intrinsic motivation of frontline staff across the NHS (not just primary and community care), local government, and VCSE to create matrix teams
• Delegate funding and decision-making to integrator function – place-based, or involve the primary care networks, provider collaboratives or the VCSE sector.