The state of integrated care systems 2021/22

This is the first annual report by the NHS Confederation’s ICS Network to assess the progress of integrated care systems (ICSs). It is based on the views of system leaders, gathered through a national survey and interviews with a range of stakeholders. This report sets out areas where leaders feel they have progressed well and where improvements are needed.

There is a risk that if ICS leaders are not given sufficient time and space they will not be able to deliver the radical changes to health and care services that the pandemic has demonstrated are needed. We encourage the Department of Health and Social Care, NHS England and the Care Quality Commission to ensure regulation, oversight and performance management are proportionate, encourage innovation and drive improvement. A distributive leadership model is encouraged, both within ICSs and from the centre. ICSs should continue to work on the basis of subsidiarity – making decisions at the most local level possible – and be empowered to define what metrics they will be assessed on based on local priorities.

One of the biggest strengths of ICSs so far has been improving joint working between partner organisations. 90 per cent of system leaders believe they have been able to improve joint working quite or very effectively. Much progress in joint working was catalysed by the pandemic, which necessitated quick adoption of innovative ways of working to adapt and respond to COVID-19 alongside increasing demand for care.

System leaders are committed to the principle of subsidiarity and 9 out of 10 stated that this principle already applies to their system to either a moderate or great extent.

System leaders feel another strength of ICSs has been their local workforce. ICS leaders feel they are making significant contributions to system-wide efforts to mitigate workforce pressures and improve working culture. Almost 80 per cent have indicated they are quite or very confident about delivering a ‘one workforce’ approach by July 2022.

On areas to improve, further support is needed to help systems achieve against the ambition of systems contributing to local social and economic development. Fewer than 1 in 20 of those surveyed stated that they had been very effective in delivering progress. NHS England should provide a suite of support for systems in this area, which should be co-developed with cross-sector leaders in a way that recognises and empowers local nuance and partnerships.

Similarly, interviews with primary care leaders have highlighted that in many areas there is uncertainty about how the experiences and insights of those leading primary care services at neighbourhood level inform system-level planning and strategy. Clear requirements for primary care governance and engagement at ‘place’ are needed to ensure this voice is not lost with the disbandment of clinical commissioning groups.

Looking ahead, system leaders feel the biggest obstacle preventing further progress is national workforce shortages. This was given as the top priority by 3 in 4 respondents. While ICS leaders report making progress on workforce issues, the national strategic framework needs to enable them by addressing long-term shortages. The NHS Confederation is seeking amendments to the health and care bill to strengthen the duties on the Secretary of State for workforce planning. Furthermore, to provide the long-term planning and ambition that is urgently required, we have called on the government to develop and publish a health and care workforce strategy as a priority.

With ICS implementation recently delayed to July 2022, system leaders will need logistical, administrative and legal support to effectively manage the period between April and July. We look forward to working closely with NHS England and the government on ensuring the right support is provided through this period, and more broadly to ensuring that the recommendations of this report are taken forward over the coming months.