Risk That ‘Optimism Turns Into Disengagement’ from Local Authorities in Integrated Care Systems Says Report

The first major stocktake on the role of councils in Integrated Care Systems (ICS) since their introduction calls for ICS leaders to turn intentions into real action or risk disengagement with councils.

IMPOWER’s new report, The Evolving Role of County Authorities in ICSs analyses the new systems which replaced Clinical Commissioning Groups this year from the perspective of councils. The study, commissioned by the County Councils Network (CCN), is based on a detailed survey and interviews with local authorities in county areas and senior health officials.

County leaders say councils and health partners are forging closer relationships in many ICSs across England, and evidence in the study shows that council leaders are investing significant amounts of time with health colleagues within these arrangements. While these signs are positive, there are significant challenges to overcome before councils can consider ICSs a truly “partnership” endeavour.

The report finds that ICSs ‘do not yet feel like a paradigm shift towards delivering truly local priorities based on local engagement.’ Mandated, top-down targets from the NHS and central government are part of this, as well as a perception that too much of their focus, to date, is tending towards addressing pressures in the health system. If this continues, it may prevent local solutions which would shift the culture of ICSs to better encompass long-term preventative and community initiatives in addition to acute care.

Pressures across the NHS and councils this winter, especially discharge operation and funding, as well as budget-setting for next year are likely to be the early tests as to whether the emerging governance structures in ICSs will lead to the health and social care integration intended by the government and drive the step change needed in service delivery.

The report, released at CCN’s Annual Conference finds:

• Local government is spending more time with NHS colleagues, with 80% of council respondents saying they have increased their time working with health partners since the inception of ICSs. But, in part because there has been too much of a focus on immediate NHS pressures, only just over half (56%) feel this is even somewhat justified.
• Local authorities are ‘very cautious’ about pooling further resources with the NHS at a time when finances are stretched, particularly as the NHS is felt to have less focus on living within budgets than councils. Nationally, county authorities have pooled £13.43 per-head from their budgets into the Better Care Fund (BCF) this year; down from £15.56 per capita in 2017-18.
• Across England, just nine of 91 Integrated Care Board (ICB) members – the decision-making body of the ICS – are councillors. The report highlights that both councils and the NHS recognise that local politicians will need to be key allies if ICSs are to deliver transformative change, but that their role in systems is still unclear.
• Councils recognise the need for decision-makers in ICBs to tackle immediate issues in the NHS and acknowledge they are also facing real pressures on their own services. However, there is concern that in the medium term it will be difficult to shift focus onto overarching, long-term system issues such as investing in preventative measures and out of hospital care as envisioned in the NHS Long Term Plan.
• Local authorities feel there is a lack of processes in place to measure the success – or otherwise – of ICSs. In the report’s survey, less than one in five (18%) of councils were confident that their ICS had a clear process for monitoring success against its primary objectives and national data on “integrated” issues is very limited.

The report recommends that the government and health service review the level of centrally imposed targets on ICSs, particularly in shared policy areas with local government, which could help move towards a culture shift that gives greater prominence to prevention. ICSs themselves should ensure that funding and decision-making is devolved down to the most appropriate level in order to best facilitate local joint-working.

It also calls on council and local NHS leaders to agree on a small number of specific and achievable inclusive ambitions this winter to build partner confidence in ICSs’ ability to deliver real change.

Cllr Tim Oliver, Chairman of the County Councils Network, said:

“Councils support the introduction of ICS and their aim to closer integrate health and care services and ultimately drive down costs for both the NHS and local government through preventative measures. Since their inception, evidence shows that councils have been enthusiastic about these arrangements and are spending more time with health colleagues.

“But today’s report acts as a useful barometer to find out what is happening on the ground in ICSs across England. Partly as a result of the funding challenges facing the NHS, and top-down central targets, there is a feeling from councils that there is too much focus on immediate and acute NHS pressures, such as hospital discharge and ambulance waiting times, rather than the preventative agenda.

“There is a risk that councils’ cautious optimism turns into disengagement, with some colleagues feeling locked out of the decision-making processes within ICS. If the focus on immediate NHS pressures continues, then there is a high chance councils will view ICSs as simply another NHS reorganisation to work around.

“It is imperative we learn the lessons of these first few months of working in ICSs’ and look to forge a culture where local decision making and preventative health and care is given equal footing to acute pressures. Today’s report sets out some key recommendations to move towards this.”