Feb 2021: Integrated Care Systems interim report published

23 February 2021

The objectives of the study are to find out:

  1. How the local leadership and cooperative arrangements with stakeholders (statutory, independent and community-based, including local authorities) are governed in the light of the ICS governance recommendations in the LTP. How statutory commissioning organisations including local authorities are facilitating local strategic decisions and their implementation; and whether different types of commissioning function are evolving at different system levels.
  2. Whether ICSs are able to allocate resources more efficiently across sectoral boundaries and bring their local health economies into financial balance.
  3. How individual organisations are reconciling their role in an ICS with their individual roles, accountabilities and statutory responsibilities.
  4. How national regulators are responding to the changes in modes of planning and commissioning and actual service configurations, in the light of the changed priorities for these regulators set out in the LTP.
  5. Which mechanisms are used to commission services in ICSs. In particular, how is competition used to improve quality and/or value for money of services; and are more complex forms of contract (such as alliancing) being used? How are local organisations reconciling new service configurations with current/evolving pricing structures, and thus how are financial incentives being used?
  6. How locality priorities, including those of local authorities, are reconciled with the wider priorities embodied in STPs and ICSs. In particular, how is co-ordination achieved between STP and ICS plans, local priorities and existing programmes of work such as any local new models of care?

The first phase of our research suggests that systems are still developing relationships and refining the governance arrangements to allow system partners to work effectively together to achieve their aims using the system form. Overall, systems are a challenging environment in which to make binding decisions, particularly those of a contentious nature. System partners are seeking to reconcile potentially competing interests in their governance arrangements: balancing representation, inclusivity and consensus with the need to act; the accommodation of both cross cutting pieces of work and issues specific to certain groups of organisations; and of the principle of subsidiarity and the need for system oversight. Measures being introduced include proposals to streamline membership of governance forums, the incorporation of existing governance architecture into system structures, and the recruitment of system leaders who hold positions of authority in statutory bodies within the system.

The development of system governance which ‘goes with the grain’ of the local context appears an important way of enabling the full engagement of local government in systems and places, and facilitating governance arrangements which are clear and functional. Interviewees acknowledged that it remains challenging to get the division of responsibilities “right” between systems and places. Not all commissioning could be carried out at ICS level, and it was necessary to make commissioning decisions at place level too. It was anticipated the progression towards a single CCG per system would lead to the delegation of some commissioning decisions to place level. At place level, agreements to formalise co-operative working and agreements to share risk, such as Alliance agreements, are under discussion but not yet widely implemented.

We found a broad acceptance among partners of the need to work collaboratively together, and to take decisions in the best interest of the system. However, some interviewees still doubted that, given the current legislative environment, partners would prioritise the interests of the system above individual roles, accountabilities and statutory responsibilities when faced with decisions significantly against organisational interests. It appears that a shift from competition to a collaborative ethos in the NHS is underway, but this is a long-term undertaking. Local government bodies were concerned about their potential exposure to financial risk, and loss of control over limited council resources.

The question of how systems were accountable, to whom and for what was far from settled. The developing landscape has made things unclear on the ground for NHS partners, with the potential for confusion in the way responsibilities flow between the system, the regulator, providers and places.

Systems were starting to make use of opportunities to agree the allocation of central resources between partners, to develop shared resources in ways that had not been possible before, and to explore novel and unique initiatives based on system partnerships, but these types of initiatives were not yet common practice. At the time of the fieldwork, action to achieve long term financial sustainability in the case studies had not been agreed or implemented.


The governance structures of STPs and ICSs are complex and making decisions through these structures can be difficult. System partners are keen to embrace collaboration, and systems are starting to make use of opportunities to agree the allocation of resources and to develop shared resources in ways that had not been possible before. It is not clear how however, ICSs and STPs, in their current form, are addressing contentious issues such as the need to achieve financial sustainability. System working is not aided by accountability relationships that are unclear to some. It is important that system governance structures ‘go with the grain’ of the local context, in order to facilitate meaningful engagement of local government, and to improve the clarity and functionality of decision making processes. The division of functions between systems and places is not straightforward. As CCGs merge to become coterminous with systems, there is a need for clear arrangements for the necessary commissioning functions at both system and place level.

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