The age of integration is officially here but how is it going to happen?

The NHS Long Term Plan could be seen as a victory for those who have long fought for an integrated NHS. After many years of pilots and programmes intended to bring about cross-boundary working (despite a system designed to guard against precisely that), there is now a very clear objective: “by April 2021, ICSs [integrated care systems] will cover the whole country”.

In just over two years, we will see commissioners sat alongside providers and local authorities making shared decisions about resource use, service design and population health. Facilitated by new legislation that would remove the systemic barriers to joint working, these ICSs would operate as partnership boards and would not be “an additional tier of bureaucracy”.

It all sounds very sensible but this direction of travel raises some quite fundamental questions that, so far, remain unanswered.

What’s the right scale for ICSs?

According to the plan, sustainability and transformation partnerships (STPs) will evolve into ICSs. Whether each STP will form a single ICS or contain multiple ICSs remains unclear, but there will be one CCG per ICS. Cancer alliances, clinical senates and other clinical advisory bodies will be aligned, and health and wellbeing boards and local authorities will work closely with ICSs.

Achieving these alignments may be straightforward on paper but, whichever way you look at this, it’s complex stuff. At the last count, there were 44 STPs, 195 CCGs, 19 cancer alliances and 353 local authorities. Inevitably, the reorganisation will involve a significant reduction in the number of CCGs. There needs to be a reality check about the amount of time and energy that these changes will require.

These arrangements also raise questions about the footprint and scale at which it is sensible for different decisions to be made. If ICSs really do emerge out of STPs, they will cover vast areas spanning hugely different localities with different priorities. Careful thought will be needed about whether smaller footprints within an ICS should be established, how large they should be and what boundaries make most sense.

As it stands, CCG boundaries are coterminous with local authorities and, where relationships between the two are strong, there may be resistance on both sides to CCGs being wrapped up into larger areas.

Past learning suggests that established relationships and a history of joint working is a key underpinning of success when it comes to delivering integrated care, and those historic relationships may not map conveniently on to a newly-drawn set of boundaries.

Some areas, of course, will fairly rapidly be able to build on foundations of trust and shared culture. Places that lack a shared culture, or have a history of antagonistic relationships, will take longer to build the much-needed trust to make partnership working a reality.

Who’s in charge?

Setting aside the practicalities of transformation, there is a fundamental question around where accountability will sit in the new arrangements. Legislative change (if it happens) will no doubt bring clarity to the current uncertainty over whether collaboration or competition is the order of the day. But, in this new collaborative system, who will be holding providers to account and driving change?

Having CCGs around the table, working with providers to establish a vision and making decisions about how to use resources, could bring huge benefit by transcending the tensions and transactional focus that have persisted in the system. But who will now be asking the difficult questions at a local level?

The plan talks about streamlined and stronger accountability, and refers to ICSs as having “transparent and publicly accountable” partnership boards. This provokes a number of questions about how big these partnership boards will be, who will be on them, who they will they answerable to, and what mechanisms the public will have to hold them to account.

For all its faults, inconveniences and much-questioned value, the purchaser-provider split has afforded a clarity that governed all interactions for over two decades. As Nigel Edwards has warned previously, by moving too far from these established arrangements, we risk losing the ‘grit in the oyster’. It will be important that grit is not replaced by a vacuum.

Without clarity over who is accountable to whom, for what and when, there is a risk there will be insufficient mechanisms for driving change, quality and efficiency.

Can working cultures adapt?

No doubt many of the questions raised above will be answered as more detail emerges about the plans and arrangements surrounding ICSs. But it shouldn’t be forgotten that the key determinant of success will be the willingness of individuals within ICSs to make change happen.

Writing an official document that CCGs and ICSs will align and work closely with local authorities doesn’t mean it will happen in reality. There is also no guarantee that the creation of high-level integrated structures will result in integrated care for patients – indeed, all the research suggests that the real work of integrated care happens at a local level via shared ways of working.

Although people running services might intuitively sign up to the concept of integration and subscribe to the ‘triple aims’, ingrained behaviours and organisational cultures may mean that the belief that integrated care is A Good Thing does not necessarily manifest in changed behaviour.

Ways of working in the system at present (whether consciously or not) are deeply rooted in the foundations of the purchaser/provider split, and a series of previous reforms have sought to strengthen and increase organisational autonomy for trusts and CCGs.

Those deliberately competitive and transactional relationships have been found time and time again to be a barrier to integrated working. Resetting those ingrained cultures by the deadline of 2021 might prove to be one of the trickiest parts of the entire plan to deliver.