On 16 June NHSEI published its ICS Design Framework, a concise document that sets out the minimum standards and expectations for ICSs, and a timetable for their implementation. This briefing from the PCN Network and Primary Care Federation Network draws out the key points of note to primary care.
Overall, we welcome the framework’s direction of travel and the flexibility it offers. The explicit recognition of primary care as a partner and provider, its role in achieving ICS objectives, and the need for clinical leadership provide a strong foundation for ICS development. However, the reliance on targeted minimum standards and each ICS’ individual constitution for its governance and delegation arrangements, coupled with resourcing uncertainty, risks inadequate or variable primary care involvement in systems.
The importance of primary care is clearly recognised in the framework. This, coupled with primary care representation on the ICS NHS body board and the shift towards longer term, outcomes-based contracts have the potential to break down historic divides within the NHS, delivering truly integrated patient care and a strategic approach to service provision. Much, however, will rely on the specific arrangements each ICS adopts with regards to the responsibilities and accountabilities of board members and we will need to see further guidance on the level of accountability placed on primary care board members.
Primary care needs to be resourced to play an effective role – this is an important add-on to their existing work
We welcome the integral role for place-based partnerships, emphasising the importance of primary care at this level in the system. There is a rightly placed focus on the importance of clinical and professional leadership for system success. However, primary care needs to be resourced to play an effective role – this is an important add-on to their existing work. At present, the Framework relies on place-based partnerships to develop primary care leadership capability and capacity, which could result in a lack of – or variable - resourcing across and within systems. Further guidance on the resourcing of place-based partnerships and leadership development will be welcome.
This lack of certainty also applies to primary care budgets and capital allocations, both of which will be decided at system-level. As ICSs move more services into primary care, its budgets must be ringfenced beyond 2024 and significant investments made in primary care estates and infrastructure to accommodate new services and a greatly expanded workforce.
The principle of trusts working alongside primary care is welcome, but this must translate into practice. All providers must focus on population health management, working collaboratively to redesign services to best meet the needs of patients, shifting activity (and resources) into the community where appropriate. The provision for trusts to take on commissioning functions for certain populations is a step in the right direction, but this must be fully inclusive of primary care providers, making explicit provision for their inclusion in provider collaboratives.
Primary care is the natural conduit for community engagement, and we would like to see guarantees for its involvement
For systems to reflect local population needs, both service provision and commissioning must take place as close to the population(s) served as possible. The expected legal duty for ICS NHS bodies to involve patients, unpaid carers and the public in planning and commissioning arrangements is the correct step. Primary care is the natural conduit for community engagement, and we would like to see guarantees for its involvement, alongside resourcing for co-design and co-production, especially given its proposed role in the transformation of community-based services.
ICSs are complex and have a short timeframe for implementation. The need for primary care involvement in decision-making at every level is recognised in the Framework, yet this must also take place before ICSs attain a statutory footing. Support for primary care involvement in both ICS design and ongoing development is therefore vital to ensure a collective primary care voice that is involved in ICS design from the outset. Existing mechanisms such as PCN collaboratives/alliances or GP federations should be used, or support for primary care providers to establish such mechanisms will be needed.
Key points for primary care
In our document The role of primary care in integrated care systems we set out five key requirements. This section details the related points from the guidance in respect of these requirements.
We asked for collective voice and representation for primary care at system level
The guidance says:
- Minimum of one member drawn from primary medical services (general practice) providers within the ICS area on the ICS NHS Body Unitary Board and primary care should be involved in decision-making at all levels.
- ICSs should recognise that there is no single voice for primary care, and providers will need to be engaged in the ICS through existing or newly formed arrangements.
- ICSs should enable involvement of clinical and professional leaders, place-based partnerships and providers, including relevant provider collaboratives through governance arrangements and committees.
- ICSs are to determine their own models of distributed clinical and professional care leadership. To include self-assessment, progress and performance measurement, with peer review encouraged.
- Each ICS will have a Partnership that is jointly convened by local authority and the NHS to improve the health and wellbeing of the population. Primary care is not included in the ICS Health and Care Partnership as minimum, but it must draw on the expertise of clinical leadership.
We asked for processes and structures for primary care at place
The guidance says:
- PCNs in a place should consider working together to lead on one another’s behalf on place-based service transformation programmes and represent primary care in the place-based partnership.
- ICSs are free to choose their place-based governance and decision-making arrangements. Suggested models are in the ‘Place-based partnerships’ section of the Framework and they should be underpinned by the principle of subsidiarity.
- ICSs have been asked to agree and define their place-based arrangements and membership with NHS, local government and system partners.
- Place-based partnerships should build on or complement existing arrangements, such as Health and Wellbeing Boards.
- As a minimum, place-based partnerships should involve primary care provider leadership and representatives of people who access care and support, amongst other system partners as a minimum.The ICS NHS body will have the freedom to set a delegated budget for place-based partnerships to support local financial decisions to spend ICS NHS resources.
- Place-based partnerships may provide targeted operational support for their PCNs, such as HR support or project management.
- The role of place-based leaders should be clear within the governance arrangements and could include: convening the place-based partnership; representing the partnership in the wider structures and governance of the ICS; and (potentially) taking on executive responsibility for functions delegated by the ICS NHS body CEO or relevant local authority.
We asked for system priorities that reflect neighbourhood need
The guidance says:
- The ICS Partnership will have a specific responsibility to develop an Integrated Care Strategy for the ICSs whole population, based on Joint Strategic Needs Assessments, and data covering health and social care (both children’s and adult’s social care).
- A legal duty for ICS NHS bodies to make arrangements to involve patients, unpaid carers and the public in planning and commissioning arrangements is expected.
- ICSs should develop a system-wide strategy for engaging with people and communities. Further guidance on engaging with people and communities will be issued.
- Place-based partnerships should consider providing analytical support for PCNs for population health management approaches.
- The NHS ICS Body is responsible for developing a plan to meet its population needs, having regard to the Partnership’s strategy.
- Primary care should have an important role in the development of shared plans at place and system, with particular regard to addressing health inequalities and access.
- Primary care commissioning will be undertaken by the ICS NHS Body, with contracts remaining nationally negotiated.
- The ICS NHS Body may set a delegated budget for place-based partnerships to support local financial decisions to spend ICS NHS resources.
- Place-based partnerships should be recognised as key to the coordination and improvement of service planning and delivery, and as a forum to allow partners to collectively address wider determinants of health.
- Provider Collaboratives may include non-NHS providers e.g. community interest companies. (Primary care is not specifically mentioned as a potential member of provider collaboratives).
We asked for systems that promote collaboration
The guidance says:
- ICS NHS bodies will have a duty to co-operate with other NHS bodies, including with NHS trusts and FTs, and local authorities; promote integration; and deliver on the triple Aim.
- Financial and non-financial ‘system by default’ ‘enablers’ will be introduced to aid transformation and a focus on overall system performance.
- Contracts are expected to evolve to support longer term, outcomes-based agreements, including national primary care contracts.
- Systems will be allocated a financial envelope based on population need.
- The oversight arrangements for 2022/23 will build on the final 2021/22 System Oversight Framework
We asked for enablers (to support primary care involvement)
The guidance says:
- PCN work in place will need to be resourced by the place-based partnership as it is additional to their core function.
- ICSs and place-based partnerships should consider the support that PCN Clinical Directors, as well as the wider primary care profession, may need to develop primary care and play their role in transforming community-based services
- The ICS Body should work with the system to establish leadership structures and processes, including leadership development, talent management and succession planning approaches.
- Spending decisions regarding primary medical care (general practice) services will be devolved to the ICS NHS Body. Funding will increasingly be linked to population health need.
- Full capital allocations will be made to the ICS NHS body.