Step 2: Asking the right questions

Moving from being transactional to transformational.


The data derived from step 1 of the model will emphasise at a high level the social and economic potential of the ICS within a given footprint, but it won’t necessarily determine where a system should focus its limited resource, energy, funding and time to achieve the desired wider local change.

Conversations are needed to explore priorities, yet often in health and care become NHS-centric, short-term and operationally focused. We believe the next step in addressing this purpose is to reframe the questions which we are ourselves asking, to ensure we are challenging orthodox NHS thinking, and to look for testable propositions to explore in more detail.

In moving away from more transactional questions to becoming transformational our focus becomes more applicable to our partners and the determinants of social and economic development more real to the ICB. It also enables an ICS to join the range of other conversations that are already taking place.


The table below reflects the same thematic areas as in step 1, yet frames new transformational questions that ICSs will want to reflect on as they look for testable propositions in which they can usefully draw in partners, including the ICB, to leverage wider change.

Not every theme will be a priority for local systems but in reflecting on a selection of the above guide questions, it will become clearer in which areas collaborative action might be usefully targeted and how the parts interplay.

Reframing the health and care workforce question

Workforce is an urgent priority for every ICS and every part of the country. Deficits in skills is one of the most cited reasons for the UK’s significant regional imbalance in productivity, with the clustering of highly-skilled work in cities often depriving local towns and rural areas of adequate supply. It is both a macro and micro crisis which restricts a place’s ability to improve its prosperity and holds back the life opportunities of our young.

An ICS asking itself ‘how can we recruit the health and care staff our system requires?’ will likely ignore the wider impact of its decision-making, potentially competing against others within and outside the sector locally, skewing the local labour market and in some cases actually widening inequalities.

A transformational reframing of this question might lead an ICS to ask ‘how can we develop a more productive place?’. This would draw in a range of partners to understand the overlaps in skills-needs between the local high-value employment sectors, such as health and care, across a geographic footprint, the emerging demographic and wider population data, the full training and education offer necessary to support long-term local recruitment, retention and reputation, and the agreement to focus on core principles of Good Work to stimulate a productive and healthy workforce in general. It would also bring external factors into the conversation such as housing, infrastructure, research and transport, as well as a range of potential funding programmes.

Such an approach would coalesce partners around pilot projects that can not only support the current and future health and care workforce, but would help develop a more consistent labour market for the benefit of all.

Reframing the health and care capital and estates question

A critical enabler of good quality care and yet collectively facing an estimated £9 billion backlog, the NHS estate is in many parts of the country in a parlous state. While the business case process for applying for and receiving capital funding in the NHS can feel antiquated, selective and overly burdensome, it also often ignores the wider infrastructure needs and context of the local place.

As ICSs gain more clarity of their strategic role in estates planning and development, they should prioritise their understanding of spatial planning and how to put health at the heart of it. To deliver on this ICS purpose, the transformational reframing of the question could be to ask, ‘how can integrated public services support the diversity and sustainability of the high street?’’.

The high street occupies a pivotal role in our communities. Situated at the very heart of every village, town and city they have for generations been the place for people to go, meet and spend money - an economic, social and cultural hub that shapes the vibrancy, wellbeing and prosperity of where we live, study and work. With the economic effects of the pandemic still clear, we are seeing a renewed battle to shape the ‘experience’ of a place.

Local economic plans will need to understand and adapt to this change, with particular focus being given to the experience that will bring people into our town centres. Not only is there an increasingly powerful argument that health and wellbeing should be integral to this experience, more and more NHS services are being hosted there, generating footfall and diversifying the local offer.

Strategic discussions around realising the potential of the high street have not traditionally been a priority for NHS leaders. Similarly, those responsible for planning the future of our town centres often fail to see the economic and social value of health. With the increasing need to align public services with growth this issue presents an ideal opportunity to pilot new approaches to estates planning which support social and economic development.

Reframing the health and care net zero question

The NHS may be the world’s first national health system to have a net zero strategy, but the nature of England’s industrial heritage and journey inevitably means progress in achieving it will differ throughout the country. With every ICS system now having a net zero strategy in place, lowering carbon emissions is a focal point for many both within and outside the NHS.

For an ICS seeking to help the NHS support social and economic development and thus improve the lives of its population, the net zero agenda provides a host of opportunities that go beyond our traditional thinking. A transformative reframing of its approach in this area might lead to an ICS to ask its partners ‘what are the challenges in moving to a net zero local economy?’.

Such a question would bring health and care and other local leaders together to develop approaches to carbonfree economies which promote, support and attract investment in the industries of the future. Going further, these discussions could focus on the impact that joint net zero strategies could have in leading to a wholesale rethink of local urban planning, housing and technology, alongside the redesign of transport and access and providing opportunities to create a range of new jobs for the local economy.

These challenges will impact on every sector in different ways. The visible physical aspect of aligning ICS capital and estates plans with local infrastructure and net zero strategies should positively support the contribution our own programmes can make towards achieving local sustainable, social and economic development. Our focus must also be on understanding the implications for health inequalities of some industries struggling to transition.

While green investment may support a range of new jobs, some of which could be health-related, there may be others for whom employment is threatened and/or re-skilling is necessary. Roles in the NHS may be suitable for these communities but more broadly the ICS can be the vanguard and truly reinforce the positive presence in local regeneration discussions, piloting new approaches to net zero that are cross-sector.


  • ICPs prioritise a selection of the transformational questions to test through the development of their integrated care strategy. As previously mentioned, many of the early local anchor institution strategies will have made progress in some of the areas listed above, though the extent to which this progress is truly transformational and place-based will vary. An integrated care strategy that asks more transformational questions can refocus minds and redouble effort, in turn sharpening and targeting local anchor strategies around where collective impact and leverage can be found. This action will also help identify what health and care policy and economic policy has in common across an ICS footprint and where some of the overlapping priorities can bring tangible and mutual benefit tailored to the local population.
  • ICPs undertake a relationship audit across their partnership. The annex in the Unlocking the NHS’s Social and Economic Potential report reflects some of the views of the NHS from other sectors in a social and economic perspective. Understanding what local partners think and want is an important part of identifying barriers, developing a successful strategy and finding out what is possible. An ICP is well placed to seek private and public views locally of where working with the NHS is and isn’t being optimised, to raise and explain its own policy agenda (including the rationale behind this ICS purpose itself) and to gauge what the asks on an ICB might be. These could relate, for example, to how we might usefully share the skills or knowledge within the NHS more widely, what parts of our own architecture most appeal to non-health partners, and to where NHS impact might accrue.