In England, an integrated care system brings together the organisations planning, buying and providing publicly-funded healthcare – including mental health and community care services – to the population of a geographical area. As well as the NHS, the organisations include local authorities and independent care providers. The NHS Long Term Plan of January 2019 called for the whole of England to be covered by April 2021.
History
2017: The first accountable care systems
Eight sustainability and transformation plan areas in England were named in June 2017 by Simon Stevens, chief executive of NHS England, as a first wave in the development of what were then called accountable care systems. He said they "will bring together providers and commissioners to help break down barriers between primary, secondary and social care". They would be given up to £450 million between them in transformation funding over the next 4 years. The eight were:
Frimley Health and Care System – a consortium of 30 public and private care providers with five clinical commissioning groups, five GP federations, 10 local, district and county authorities, two ambulance trusts and five mental health and community providers including Virgin Care;
South Yorkshire and Bassetlaw – seven NHS hospital trusts covering 15 hospital sites, which employ 45,000 staff and service 2.3 million residents;
Greater Manchester was not included because it already had more advanced arrangements under its 2015 "devolution" deal. Surrey Heartlands began a similar arrangement in 2018. In each area a provider or, more usually, an alliance of providers will collaborate to meet the needs of a defined population with a budget determined by capitation. There will be a contract that specifies the outcomes and other objectives they are required to achieve within the given budget over a period of time. This may extend well beyond health and social care services to encompass public health and other services. In Manchester the objectives are specified over ten years. Keeping people out of hospital by moving services into the community is a common feature. NHS trusts, Clinical Commissioning Groups and local authorities in the new ACSs will ‘take on clear collective responsibility for resources and population health’. The process was denounced by John Sinnott, Chief Executive of Leicestershire County Council in September 2017 as lacking any element of public accountability. He said that existing models in other countries were interesting but not relevant to democratic accountabilities in the UK since they had different governance structures and forms of service provision. It is proposed that systems employing general practitioners would have to meet the costs of their indemnity insurance. In September 2017 NHS England produced a handbook designed to support the creation of new payment models which are intended to remove the direct relationship between NHS activity and payment, improve the alignment of payment for all providers within the care model and better incentivise prevention and wellbeing.
In February 2018 it was announced that these organisations were in future to be called integrated care systems, and that all 44 sustainability and transformation plans would be expected to progress in this direction. The ten pioneer systems were described as nascent and fragile by the Health Select Committee in May 2018. They were described by Chris Ham as "coalitions of the willing" in 2018. He said that real progress had only happened in places where there was a history of collaborative working. He also commented that there was little guidance and so more latitude than is usually the case with national NHS initiatives. In January 2019 it was announced in the NHS Long Term Plan that by April 2021 integrated care systems were to cover the whole of England with a single clinical commissioning group for each area. Each one will be run by a partnership board with members from commissioners, trusts, and primary care. Three more areas were designated in June 2019 and four more in May 2020, bringing the total to 18.
Integrated Care Providers
A consultation on the draft contracts for what are now called Integrated Care Providers was launched by NHS England in August 2018 after the failure of two legal challenges to an earlier draft contract. The consultation said that this was not a new type of legal entity, but merely the "provider organisation which is awarded a contract by commissioners for the services which are within scope." Dudley clinical commissioning group is at the forefront of this exercise and will be able to implement the draft voluntary contract, subject to the outcome of this consultation exercise. It is proposed that general practitioners will be able to sign fully or partially integrated contracts, and that fully integrated practices would give up their existing contracts to become salaried.
