# Integrated care system

In England, an integrated care system (ICS) is a statutory partnership of organisations who plan, buy, and provide health and care services in their geographical area. The organisations involved include the NHS, local authorities, voluntary and charity groups, and independent care providers. The NHS Long Term Plan of January 2019 called for the whole of England to be covered by ICSs by April 2021. On 1 July 2022, ICSs replaced clinical commissioning groups in England.

## Statutory bodies

The Health and Care Act 2022 put these systems on a statutory basis, each with an approved constitution. On 1 July 2022, a total of 42 ICSs became statutory. There are more than 70 performance metrics by which they are judged, grouped into six "oversight themes": quality, access and outcomes, preventing ill health and reducing inequalities, leadership, people, and finances. The poorest performers will be put in a "recovery support programme", which will replace the label of special measures. Each system is to set their own constitution, determine staff pay and can raise "additional income" but the chair must be approved by the Secretary of State for Health and Social Care.
The areas covered by each ICS vary considerably by population and demographics. Population size ranges from 500,000 to more than 3 million people. Some have more than 10 upper-tier local authorities and some only one. Nearly 50% of the neighbourhoods in Birmingham and Solihull are in the most deprived fifth of the neighbourhoods nationally, compared to 1% in Surrey Heartlands.

### Governance

NHS England produced a model constitution in July 2021, which systems are expected to use when developing their own arrangements. Each ICS must have an integrated care board with at least five executive directors and three non-executives.

### Integrated care partnership

The boards must work with local authorities to create an integrated care partnership (ICP) committee for each system, to include local organisations such as the voluntary sector and social enterprises. The ICP works on prevention, wider social and economic factors affecting health, and reducing health inequalities.

### Pharmacy

Each ICS is to have a community pharmacy clinical lead, funded by the Pharmacy Integration Programme for the first two years.

## History
### The first accountable care systems (2017)

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;
* Nottinghamshire – with an initial focus on Greater Nottingham and the southern part of the sustainability and transformation partnership; includes seven public bodies and Circle Health;
* Blackpool and Fylde Coast, with the potential to spread to other parts of the Lancashire and South Cumbria STP at a later stage;
* Dorset;
* Luton, with Milton Keynes and Bedfordshire;
* West Berkshire;
* Buckinghamshire.
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 was to collaborate to meet the needs of a defined population with a budget determined by capitation. There was to be a contract specifying the outcomes and other objectives they were required to achieve within the given budget over a period of time. This might extend well beyond health and social care services to encompass public health and other services. In Manchester, the objectives were specified over ten years. Keeping people out of hospital by moving services into the community was a common feature. NHS trusts, clinical commissioning groups and local authorities in the new ACSs were to "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 was 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 were 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.

### Integrated care systems (2018-)

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. In May 2018 the ten pioneer systems were described by the Health Select Committee as nascent and fragile. Also in 2018 they were described by Chris Ham as "coalitions of the willing". 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 was to be run by a partnership board with members from commissioners, trusts, and primary care. But it has been suggested that "All ICSs are structured differently as there is no fixed model for how they should be developed; and the leadership is defined in terms of roles and agents, with little to guide leadership practices and behaviours in a complex, collaborative governance arrangement."
Three more areas were designated in June 2019, and four more in May 2020 (Hertfordshire and West Essex, Humber, Coast and Vale, South West London, and Sussex), bringing the total to 18.
In March 2021, nineteen NHS minority ethnic leaders demanded that the executive officers (not just the non-executives) in the 42 emerging ICSs should be representative of the ethnic diversity in their communities. They wanted to see ethnic diversity and inclusion a part of every NHS board's core business and that every system should develop a 10-year strategy, with annual milestones, for reducing inequalities. In July 2021 chairs had been appointed for 25 of the 42 NHS integrated care boards. 11 were women, and five had a minority ethnic background. The chairs must not be councillors or MPs, or work for any of their ICS's constituent organisations.

## Integrated care providers

In August 2018 NHS England launched a consultation on the draft contracts for what were then called integrated care providers (ICPs), following 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 was at the forefront of this exercise and was to implement the draft voluntary contract, subject to the outcome of this consultation exercise. It was proposed that general practitioners would be able to sign fully or partially integrated contracts, and that fully integrated practices would give up their existing contracts to become salaried.

## Evaluation

A report from the Nuffield Trust in December 2021 found that there was very little evidence that integration policies across the UK – including pooling budgets and creating new integrated boards and committees – had dramatically improved patient experience, quality of services or supported the delivery of more care outside of hospitals. They warned that without concurrent investment in social care and broader public services, it was “very likely” further reforms would not yield the desired results.

## Integrated Care Boards

On 1 July 2022 NHS England established 42 integrated care boards, covering the whole of England.
| Name | Local authority areas covered |
| NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board | Bath and North East Somerset, Swindon, Wiltshire, and part of the Vale of White Horse |
| NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board | Bedford, Central Bedfordshire, Luton, Milton Keynes, and part of Buckinghamshire |
| NHS Birmingham and Solihull Integrated Care Board | Birmingham and Solihull |
| NHS Black Country Integrated Care Board | Dudley, Sandwell, Walsall, and Wolverhampton |
| NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board | Bristol, North Somerset, and South Gloucestershire |
| NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board | Cherwell, Oxford, Reading, South Oxfordshire, West Berkshire, West Oxfordshire, Wokingham, part of Buckinghamshire, and part of the Vale of White Horse |
| NHS Cambridgeshire and Peterborough Integrated Care Board | Cambridge, East Cambridgeshire, Fenland, Huntingdonshire, Peterborough, South Cambridgeshire, and part of North Hertfordshire |
| NHS Cheshire and Merseyside Integrated Care Board | Cheshire East, Cheshire West and Chester, Halton, Knowsley, Liverpool, Sefton, St Helens, Warrington, and Wirral |
| NHS Cornwall and The Isles of Scilly Integrated Care Board | Cornwall and the Isles of Scilly |
| NHS Coventry and Warwickshire Integrated Care Board | Coventry, North Warwickshire, Nuneaton and Bedworth, Rugby, Stratford-on-Avon, and Warwick |
| NHS Derby and Derbyshire Integrated Care Board | Amber Valley, Bolsover, Chesterfield, Derby, Derbyshire Dales, Erewash, High Peak, North East Derbyshire, and South Derbyshire |
| NHS Devon Integrated Care Board | East Devon, Exeter, Mid Devon, North Devon, Plymouth, South Hams, Teignbridge, Torbay, Torridge, and West Devon |
| NHS Dorset Integrated Care Board | Bournemouth, Christchurch and Poole, and Dorset |
| NHS Frimley Integrated Care Board | Bracknell Forest, Rushmoor, Slough, Windsor and Maidenhead, part of Hart, part of Surrey Heath, part of Guildford, part of Runnymede, and part of Waverley |
| NHS Gloucestershire Integrated Care Board | Cheltenham, Cotswold, Forest of Dean, Gloucester, Stroud, and Tewkesbury |
| NHS Greater Manchester Integrated Care Board | Bolton, Bury, Manchester, Oldham, Rochdale, Salford, Stockport, Tameside, Trafford, and Wigan |
| NHS Hampshire and Isle of Wight Integrated Care Board | Basingstoke and Deane, East Hampshire, Eastleigh, Fareham, Gosport, Havant, the Isle of Wight, New Forest, Portsmouth, Southampton, Test Valley, Winchester, and part of Hart |
| NHS Herefordshire and Worcestershire Integrated Care Board | Bromsgrove, Herefordshire, Malvern Hills, Redditch, Worcester, Wychavon, and Wyre Forest |
| NHS Hertfordshire and West Essex Integrated Care Board | Broxbourne, Dacorum, East Hertfordshire, Epping Forest, Harlow, Hertsmere, St Albans, Stevenage, Three Rivers, Uttlesford, Watford, Welwyn Hatfield, and part of North Hertfordshire |
| NHS Humber and North Yorkshire Integrated Care Board | East Riding of Yorkshire, Hambleton, Harrogate, Kingston upon Hull, North East Lincolnshire, North Lincolnshire, Richmondshire, Ryedale, Scarborough, Selby, and York |
| NHS Kent and Medway Integrated Care Board | Ashford, Canterbury, Dartford, Dover, Folkestone and Hythe, Gravesham, Maidstone, Medway, Sevenoaks, Swale, Thanet, Tonbridge and Malling, and Tunbridge Wells |
| NHS Lancashire and South Cumbria Integrated Care Board | Barrow-in-Furness, Blackburn with Darwen, Blackpool, Burnley, Chorley, Fylde, Hyndburn, Lancaster, Pendle, Preston, Ribble Valley, Rossendale, South Lakeland, South Ribble, West Lancashire, Wyre, part of Copeland, and part of Craven |
| NHS Leicester, Leicestershire and Rutland Integrated Care Board | Blaby, Charnwood, Harborough, Hinckley and Bosworth, Leicester, Melton, North West Leicestershire, Oadby and Wigston, and Rutland |
| NHS Lincolnshire Integrated Care Board | Boston, East Lindsey, Lincoln, North Kesteven, South Holland, South Kesteven, and West Lindsey |
| NHS Mid and South Essex Integrated Care Board | Basildon, Braintree, Brentwood, Castle Point, Chelmsford, Maldon, Rochford, Southend-on-Sea, and Thurrock |
| NHS Norfolk and Waveney Integrated Care Board | Breckland, Broadland, Great Yarmouth, King's Lynn and West Norfolk, North Norfolk, Norwich, South Norfolk, and part of East Suffolk |
| NHS North Central London Integrated Care Board | Barnet, Camden, Enfield, Haringey, and Islington |
| NHS North East and North Cumbria Integrated Care Board | Allerdale, Carlisle, Durham, Darlington, Eden, Gateshead, Hartlepool, Middlesbrough, Newcastle-upon-Tyne, North Tyneside, Northumberland, Redcar and Cleveland, South Tyneside, Stockton-on-Tees, Sunderland, and part of Copeland |
| NHS North East London Integrated Care Board | Barking and Dagenham, City of London, Hackney, Havering, Newham, Redbridge, Tower Hamlets, and Waltham Forest |
| NHS North West London Integrated Care Board | Brent, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, Kensington and Chelsea, and the City of Westminster |
| NHS Northamptonshire Integrated Care Board | North Northamptonshire and West Northamptonshire |
| NHS Nottingham and Nottinghamshire Integrated Care Board | Ashfield, Bassetlaw, Broxtowe, Gedling, Mansfield, Newark and Sherwood, Nottingham, and Rushcliffe |
| NHS Shropshire, Telford and Wrekin Integrated Care Board | Shropshire and Telford and Wrekin |
| NHS Somerset Integrated Care Board | Mendip, Sedgemoor, Somerset West and Taunton, and South Somerset |
| NHS South East London Integrated Care Board | Bexley, Bromley, Greenwich, Lambeth, Lewisham, and Southwark |
| NHS South West London Integrated Care Board | Croydon, Kingston upon Thames, Merton, Richmond upon Thames, Sutton, and Wandsworth |
| NHS South Yorkshire Integrated Care Board | Barnsley, Doncaster, Rotherham, and Sheffield |
| NHS Staffordshire and Stoke-on-Trent Integrated Care Board | Cannock Chase, East Staffordshire, Lichfield, Newcastle-Under-Lyme, South Staffordshire, Stafford, Staffordshire Moorlands, Stoke-on-Trent, and Tamworth, Staffordshire |
| NHS Suffolk and North East Essex Integrated Care Board | Babergh, Colchester, Ipswich, Mid Suffolk, Tendring, West Suffolk, and part of East Suffolk |
| NHS Surrey Heartlands Integrated Care Board | Elmbridge, Epsom and Ewell, Mole Valley, Reigate and Banstead, Spelthorne, Tandridge, Woking, part of Guildford, part of Runnymede, part of Chichester, part of Surrey Heath, and part of Waverley |
| NHS Sussex Integrated Care Board | Adur, Arun, Brighton and Hove, Crawley, Eastbourne, Hastings, Horsham, Lewes, Mid Sussex, Rother, Wealden, Worthing, and part of Chichester |
| NHS West Yorkshire Integrated Care Board | Bradford, Calderdale, Kirklees, Leeds, Wakefield, and part of Craven |