Integrated Care explained - NHS Support Federation

There are 42 integrated care systems (ICS) in England covering populations from 500,000 to 3 million people.

Integrated care has existed in one form or another for many years in the NHS and as integrated care systems (ICSs) since 2016 on an informal basis.

The term ‘integrated care’ has over time covered a number of different models of care, however what they all have in common is that there is close collaboration between NHS organisations, local councils and other providers (charities, not-for-profits, private companies) for planning and delivery of healthcare. Integrated care can cover NHS care, including community care, urgent and emergency care, primary care (GP surgeries), and hospital care, and council services, including social care and public health.

Following the passage of the 2022 Health and Care Act, ICSs became legal entities with statutory powers and responsibilities on 1 July 2022.

What is an integrated care system?

All forms of ICS, according to NHS England, should involve NHS organisations, local authorities and other non-NHS organisations providing health and social care, working more closely together.

Following the passage of the 2022 Health and Care Act, ICSs became legal entities with statutory powers and responsibilities. ICSs comprise two key components:

Integrated care boards (ICBs): The ICB will be responsible for NHS strategic planning and allocation decisions, and accountable to NHS England for NHS spending and performance within its boundaries. It will be governed by a unitary board which will be directly accountable for NHS spend and performance. The board will include a chair, chief executive, representatives of NHS trusts, general practice and local authorities, and others.

Integrated care partnerships (ICPs): statutory committees that bring together the system partners (including local government, the voluntary, community and social enterprise sector (VCSE), NHS organisations and others) to develop a health and care strategy for the area.

ICSs have four key aims:

improving outcomes in population health and health care
tackling inequalities in outcomes, experience and access
enhancing productivity and value for money
helping the NHS to support broader social and economic development.

What is an ICB?

The ICB will produce a five-year plan (updated annually) for how NHS services will be delivered to meet local needs. The ICB must refer to the ICP’s integrated care strategy and work with the joint health and wellbeing strategies published by the health and wellbeing boards in their area. Additionally, each ICB must outline how it will ensure public involvement and consultation.

Each board must fulfil requirements set by the Health and Care Act 2022 and NHS England guidance and have at least 10 members that include the following:

a chair and chief executive
a director of finance, medical director and director of nursing
at least two non-executive members
at least three ‘partner’ members to bring ‘knowledge and a perspective from their sectors’, nominated by NHS trusts, primary medical services and local authorities in each ICB area respectively
one member should bring knowledge of mental health services
no board member should be appointed if their involvement in the private health care sector would impact on their role.

There is no obligation to have an expert in public health or social care on the board, however, there will always be at least one and maybe more representatives from a local authority, and this can often cover public health and social care.

It should be noted, however, that the ICB does not have to have a member representing people who work in the NHS, such as a trade union representative, or a member representing patients and the public, such as a member of Healthwatch or from a community organisation.

Outside of the board of ten, more members can be recruited, and the guidance on membership is flexible, so it could include trade unionists and organisations representing patients should the ICB wish. Additional members often include public health experts, directors of adult social services, representatives of local charities, and academics specialising in healthcare.

Many ICBs also invite non-voting ‘regular participants’ and observers to try to get broader contributions, and these include community volunteer organisations, patient advocacy, public health, and CEOs of local trusts.

What is an Integrated Care Partnership?

The ICP is a statutory joint committee of the ICB and local authorities in the area. The ICP brings together system partners to support partnership working and develop an ‘integrated care strategy’, a plan to address the wider health care, public health and social care needs of the population. The ICB is supposed to have this plan in mind when making decisions.

An ICP must include one member appointed by the ICB, one member appointed by each of the relevant local authorities, and others to be determined locally, which could include social care providers, public health, Healthwatch, voluntary sector organisations and others such as local housing or education providers.

Places and provider collaboratives

ICS areas are massive often covering over 1 million people, as a result NHS England expects these areas to be broken down into smaller units within which providers and commissioners will integrate care. It proposed a three-tiered model of systems, places and neighbourhoods in its guidance on ICSs, but there is a great deal of flexibility over how partners in ICSs work together in their area. It will depend on many factors like size, geography, population size, and how many health and care organisations there are.

Most larger ICSs have a number of place-based partnerships that design and deliver integrated services for particular areas within the ICS, such as a particular town or borough. They involve a range of organisations, including the NHS, local councils, the voluntary, community and social enterprise sector, and other local organisations.

Provider collaboratives bring together providers of local services to plan, deliver and transform. They are partnership arrangements of at least two trusts, working across multiple places with a shared purpose. NHS England has asked all acute and mental health trusts to be part of a provider collaborative, and some include independent providers.

Provider collaboratives can be ‘vertical’ collaboratives involving local acute, primary, community, social care and mental health providers, while others could be ‘horizontal’ collaboratives involving providers working together across a wide geography with other similar organisations.

All NHS providers will need to join a provider collaborative, and individual providers may be involved in more than one.

ICB finances

The NHS Support Federation has been scrutinising the finances of England's ICBs for some time now. The ICBs are under extreme pressure to save money to bring down the overall NHS deficit. Regular updates on their financial situation are available on The Lowdown website.

How can the public scrutinise their ICB?

The Health and Care Act 2022 states that citizens, their carers and representatives have the right to be involved in the planning of healthcare services, the development and consideration of proposals for changes in how those services are provided, and in decisions affecting the operation of those services.

But just how easy is it for a member of the public to get involved with the work the ICB does?

Can an individual member of the public question plans or raise objections to plans devised by the ICB?

It goes without saying that the public can only be involved in healthcare planning if they are given access to what the ICB does. Objecting to plans that have already been given the green light is difficult. So, how easy is it for a member of the public to find out about an ICB’s actions and plans?

Public meetings

The vast majority of ICBs hold meetings in public every two months, plus an AGM at some point in the year. However, longer gaps are not uncommon and some ICBs have met in public more frequently. These meetings are the only ones in public. Other committees run by the ICB are not in public, and it is generally unclear how frequent such committee meetings are as they are not advertised on ICB websites.

Agenda and documents

The public meetings are supposed to inform the public of what the ICB has done and plans to do. The agenda of the sessions can vary considerably, but the core agenda is a report from the ICB’s CEO, a financial update, a performance and quality report, plus some form of board assurance framework report. The latter report is supposed to be a monitor of how well the ICB is performing against agreed strategic priorities, what is the risk that the priorities won’t be achieved, how the risks can be controlled and what actions are being taken.

Outside of this core, the agenda could include the minutes of other committees, workforce reports, reports on big projects, such as maternity or a new primary care centre, results from consultations, or partner organisations, such as the council or Healthwatch.

For a member of the public, in particular one who does not work in the NHS, the information presented is difficult to interpret and contains few concrete plans. Much of the information is performance data for various partner organisations, including hospital trusts, or reports on past achievements. Outside of the core elements of the ICB agenda, the reports and minutes of other meetings can be many months old.

For organisations that are supposed to be focused on forward planning, there is remarkably little detail of such forward planning. Goals are outlined, but it is difficult to determine just exactly how these goals will be achieved.

Putting Questions

As a member of the public, you can question the ICB and attend the public meetings. However, questions must always be sent in writing days in advance. The question is given at the meeting plus the ICBs’ answer, no follow-up questions are allowed or discussion. Not by any stretch of the imagination is this really being involved with ICB planning.

Joining a forum

Another option could be to join a forum or committee: according to NHS England’s guidance, in addition to opinion and discussion by the board members, the board should be informed through discussion from other forums and organisations, although these have to “have a formal role in the system”, such as public, patient and carer engagement forums (set up by the ICB or Trusts), Healthwatch, and VCSE representative bodies/forums. Groups with no “formal role in the system”, which would include all campaigning organisations, get no automatic access to the ICB discussions.

Responsibilities are unclear

If the lack of access to ICB plans, the opaqueness of its reports, or the complexity of the structure of engagement forums, doesn’t put you off trying to question ICB plans, there is also the issue that the roles and responsibilities of ICBs seem to be more than a little unclear. Lord Darzi wrote in his report on the NHS that more needs to be done to clarify the role and responsibilities of ICBs.

At the end of January, planning guidance for 2025-26 said that a ‘more devolved system’ should be developed. The model will be piloted in some areas where some trusts will take over responsibility for the “planning and transformation” of services from ICBs by March next year. ICBs are no longer going to undertake performance management, but are to focus on “strategic commissioning”.

So just when you’d worked out what the ICB does and how you could possibly influence plans – everything changes.