Integration is an easy word to say but a harder concept to deliver.
The people our system serves have some of the worst physical and mental health outcomes of any group in the UK. They experience multiple, overlapping issues and premature death. Stigma underpins society’s indifferent response, and care pathways are often cluttered and difficult to navigate.
Integration is an easy word to say but a harder concept to deliver. People struggling with their use of drugs or alcohol need no lessons from policy wonks on the importance of better integrating health and social care services. They have lived it. Their families have lived it: “With all the services in and around, why is it so fragmented? Why is there no single thing pulling everything together?…You can’t give somebody half a treatment.[i]”
Historically we have organised public services to suit Whitehall’s departmental boundaries rather than our citizens’ needs. We have focused on conditions and co-morbidities at the expense of people, their experiences and their communities.
But the tide is turning. Following the failure of Andrew Lansley’s belief in supremacy of internal markets – embodied in the 2012 Health and Social Care Act – ‘collaboration’ is the new watchword. The groundwork for change having been laid by Strategic Transformation Partnerships, the NHS’ Five Year Forward View is recognised by the World Health Organisation as the biggest plan for integrated health anywhere in the world.
As policy shifts go, then, this is a major one whose effects are only gradually coming into view. To aid readers through the wealth of information and ideas that exist we below address seven key questions.
Where have ICSs come from and how are they developing?
Their introduction represents an attempt to drive integration through collaboration by creating the conditions where new health and care ecosystems of providers, commissioners and citizens can flourish. They absorb Clinical Commissioning Groups and some NHE England commissioning powers and will bring in local government to serve between 1 and 3 million citizens each. (For context there are 42 ICSs covering England’s 343 local authorities).
Each ICS is made up of a powerful Integrated Care Board (ICB) with a substantial commissioning budget, CEO and directors, and an Integrated Care Partnership (ICP) which supports and challenges the ICB and ‘develops a plan that addresses the wider health, public health, and social care needs of the system’.
A new Provider Selector Regime will come into effect in 2023 to slow the required pace of re-commissioning (including for local authorities) and after a gradual maturation, the Health Care Bill put ICSs on a statutory footing in July. Finally, the Bill granted major powers to the Secretary of State to intervene in healthcare decisions, acknowledging the impossibility of depoliticising the leadership of our health and care systems (which was intended through the creation of NHS England).
How will, or could, drug and alcohol treatment and recovery feature within them?
Great change is already unfolding on the near horizon. Dame Carol Black’s Independent Review has triggered a new, funded Drug Strategy with the necessary local Combatting Drugs Partnership (CDPs) currently forming. CDPs are a key feature in the new landscape and commissioners and providers should continue attempts to gain influence.
But the reach and budgets of ICSs demand the consideration of a further horizon too. Whilst recent investment will rebuild treatment and recovery systems battered by a decade of austerity, ICBs will command commissioning resource of up to four billion pounds each.
Whilst alcohol treatment reaches just 18% of those in need and struggles for political relevance, ICS chiefs see those devastated by long term drinking struggle to progress through their costly acute services. Surely as a field we can make a compelling case for ICS budgets to properly fund alcohol treatment to reduce this human suffering and financial cost?
Drug and alcohol treatment (in its wider public health context) is one of the few healthcare functions commissioned by local government to feature in this new world. The role of local government in shaping and influencing ICSs is therefore absolutely critical. Drug and alcohol treatment providers and commissioners should see local authorities as natural allies, support and influence their voice at the ICB level (via Directors of Public Health) and encourage CDPs to engage with emergent integrated systems.
How will, or could, the VCSE sector feature within them?
Understanding of charities within mainstream health circles is sometimes limited to small projects adept at delivering culturally appropriate support to local populations but relatively un-professionalised. Large-scale providers regulated by the Care Quality Commission and delivering high quality health and social care to disenfranchised citizens with complex needs are much less familiar. National providers may run the risk of being too big to be thought of as charities but too unfamiliar to be thought of as healthcare providers.
Strategic relationship building, a spirit of intellectual curiosity, a better understanding of the necessary flows of information needed within ICSs and a willingness to reshape services (and the language used to describe them) will be needed to gain access to the vital provider collaboratives commissioned at the system level though multi-billion pound budgets.
How will, or could, health inequalities be addressed by ICSs?
ICSs will have a statutory requirement to reduce inequalities in both access to and outcomes from local health services. They also have a legal obligation to collaborate with necessary partners, most obviously local authorities with their key role delivering public health services and deep reach into communities.
Drug and alcohol providers, accustomed as they are to working with people with complex support needs, could act as effective bridges to those people and communities experiencing the most acute inequalities.
What could the future look like?
If fully integrated within the vision of the ICS, drug and alcohol services could act as a gateway to the totality of health and social care to meet huge unmet needs for the people we serve. Access to substantial budgets could also open up.
The law has already changed but ICSs are very much still forming. By pausing to reflect and respond readers can build their understanding and identify ‘leverage points’ locally. These may include the drug- and alcohol-specific integration strands each ICB is expected to develop; Combatting Drugs Partnerships; needs assessments conducted though ICPs and/or Health and Wellbeing Boards; and the sub-groups which will form under the ICB itself.
What should I do to keep up?
- Read these explainers from the King’s Fund and from the Health Foundation.
- Figure out how your local ICS is working – how does primary care connect with acute services or public health services commissioned by the council? How is data shared (or not shared)?
- Use your existing relationships to talk to, and encourage, public health commissioners in your local authority.
- Be curious!
- Build on the first four steps to map relevant leverage points in your local ICS
What is Collective Voice doing to help?
We will continue to explore this unfolding subject, convene conversations and share our learning. Do drop us a line if you are a like-minded ally who would like to chat.
We are running a webinar exploring these issues on 29 November – do join us.
With thanks to Kevin Crowley for his input.
Read our submission The Advisory Council on the Misuse of Drugs (ACMD) has issued a call for evidence around drug use in ethnic minority groups.
National Audit Office report highlights need to build upon the Drug Strategy and develop a long term, funded plan for full delivery.
Read the report “The government will only achieve value for money if it builds on the initial momentum of the new strategy and develops a