It is a year since integrated care boards (ICBs) went live and much of those first 12 months has been spent in set-up mode. Despite this and an extremely difficult winter for the NHS, most have now published their strategies while working to fulfil the NHS England recovery plans. We spoke to four ICB leaders about the progress they have made in their first year.
Integrated Care Boards (ICBs) were established last July with a remit to deliver on four core aims: to improve outcomes, tackle inequalities, enhance value for money and improve the social and economic development of their area. Any assessment of ICB progress so far must take into account that, as new statutory NHS organisations, it has taken time and energy to get the infrastructure required to deliver on these aims.
Of course, ICBs were not all starting from the same position. Rob Webster, chief executive of West Yorkshire ICB, says they had a lot of ingredients in place that have allowed them to ‘get on with the business’ of improving outcomes and delivery of services.
‘We knew that we had to be resilient given the ongoing living with Covid work and the likelihood of financial distress. We’ve definitely lived through the worst winter I’ve ever been involved in, and we’ve got to see everything that we’ve done in that context,’ he says.
‘In the first year, we’ve had a 94% reduction in long waits for hospital treatment, so I think the staff deserve a huge amount of credit for that in all of our hospitals and all of our systems. We have now got to continue that journey.’
He adds trusts were able to learn from each other on strategies around things like ambulance turnaround times. ‘Because we’ve got such a strong set of arrangements that have built over time, I think we were able to get through without declaring a major incident.’
Like everyone else, says Felicity Cox, chief executive of Bedfordshire, Luton and Milton Keynes ICB, they were ‘driving the train and laying the track as we go along’. The partnerships developed during Covid helped that process, she adds, but equally, there has been no time for staff to recover.
‘We’re only a year old, but we are starting to see some of the benefits of the ICB and, increasingly, we’re talking about how we keep people out of hospital and prevention.’
Projects have included mental health crisis cafes, working with MK Dons Football Club to get young people into sport, a holistic project on knife crime and working with the fire service to help identify vulnerable elderly people. ‘There’s some really exciting stuff coming up because we’re looking at different aspects of how we keep people well.’
Most of the work that ICBs have done to date will address more than one of those four aims, points out Kent and Medway ICB chief executive Paul Bentley. They worked with Maidstone Council to set up a community food larder but also used that as a way to deliver healthcare support and advice. Working with Kent Police and their mental health trust, they have changed how they care for people in mental health crisis.
‘We do have real challenges, but all of the 1.9 million people in the ICB area deserve healthcare that allows them to live longer, fuller lives and to be economically viable,’ he says.
In Nottingham and Nottinghamshire ICB, a key focus has been better information. ‘We have done an awful lot to develop our data and intelligence so that we understand the population better and where the outcomes are different,’ says chief executive Amanda Sullivan.
This has enabled projects on issues such as fuel poverty where the data can help flag up the most vulnerable patients to healthcare services for a range of targeted interventions, she says. ‘Places approached that differently, but it did have quite an impact.’
Tackling inequalities in outcomes, experience and access
That very detailed data has been fundamental to their work on tackling health inequalities, she adds. ‘We are much clearer now than we were a year ago down to a very granular level.’
They are currently in the process of allocating £4.5 million through their health inequalities innovation fund and they are also an accelerator site for the NHS England Core20PLUS5 initiative.
‘We have started with the severe and multiple disadvantages groups and we have commissioned some primary care, enhanced services around that, but also the place-based partnerships are doing a lot of work with targeted services,’ she adds.
Webster explains they have been doing early detection of cancer by targeting interventions like lung health checks in deprived areas and reducing the differential in life expectancy for people with learning disability and those with severe mental health issues.
‘In the midst of general practice being under massive pressure, we’ve prioritised within primary care in all of our places the learning disability health checks,’ he says. ‘In Bradford, 88% of people with learning disability have had a health check in the most pressured time for general practice.’ Those patients have also been prioritised on hospital waiting lists.
By working more closely with the local authority and the voluntary sector, they are doing things differently on inequalities, says Cox, and that includes waiting lists. ‘If somebody can’t work, then you might be tipping the whole family into mental health crisis, into poverty and greater reliance on benefits. Just having those different voices around the table is starting to make a real difference to how we think about access.’
In Kent and Medway, you can drive from one end to the other in an hour and a half, but there’s an 18-year difference in life expectancy, says Paul Bentley. They have been working with a large Sikh temple to ensure health services for the Sikh community are better than they were previously.
There was also a massive variation in waits for elective care. So they opened up the option for 5,000 patients who had been waiting the longest to choose to have that care at another hospital in the region, almost all of whom took up that offer.
Enhancing productivity and value for money
It is taking steps like reducing variation in waits that will help them ensure they are spending their £3.95bn budget wisely, Bentley adds.
‘While there are areas where we are not performing as well as I would want, there are areas where we’re performing exceptionally. You learn from the best and you transfer that knowledge and that understanding,’ he says.
Access to GPs and dentists is another big problem, he notes. ‘We are under-doctored and we have to continue to do more work to recruit and retain more doctors, both general practitioners and in secondary care.’
Webster says in West Yorkshire they have historically delivered their financial targets and have continued to do so in the past year. Like other ICBs, they are using the Getting it Right First Time (GIRFT) programme to benchmark. Collaboration across trusts on the best ways to improve theatre utilisation, day case rates, and cutting treatments with no clinical value is key, he says.
‘But we’re also investing in things which are more cost-effective, so investments in the third sector, investments in identifying and supporting carers,’ he adds.
That value for money can be achieved in various different ways that improve patient flow and prevent hospital admissions in the first place, says Cox. The ICB progress made on this includes the provision of tech in care homes to provide early warning signs and prevent deterioration, as well as acoustic monitoring at night to alert staff should any patients with dementia start wandering.
‘We’ve worked with the rural charities in central Bedfordshire to support people going home, and we’ve got a huge cancer programme working on moving people through as quickly as we can. We’ve set up the MK deal in Milton Keynes, where we’ve delegated four areas which includes flow, and that’s working really well.’
In Nottinghamshire, the GIRFT data is helping with elective recovery and driving productivity, says Sullivan. ‘We’ve done a lot on delayed discharges in terms of looking at our pathways, home support, working with councils, and getting integrated discharge or transfer of care hubs up and running. Those are all good building blocks for a more productive and efficient system.’
Supporting broader social and economic development
It is not just about value for money but getting the most economic and social return on that investment, which includes supporting the sustainability of the voluntary sector, says Webster. ‘At the end of the year, another £2.8 million went into the third sector, and we try and ensure that there’s a real level playing field for the sector to be involved in the work that we do.’
Capital investments, such as a brand new A&E being built in Calderdale and Huddersfield, require people working on the construction to live in the area. Supply chain is delivered through local businesses and there are funded apprenticeships, Webster notes.
‘We opened a brand new inpatient mental health unit for children, and we made it so that people from the local community, some of whom had never had a job, could work there and we have found they are more likely to stay than other staff would be.’
That approach will be replicated in the future development of new hospitals in Leeds, he adds. ‘The impact of that, plus the fact that 22% of med tech jobs in the UK are in this region, you start to see that that investment is about economic development.’
Cox says they too are looking at social contributions in construction contracts. In July, health, local authority and voluntary sector partners will be holding a day-long session on how to harness growth in the region. ‘Our working population roughly doubles during the day, so that’s lots of people coming into the higher paid jobs in our patch, and we’re looking together at how we can keep those higher paying jobs within people living in the patch. Also, how we can reduce ill health related job loss and how can we use the power of the health service to keep people in meaningful employment,’ she says.
Bentley admits this is the aim where they have made the least progress as an ICB. But he says, from conversations with colleagues, he knows ‘we’re not unique in that’.
They have set up an academy to find routes for young people into healthcare jobs, and there have been long discussions about how to sustainably deliver healthcare services, he says. ‘Part of that is about accessing things like the hospital food and the products and the furniture from Kent and Medway so you drive local productivity.
‘We need to go further and faster, and I genuinely think the way to do that is to work with our colleagues in Kent County Council and Medway Council.’
Care for Notts is a set of different projects that has delivered 700 apprenticeships and over 10,000 people attending careers events or getting support to ensure more a sustainable workforce, says Sullivan. ‘The ICB is also working with the universities around the skills pipeline agenda and there’s a lot of activity around the green agenda, which we wouldn’t have done a year ago,’ she adds.
Looking to the future
Whatever ICB progress has been made in the past year, all leaders are looking ahead. For year two, the commitment will remain the focus on inequalities and working with communities, says Cox. ‘It’s been a challenging first year, but I haven’t lost my enthusiasm. I haven’t lost the reason why we’ve been set up.’
Waiting times and access will remain at the top of their agenda, says Webster and they are required to deliver on that. ‘But we’re also going to focus on how we get to have a sustainable strategy, which is going to take us into the medium term, which addresses these other issues around inequality.’
Bentley notes the ICB progress made so far. The platform of the ICB has been built and the appointments made. ‘What we need to do now this year is to accelerate and to recognise that we need to work with our council colleagues in a much more inclusive and responsive way to continue to reduce those health inequalities.’
Recovering services and resetting some of the demand and capacity across the whole system will continue to be a big piece of work in the next year, agrees Sullivan. ‘We’re in the final stages of developing the joint forward plan and how we’re going to work differently, particularly around integration prevention and equity. So my other priority is to make a difference in those areas alongside the here and now.’