Creating Integrated Care Systems (ICSs). The right process, the right targets?

It now seems several lifetimes ago, but was in fact only 2003/4, when I was part of the team devising the policy to create Foundation Trusts (FTs). The legislation squeaked through in October 2003 and we had a few months to set up the architecture and drivers to implement the policy.

Potential FTs had been involved in discussions about the policy since the end of 2001. These had indicated that what good trusts would want from any new status was greater autonomy. So that was what the legislation created. It was this that caused so much disagreement within the Labour Party many of whose members felt that giving hospitals any autonomy would undermine the principles of the NHS.

We therefore combined offering an incentive that trusts wanted (greater autonomy) with a rigorous process by which they could become FTs. We specifically created an independent organisation – Monitor – initially responsible for setting the bar decide whether trusts were good enough to have this extra autonomy and subsequently to regulate them.

Looking at the current policy of developing STPs into ICSs in the light of that experience there are some important lessons here.

First if you want to put an organisation through hoops to become different and better you need to ensure that there are incentives to go through the hard work of change, and that improvement is something they want. Making changes – organisations becoming something different from what they are at the moment – is very hard work. Becoming an FT required organisations to go through a lot of serious changes and they had to be strongly motivated to do so. To be that motivated the incentive – in the case of becoming an FT greater autonomy – had to be something that trusts really wanted, otherwise they wouldn’t go through the very hard work of change.

So much, so obvious.

BUT whilst we had done a great deal of research and conducted many discussions with what were at the time the best non FTs and found that every one wanted greater autonomy, the mistake we made was to assume that all trusts – the very good, the middling and the not so good – wanted that same autonomy.

In reality after the policy had worked its way through the first half of these better trusts, the notion of wanting greater autonomy became less and less significant for the remainder .

If a trust wasn’t very good it wasn’t sure that it wanted greater autonomy. It rather wanted to “hang on to nurse” (in this case the Strategic Health Authorities) because it feared that autonomy would be something worse.

One of the reasons the policy failed to get the second half of trusts into FT status was that the amount of work required to become an FT increased significantly as you progressed through the best trusts, and the incentive that motivated that hard work – greater autonomy – seemed disproportionate to the amount of effort.

Did they think it was worth it? Less and less.

So if we want all STPs to become ICSs then it’s going to be important to get the incentives right in order to motivate them to make the difficult transition. And it’s important to get the process of becoming a different organisation right.

The second lesson is about who sets the bar that decides whether the organisation is allowed to reach the new status. We recognised that if the organisation setting the bar was the same as the one that had a policy of trusts becoming FTs – then the Department of Health – it was likely that the pressure to get all trusts through to the new status would lead to the bar being lowered.

Since we wanted the new status of FTs to mean something, we made sure that the assessors were independent of the government.

Monitor, an independent organisation specifically set up to develop the policy and practice of Foundation Trusts, was separate from government and applied the tests on whether a trust could attain the new status. As many people would agree – this was tough and many trusts did not get through first time. It took a lot of work.

As time went on the government policy (“all trusts will become FTs”) clashed against the rigour with which Monitor applied the process.

Monitor didn’t budge. And the policy only got half way through the possible trusts. What had been known as ‘the pipeline’ to become an FT became a trickle.

In the last few years, given the greater universal performance management for all trusts, the whole notion of ‘greater autonomy’ raises a laugh.

But what is interesting is that we are now back again with a policy where one organisational form – STPs – is being transformed into a better one – ICSs.

We have some experience of this and, on the ground in reality (like becoming an FT), it is very hard. It involves very different governance and practice and above all it involves very different services coordinated around the individual rather than the service provider.

“We will continue to develop ICSs, building on the progress the NHS has already made. By April 2021 ICSs will cover the whole country.”

(NHS long-term plan para 1.51)

Some STPs are close to becoming ICSs. Some are a long way away. The reality is that it is a big change (in some way bigger than becoming an FT) and those that are a long way away from becoming an ICS will need to work hard for several years running to change themselves.

The incentive to become an STP is to gain some finance and also to gain a little less performance management from the top.

Becoming an ICS will also get the NHSE/I off your back about the process of becoming an ICS.

But the problem is that you know that the people who are going to grant you the new status (NHSE/I) are also committed to you having it by 2021. It’s also likely that in order to get the last 4 or 5 over the line they are going to have to make it a bit easier. Therefore if STPs wait for 2020/21 it’s likely to be an easier transition than it is now. (because your examiners are committed to you making it)

I’m not sure the incentives are in the right place here.

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