Integrated Care Systems: What can current reforms learn from past research on regional co-ordination of health and care in England? A literature review

This report is part of the research of the Policy Research Unit in Health and Social Care Systems and Commissioning (PRUComm) on the developing architecture of system management in the English NHS – including Sustainability and Transformation Partnerships, Integrated Care Systems, Integrated Care Providers or their successors – commissioned by the Department of Health and Social Care.

Five years since the publication of the Five Year Forward View (NHS, 2014), the integration of health and social care at a ‘system’ level remains a central NHS policy priority in England. The NHS Long Term Plan (NHS, 2019b) further set out how organisations are to continue to work together collaboratively across defined geographic territories to improve the co-ordination of local health and care services to encourage the better use of resources, with an emphasis on managing population health. New ‘system wide’ non-statutory partnerships comprised of NHS commissioners and providers, local authorities, and in some instances, private and voluntary sector organisations, have been mandated as 44 Sustainability and Transformation Partnerships (STPs) covering all parts of England. 17 of the more ‘mature’ partnerships have been designated Integrated Care Systems (ICSs) intended to be granted increased autonomy, providing greater freedom over how they manage resources collectively. Additionally, seven new regional teams have been created as outposts of NHS England and NHS Improvement, intended to harmonise their operations to support system-wide collaboration rather than privileging organisational competition. Without change to primary legislation, facilitating collaboration at a system level marks a substantive shift in the national policy direction away from the primacy of quasi-market competition.

Regional and/or sub-regional tiers are by no means new to the NHS. Despite undergoing continuous reinvention, an intermediate tier has existed for almost its entire history, with statutory authorities (at times, several layers of authorities) responsible variously for long-term strategic planning, allocating resources, acting as market umpires, and overseeing the delivery of local health services. The latest reforms thus mark a return of an intermediate tier, in-filling a vacuum left behind by the abolition of Strategic Health Authorities (SHAs) in 2013. However, unlike previous health authorities, STPs and ICSs are not statutory bodies, but instead exist as non-statutory voluntary partnerships despite being effectively mandated by NHS England.

This report summarises the findings of a review of literature on previous intermediate tiers in the NHS. It examines their functions and responsibilities, how they operated in practice and how they interacted with local government. We draw on peer-reviewed academic research, historical analysis and commentary from academic, health policy and think-tank sources in the absence of extensive, systematic research. Through putting current reforms in their geographical and historical context, we draw out lessons for the challenges and opportunities STPs and ICSs may encounter in the years ahead.