An interview with Nicola King
1.) In a nutshell could you describe what an Integrated Care Board (ICB) is?
There is legislation going through parliament at the moment which will change the way organisations work together to commission health and care services. If the legislation goes through as expected, CCGs will be abolished and replaced with new statutory NHS bodies. There will be 42 of these ICBs nationally and they will be much larger organisations than current CCGs. The ICB will take on all of the commissioning functions that CCGs currently have, and NHS England is also proposing to delegate primary care (for all four contractor professions) and specialised commissioning to ICBs. Whilst ICBs will be NHS Bodies, they will be required to work very closely with local government and the NHS providers in their area. Each ICS will have an ICP (the Integrated Care Partnership) which will be established jointly by the ICB and local Authorities, but which will be a widely inclusive arrangement of small and large organisations locally that are stakeholders in health and social care. The ICP’s job will be to produce the strategy for the ICB area which responds to the health and care needs of local people. The ICB and the local authority then have to plan services to deliver the strategy. Within each ICS there will be local areas known as “places”. The legislation for ICBs is really permissive and it’s expected that lots of its work will be delegated to arrangements to bring parties together in each place.
2.) Can you talk about some of the work you have been doing recently, in particular around getting the right governance and constitutions in place for integrated care systems (ICSs)
The first thing to say is that the ICS is composed of the whole system, including the ICB and the ICP. The statutory body, as set out in the draft legislation, will be an integrated care board (ICB). I’ve been working with policy leads in NHS England to help craft the governance requirements and in particular, draft a model constitution for ICBs. That’s involved looking at the draft legislation in terms of what’s required by legislation for constitutions and considering best governance practices. I’m balancing all of that with a with a heavy dose of pragmatism, recognising that the most important thing is that we have systems established that work. We need the theoretical good practice and the compliance with the law to fit with practical arrangements that will work on the ground. I really hope that’s what we’ve achieved.
The model constitution is written in such a way that it’s a very simple template into which the ICBs can insert local arrangements. The legislation will be very permissive and using the template will help ensure compliance with the legislation. We’ve used some colour coding and anything in the model that’s written in green text indicates something to think about and design locally. Throughout the template are also lots of superscript numbers which link to a separate document containing supporting notes. So everywhere where there’s a number, there’s a corresponding note, and those notes provide explanations as to why something is important, a set of options or some suggestions for things to think about locally.
3.) What is the biggest challenge in getting the ICB governance structure right?
A lot of people are currently talking about what’s the best way to go about setting up the ICB governance structure, but my advice is to think very carefully about the order in which to do things. The first thing is to determine what functions should happen where and with whom. Some things should be done close to communities, at place and others will be best exercised at much larger scale, maybe even across more than one ICB area. Once it’s been determined what should be done where the next thing is to ask who needs to be involved. Its only once you’ve answered the questions what should be done where and with whom that you should start to talk about the mechanisms and structures for doing it. So, I’m really kind of encouraging people to hold back. As I’ve said, the legislation is really permissive so there are many possibilities for the “how”. ICBs will be able to delegate functions to other statutory bodies and to a range of committees and joint committees in the way that CCGs were not allowed to do. In summary, the first questions to ask are ‘What do we want to do, where and with whom?’ and then think about ‘how?’.
4.) What about the potential for conflicts of interest – how will these be managed?
Of course, conflicts of interest will remain, but I think it’s less of a challenge than it has been previously. The main reason we had separate primary care commissioning committees (PCCCs) was because it was a way of managing conflicts of interest that arose due to the boards of CCGs being populated largely by GPs. That particular issue goes away with ICBs because the Board will have a GP, maybe two, possibly three in some areas, but they will certainly not form a majority. Nor will there be a majority of any other potentially interested party.
Interests themselves are not a problem, in fact interests are a good thing. It’s people’s interests that contribute to them being a good Board member. The more interests there are amongst the Board members, the greater the diversity of perspectives, data and intelligence you have and that leads to good decision making. Interests only become a problem when they are allowed to interfere with the best decisions being made.
It’s all got to be worked through, and yes there is work to do, but I think it’s going to be easier than it was with CCGs.
5.) How will primary care get their voice heard at the ICB table? What about the other primary care contractors – dentists, community pharmacists, optometrists?
Each ICB will have on its Board someone who is appointed to bring the perspective of primary medical care. Local GP practices will have a part in the nomination of the individual and it’s likely that most if not all ICBs will appoint a GP into this role. In terms of the Board, there’s no mention specifically of other primary care contractors at all but I think that where the other contractors will have their greatest influence is more locally, at place. This will very much depend on the decisions taken within each ICB about what will be commissioned where.
The vast majority of the contribution made by the other contractor groups is in the delivery of care locally; it’s not really in commissioning. Clearly, they will want to influence commissioning because you’ve got to get the right services commissioned in the right way, but I think their greatest contribution will be through PCNs.
Some ICBs are planning to set up structures that mirror the Partnership arrangements in each Place and this will bring together all of the relevant stakeholders locally, I would encourage primary care contractors of all professions to get involved with their local PCNs as a way of being included in local partnership fora.
6.) The culture of local government, with elected representatives, and the health service, with national direction, is very different – what challenges do you see at ICB level given these differences? How can these tensions be overcome?
The development of an effective thriving ICB all hinges on relationships and if you’re working in a system where the relationships are not good to start with then things are going to be much more challenging. So that’s the space where I think the vast majority of effort needs to be spent. You don’t have to like everybody, and you don’t have to do everything the same way, but you absolutely need to understand and trust one another.
It is important to recognise that dealing with this will require time and commitment. Whilst mechanisms will be put in place by the legislation that will automatically focus people’s attention on the collaborative and cultural relationships, all the parts of the system still need to understand that they need to take the time to develop the relationships in the first place.
There is also a lot we could do in future around thinking about career paths. Even within the NHS, gaps exist between the career provider person and the career commissioning or primary care person and we really need to do much more about addressing this through training our people. We need to be giving them time in different settings so that they understand different perspectives. Building in plans for people to spend time in local government as well as for local government people to spend time in NHS bodies has to be a good idea.
With specific regard to elected local government representatives, it won’t be possible for local government politicians to be members of the Board of the ICB. However, one of the flexibilities that is clear in the legislation is that committees of the ICB and joint committees of the ICB can be populated by people who are not Board members. This means that both elected members and local government officials who aren’t part of the Board of the ICB can be members of place-based partnerships and can be members of committees which have delegated decision making responsibilities. Just because you’re not on the Board doesn’t mean to say you don’t get to take part in decision making. Individuals will need to understand that if taking part in ICB business their role is to focus on the health of the whole ICB population and loyalties to particular organisations, sectors, sub-geographies, etc must be left at the door. So just like for primary care contractors, there will be lots of opportunities for the local authorities to take part in the decision making of the ICB, even though not at the Board level and each ICB will be looking at the best ways to do this for their area.
7.) What do you think will happen at Place level – what will be delegated and how?
The recent guidance “Thriving Places” which is a joint publication with the NHS and Local Government Association sets out the potential range of options for place-based partnerships. This is different to the Integrated care partnership which will be set up as a committee of the ICB and the local Authority. There’s an intent nationally, and an appetite locally, for the application of subsidiarity which means decisions being taken as close as possible to communities, so the whole notion about “no decision about us without us” becomes a reality. Place is where an individual primary care contractor or PCN is likely to have its greatest influence as the ICB is going to be too big an entity for the for the average PCN, GP practice, dentist, pharmacy or opticians to get involved with. The legislation really opens up the possibilities.
With CCGs the relationship was really rather transactional and the CCG decided what it wanted to commission, and it then commissioned a service from a provider, be it general practice provider or a big acute trust. Currently there is no opportunity for formal collaboration or integration with providers or other commissioners because the legislation doesn’t allow it. The planned legislation allows the ICB to exercise those functions in different ways.
The Board may exercise the functions itself, or it might delegate to a member of the Board, or a member of staff. This is what you’d expect, and is what CCGs were allowed to do. In addition, ICBs may also delegate to certain another statutory bodies and may also jointly exercise functions with them. By way of an extreme example of how this could work, one potential future scenario could be that an ICB delegates all of its mental health commissioning functions to a large mental health trust. This would mean that that mental health trust could provide the inpatient services, commission some enhanced services from general practice or community pharmacy, commission community mental health services from the community trust, commission some specialised mental health services from a specialist trust and commission some private sector beds for additional capacity on the spot when they need to do it for individual patients. In this scenario, as the whole of mental health is being commissioned and managed within a single envelope it opens up the potential for being creative, for managing people in the community, for not holding beds open just in case and for having high quality crisis intervention services which genuinely reduce the need for admission. All of the incentives to provide joined-up, high-quality care are aligned. It’s been really difficult for CCGs to commission in this sort of creative way before now but the legislation opens up to this sort of arrangement, and many others, as realistic possibilities to improve efficiency and the quality of care that people receive. I doubt we’ll see this sort of arrangement immediately as it will require strong relationships and mature systems to make it work well, but there’s definite potential in the next few years.
8.) What does good look like for ICB governance?
The first element of good ICB governance goes back to what I said earlier about determining where decisions are to be taken and identifying which decisions should be taken close to communities and which decisions should be best taken at large scale at ICB or even across more than one ICB. Only after this should work be done on designing committee structures and membership.
The other thing is that the Board can delegate responsibility for the decisions, but it can’t delegate the accountability. Regardless of where decisions are taken, for every function that the ICB is legally responsible for, it should be both clear where decisions are taken and also clear as to what assurance mechanisms are in place for those functions. Individually each Board member needs to have confidence that all functions are being exercised efficiently and effectively, is having the greatest positive effect and that the ICB is compliant with all of its legal duties. This will require some careful thinking through to ensure that the ICB Board members can have this confidence without there being a bureaucratic industry that stifles innovation.
Last Updated on 5 October 2021
