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July 18, 2023
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Putting the ‘integrated’ in ICSs

As with other system changes before it, DsPH and their teams have adapted and have worked hard with ICSs over the past year to enable strong partnership working for the benefit of everyone’s health and wellbeing. However, moving forward, the i’s need to be dotted and t’s need to be crossed for them to work effectively and, the sooner that is done, the better the outcomes will be for all.

Prof Jim McManus
ADPH President

Last July, following the passage of the 2022 Health and Care Act, integrated care systems (ICSs) were formalised across England as legal entities with statutory powers and responsibilities. Before last year, ICSs existed as informal local partnerships. The new statutory ICSs, which are made up of integrated care boards (ICBs) and integrated care partnerships (ICPs), are a welcome recognition that, in order to improve population health, all the different agencies and professionals involved in providing services that improve and protect people’s health need to work together.

Public health is of course an integral component of this ambition so, in this month’s blog, I want to take the opportunity to explore ICSs one year on.

The key point about ICPs is that they are made up of local leaders and partners. Each member has a valuable and complementary grasp of the specific issues facing their area and population and, as such, can work together to provide services that will best suit that population. Leaders on the ICB should therefore ensure they take the ICP’s views and priorities seriously.

There are myriad facts and figures that show that people in different areas have different health outcomes. For example, since 2009 there has been a consistent gap of over ten years between healthy life expectancy in the bottom 10% of local authorities, compared to the top 10%. This, and other, health inequalities have only been exacerbated by the Covid-19 pandemic and the rising levels of poverty as a result of the cost-of-living crisis.

In order to improve population health overall, we must tackle these inequalities, not only for people from different areas and sections of society’s outcomes but also in their experience of accessing health services.

As local leaders for the public’s health, Directors of Public Health (DsPH) and their teams are ideally placed to work with – and across – the system to turn evidence into action to address these issues. It is therefore crucial that ICSs – both the Board and the Partnerships of ICSs – work with DsPH and their teams and do not develop in parallel.

Unfortunately, while a lot of positive partnership working is happening, there are a number of barriers to embedding DsPH and public health into ICSs which, left unchecked, could significantly hamper their work and potential for change.

Arguably, the biggest barrier is geography. DsPH are responsible for areas aligned with their local authority (LAs) boundaries. The 42 ICSs however are aligned to NHS regions, which, with only a few exceptions, have vastly different population sizes and borders to LAs.

Even with the best intentions, the capacity and capability for public health to act within different geographies is limited.

It is important too, to avoid confusion and duplication of roles. For example, NHS England’s Director of Population Health role is, to the outside world – including Google – easily confused with a DPH, who works to protect and promote good health and prevent ill-health.

It’s not just in the name. While DsPH have a number of health protection responsibilities such as preparing for major outbreaks which ICS Directors of Population Health may not, it is the prevention strand that is key to understanding the challenges of how we can ensure that public health fits meaningfully into ICSs and the differences between DsPH and ICS Population Health Directors. DsPH, who in England are employed by local authorities, commission a huge variety of services to support everyone who lives in their area to live longer, healthier lives. This means providing an environment where people of all ages can live in such a way that they don’t become ill or need health care for preventable disease – for instance, because they are encouraged to use active transport, or shown at an early age the effects of substance use or given access to sexual health advice.

Directors of Population Health however, who are employed by the NHS, are largely concerned with how health care can improve the health of their population – which not only differs geographically to that of DsPH, but also who they are. By definition, the NHS serves people who need health care. In the overwhelming majority of cases, this means people who are already in the system – people who, for example, have already had a heart attack or might be trying to quit smoking or cut down on alcohol consumption.

The difference may well seem subtle, especially with the increasing talk of prevention by politicians. However, it is a difference that can lead to widely opposing resource needs in an organisation that, although set up to work collaboratively with all concerned, is ultimately funded and managed by the NHS.

This difference between how the NHS, local authority and commissioned public health service workforces – including the voluntary and community sector – are managed is of course another barrier. With different contracts, terms and conditions it is a huge challenge for people across the different sectors to be able to contribute to ICSs equitably. Issues around accountability also need to be addressed as the fact that LAs answer to locally elected members and ICSs report nationally to NHS England means there are often conflicting priorities at play.

All of this can get in the way of doing the right thing for the residents who expect us to do our best for them. So, how do we ensure that we, as DsPH, can contribute to ICSs and collaborate effectively? There are seven key things we should do to ensure we get the best of all skills for the best health of our populations.

First, we need a culture of collaboration and a recognition that NHS and DsPH need each other to create a healthy population. Focus on what needs to be done, not governance boundaries. Second, as we set out in our response to the Hewitt Review, which examined what was needed to help ICSs succeed, maintaining an effective and flexible workforce is essential to give resilience to the system, give breadth of experience and mobilise expertise across ICSs.

Third, to make this happen we need to enable the public health workforce to move between the different levels of geography and different institutions. That will mean removing bureaucratic barriers and aligning terms and conditions. Jointly funded DPH and ICS teams is another possible solution to the capacity and mobility of the workforce.

Fourth, we need to integrate the various roles as well as geographies – public health teams are proactive in their approach to keeping the population healthy, but the NHS is historically reactive to existing disease.

To really improve health and enact change at a population level, prevention must be placed at the heart of everyone’s agenda. This means that tackling the causes of health inequalities and prioritising early intervention is paramount. Crucially, this needs to be reflected across all policy areas, including budgetary and allocative decisions and not confined to a separate prevention ‘workstream’.

A sixth component to successful collaboration is for ICSs to use the experience of public health teams – and vice versa – so we don’t waste time and effort reinventing the wheel or trying to find new solutions to long standing challenges. It is equally vital to engage with the voluntary sector and other local partners, including those beyond health and care who, as we saw when trying to increase uptake for the Covid-19 vaccine, can play a pivotal role in changing outcomes for specific communities.

Finally, we must ensure that barriers to data sharing are overcome – when different agencies have different access to different statistics, it presents untold challenges. By sharing local data effectively ICSs can take a targeted, data-led approach to designing and delivering services, identifying and reducing inequalities and, ultimately, improving population health.

There is hope though, and while we were disappointed to see the Government’s recent response to the Hewitt Review dismissed the proposal to commit to increasing the share of NHS spend on prevention, we do definitely share the ambition for ICSs to focus on prevention and health inequalities.

As with other system changes before it, DsPH and their teams have adapted and have worked hard with ICSs over the past year to enable strong partnership working for the benefit of everyone’s health and wellbeing. However, moving forward, the i’s need to be dotted and t’s need to be crossed for them to work effectively and, the sooner that is done, the better the outcomes will be for all.

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