The relationship between hospital Trusts and integrated care boards has lacked clarity and, with an increasing push towards providing more care closer to home and the demise of NHS England, much is dependant on how the system and organisations can work to actually achieve this transformation. Kathy Oxtoby investigates the tensions and collaborations.
It is almost three years since the formalisation of integrated care boards (ICBs) under the Health and Care Act 2022 – time enough for relationships to have been building and developing between hospitals and ICBs. Time also for issues with those relationships to have emerged.
In his Independent Investigation of the National Health Service in England in September 2024, Lord Darzi highlighted tensions and duplications between trusts and ICBs.
‘There are significant implementation challenges for the 2022 Act. The function and authority of ICBs remains unclear in some important respects. The 2023 Hewitt Review was unable to clearly define the relationship between providers and ICBs, and the ambiguity persists,’ it stated.
Trusts and ICBs working together
One of the reasons that ‘ambiguity’ exists could be because relationships between hospital trusts and ICBs are still developing.
One of the roles of ICBs is to bring together the providers within its area and to arrange the provision of NHS care. ‘Trusts provide that care. And that’s the core of the relationship between trusts and ICBs,’ says David Williams, head of policy and strategy at NHS Providers.
Then there are the responsibilities of NHS organisations, including ICBs and hospital trusts, as part of the wider system.
The 2022 Act places ‘a triple aim duty on NHS trusts, foundation trusts, ICBs, and NHS England’, says Sarah Walter, director of the integrated care system (ICS) network at NHS Confederation.
She says this duty requires those NHS bodies that commission and provide services to consider the wider effect of their decisions on their population’s health and wellbeing, including inequalities, the quality of services provided, and the sustainable resources.
This relates not only to separate statutory entities, but also other relevant bodies. ‘It’s not just about your own organisation and the impact you’re having – it’s considering the impact that you have across the wider system,’ says Ms Walter. ‘Those duties help to shift the balance at all parts of the system towards collaborative working.’
Acute trusts have a statutory requirement to consider their impact across the wider system and they are also required to be part of a provider collaborative, which often operate at ICS scale or across multiple ICSs.
Ms Walter says ICBs will have ‘a relationship with their trusts through their commissioning function. But the relationship is not limited to this’.
Many acute hospital chief executives will also sit on the ICB board and be part of the decision-making process about the system’s strategy and priorities and are there to represent trusts across that system more broadly, rather than to pursue the specific interests of their organisation.
And as stewards of their ICS, ICBs have a role in convening the system as a whole, in supporting problem solving, and in looking at system performance.
Shared aims
ICBs and trusts have shared aims, says Ms Walter. They have four core purposes, which relate to improving the health of their population, reducing inequalities, improving productivity and value for money, and enhancing socioeconomic development for their area. ‘Those are the aims of the ICS, but they apply just as much to the different partners within the system, including the trusts.’
Each ICS will have a five-year strategy that has been set following engagement and discussion with all system partners, including trust leaders, which will set out their ambitions for their specific population and the areas they want to prioritise. ‘So, there should be a high degree of alignment for what the ICSs and the ICBs are seeking to do, and the role of the trust in helping to deliver that,’ says Ms Walter.
However, the plans contained within these strategies are likely to be under significant pressure given the recent call for 50% cuts to the ICB workforce.
Evolving relationship
The relationship between hospital trusts and ICBs is ‘evolving’, says Chris Naylor, senior fellow at The King’s Fund.
The way the NHS has been run for 30 years ‘has encouraged hospital trusts to focus on their own organisational performance, provision of good quality care within their hospital, growing their market share and ensuring that they remain financially viable. So, it’s an “organisation first” paradigm,’ he says.
‘We’re shifting to a system focus, where hospital leaders are still being asked to run their own ship well, but also to take part in the wider system they are operating in and to take responsibility for the performance and sustainability of that wider system,’ he says.
‘What hospital leaders are being told now is that if you’re providing great services in your local hospital, but down the road there’s a hospital that’s really struggling and providing poor care, that’s not a sustainable situation and not something you should be turning your back on. As a partner in the system, you should be involved in thinking about that broader system.
‘We’re now working in a very different world. But it takes time for behaviours and cultures to change,’ he adds.
The King’s Fund has been doing research looking at how hospital trusts are working with ICBs and ‘it’s a mixed picture’, says Mr Naylor.
‘We do see some evidence of “system focused behaviours” taking root, but we also see a persistence of “organisation first” behaviours’, for example neighbouring hospital trusts competing against each other to attract workforce.’
With budgets ‘under so much pressure it does make some of this system working harder – we see protectionism around budgets, and competition for staff’, he says.
‘Some of the old behaviours are still going on. We’re moving to a different paradigm, but we’re not fully there yet.’
How hospital trusts describe their relationship with ICBs is ‘very variable’, says Mr Naylor. ‘There are parts of the country where there are constructive relationships between hospitals and ICBs, and others where that relationship is still maturing.’
He says The King’s Fund hears that trust leaders are being asked to attend all kinds of system level boards and committees, ‘and there is sometimes a degree of frustration about “is that the best use of my time?” and “are these conversations we’re having leading to action?”’.
Duplication
Duplication between the Department of Health and Social Care (DHSC) and NHS England was cited as key reason for abolishing it, by Prime Minister Sir Keir Starmer when announcing the move.
At the lower levels of the NHS system – between NHS England and ICBs and trusts and ICBs – duplication is also a target of changes in the NHS.
Indeed the new head of NHS England, Sir James Mackey, has written to ICBs asking them to reduce duplication by looking at assurance and regulatory functions, wider performance management and communications and engagement functions.
Successive reports highlighted these various duplications. In his independent investigation, Lord Darzi highlighted the ‘duplications of functions between ICBs and providers, such as in infection prevention and control, where trust boards should be held accountable’, it stated, calling for, ‘more consistency’ and ‘standardisation’ in the way ICBs are organised.
On matters of operational performance, ‘trusts are answerable to NHS England – their statutory regulator as set out in the 2022 Act. As their commissioners, ICBs have a legitimate interest in trusts’ performance, but they have been positioned by NHS England as being expected to do the day-to-day performance management as well, which is a different thing’, says Mr Williams.
As a trust, this meant being answerable to two sets of people for basically the same thing, ‘which has been duplicative’, he says.
Duplication had also been highlighted by NHS Providers Regulation and Oversight survey 2024, which found that while people were enthusiastic about system working they felt ICBs had been put in a position of duplicating NHS England’s work.
Oversight
The new NHS Improvement and Assurance Framework, published by NHS England at the end of March, provides greater clarity on how systems and trusts performance will be assessed.
NHS Providers welcomed ‘The shift in the role and responsibility of ICBs towards strategic commissioning and away from provider oversight’ which had been an ‘added burden’ creating ‘duplication and confusion, and undermining their role as system leaders and partners’.
It replaces the oversight framework, and it is going out to consultation and testing during the first quarter of 2025/26, ahead of final publication and formal implementation in July.
Under the framework, every ICB and provider will be allocated a ‘segment’ score from one to five to indicate level of delivery. One will be high performing, four poorly performing and five to indicate intensive support needed.
Individual organisations will be measured against metrics based on their responsibilities. But ICB scores will be system-adjusted, using system level metrics that will assess performance against national priorities.
Provider scores will also include a separate capability rating based on the extent to which they are collaborating.
Organisations that are in financial difficulty will face a cap on the score they can achieve, with those in deficit limited to a three.
In response to the framework, Ms Walter, raised concerns that ‘ICBs are to be held accountable for all the organisations in their system while providers are not held to account for the part they have to play in system performance. This calls into question the ability of systems to achieve the three shifts’.
She added: ‘Given that many of the intractable issues leading to poor performance are often system issues that can require partnership working to solve, we would want a long-term commitment to system – not just organisational – oversight. Otherwise, this could undermine the positive work undertaken so far to support greater integration across services.’
Moving care into the community
Ms Walter says there is a higher degree of consensus around the need for the shift out of hospital into the community, and that many services could be provided effectively closer to home and in community settings.
Trusts are ‘open to supporting out of hospital clinics’, and many are also now integrated, and cover a range of different types of services, such as acute, community and primary care, she says.
However, while hospital trusts can be supportive of out of hospital clinics and this move of care into the community ‘in principle’, there are ‘all kinds of practical issues that can get in the way of putting this into practice’, says Mr Naylor.
For example, hospital finances ‘are complicated and hard to disentangle, with all kinds of interdependencies between different services within the hospital’, he says. There can be cross subsidisation, with one part of the hospital depending financially on another part of the hospital.
‘The argument we sometimes hear from hospital leaders is that because of those interdependencies across the hospital: “if you take out some of our activity it puts the rest of the hospital’s work in jeopardy”.’
There are, however, ‘positive examples’ of ICBs and trusts working together, says Mr Naylor. For instance, in some areas, ICBs are helping to scale up a successful initiative that has gone on in one trust and spreading it across the whole system.
‘There are also examples of ICSs helping different hospital trusts and other providers within an area to build a sense of shared purpose,’ says Mr Naylor.
‘One of the roles ICBs can play within a system is to be a facilitator between all of the different providers and help them to understand each other better, and to make sure they are pulling in the same direction.’
Integration and ‘left shift’
So, how achievable is integration and the shift out of hospital?
‘Improvement is always possible, and the models of care can change quite a lot,’ says Mr Williams.
For instance, now there are virtual wards where people are receiving specialist care in the community, where once they would have received care in hospital, he says.
Another example is ‘urgent community response’ – getting urgent care to people in the community, rapidly – which did not exist on a large scale a few years ago.
These examples demonstrate that it is ‘possible to bring in quite radical changes to how people are treated within a relatively short space of time’, he says.
‘We’ve seen a lot of progress in recent years towards integrating of services, but there’s clearly still a long way to go. Integrating is as much about cultural change as it is about reforming structures, so it takes sustained commitment over time,’ says Ms Walter.
‘Trusts will play a key role alongside place-based partnerships and neighbourhood teams in supporting the shift towards care closer to home, but it’s certainly not straight forward.’
The NHS Confederation’s state of ICSs survey 2023/24, revealed that while over 90% of ICS leaders surveyed are committed to shifting resource to allow more people to access care closer to home, ‘they are struggling to match that ambition due to financial constraints’, says Ms Walter.
Integration has been a long-term aim. But it’s now that the Government has put delivering care closer to home at the heart of its agenda to reform the NHS.
However, NHS Confederation research shows that with the current environment, where there is a focus on acute hospitals dealing with elective care backlogs, financial deficits and operational pressures, ‘there is a risk that we continue to be locked into a cycle of short-termism, says Ms Walter.
‘It’s important that the Government demonstrates its commitment to moving care closer to home and is able to move from the policy rhetoric, into making it happen.’
Some specific areas where the NHS Confederation believes change would help include ‘ensuring that oversight moves from being focused purely on short term pressures, which are often more acute focused, towards something more holistic, including areas like access and prevention’, she says.
It is also worth considering ‘how we might develop and implement some kind of measure, which enables us to see whether that shift from acute to community is happening in reality’.
Mr Naylor says integration and the shift out of hospital is ‘achievable, but we need a total change in focus across the system’.
‘We need more leadership focus on primary and community health services and social care, and more of a focus on implementation – the “how” of change not just the “what” – tackling those knotty practical issues.
‘All of the government policies – workforce strategies, performance management frameworks, the financial architecture – have to be aligned to the vision in order to make it happen.’
And the way the demographics are changing, including the growing older population, makes integrated care ‘more important than ever’, says Mr Naylor.
To ICB leaders, on achieving closer integration and partnership working Mr Naylor says: ‘It’s about building mutual understanding and investing in relationships with counterparts in hospital trusts, so that you build that strong sense of shared purpose, create a climate of trust, and where there is friction or conflict, you’re able to surface that and manage it quickly and constructively.’
Ms Walter says ICBs and trusts will be ‘working hand in glove to implement change’. ‘There are some areas of complexity to work through, but they’re aligned in their overall ambitions for the impact they are seeking to have on their population.’
ICBs and trusts can expect to work together more on initiatives that bring care out of hospitals and into communities. In his speech at the NHS Providers annual conference last November, Wes Streeting said he wanted ICBs to ‘focus on their job as strategic commissioners and be responsible for one big thing: the development of a new neighbourhood health service’. ‘It will focus on building up community and primary care services with the explicit aim of keeping patients healthy and out of hospital, with care closer to home and in the home.’
Mr Williams says in order for that to happen, it will involve ‘a different way of working between ICBs and providers’.
‘It might mean ICBs being more strategic and less involved in the day-to-day, and therefore providers overseeing more of the day-to-day delivery, and providers in primary, community and secondary care working together in a much more integrated way than they typically do at the moment,’ he says.
‘We now need to work out, as an entire system, how to make that real, rapidly, everywhere. That’s an important task for ICBs and providers to work on together.’
A version of this article was originally published by our sister publication Healthcare Leader.
