Guidance on the preparation of integrated care strategies

Question 1

Introduction

Accepted Answer

Purpose of guidance

This is guidance for ICPs on the preparation and revision of integrated care strategies. This document contains:

an introduction
2 sections of statutory guidance on the preparation and revision of the integrated care strategy including involvement and content
a section of non-statutory guidance relating to the publication and review of the integrated care strategy

In preparing an integrated care strategy, an ICP must have regard to any guidance issued by the Secretary of State.^{[footnote 1]} This includes the 2 sections of statutory guidance within this document.

Case studies have been included to demonstrate and share some of the innovative approaches to service planning and delivery taking place throughout England.

Context

The Health and Care Act 2022 amends the Local Government and Public Involvement in Health Act 2007, and requires ICPs to write an integrated care strategy to set out how the assessed needs (from the joint strategic needs assessments - see glossary in annex B) can be met through the exercise of the functions of the integrated care board (ICB), responsible local authorities (see glossary in annex B) or NHS England (NHSE).

This guidance is focused on the integrated care strategy and does not include all of the benefits we expect ICPs to bring to health and social care, such as their role in convening partners to facilitate cooperation and integration. Our previously published engagement documents include some of those benefits:

This guidance seeks to support systems in the preparation and revision of their integrated care strategies. We recognise the first iterations of integrated care strategies were developed under tight timeframes during the transition year (2022 to 2023) which may have limited their breadth and depth. We have seen some ICPs develop a first interim strategy, with a more complete strategy to follow as ICPs mature and develop. Following engagement with stakeholders on their experiences of developing and writing the integrated care strategy with system partners, we have refreshed this guidance to reflect feedback and learning.

The integrated care strategy should build on existing work and momentum to further the transformative change needed to tackle challenges such as reducing disparities in health and social care; improving quality and performance; preventing mental and physical ill health; maximising independence and preventing care needs, by promoting control, choice and flexibility in how people receive care and support.

The integrated care strategy should set the direction of the system across the area of the ICB and ICP, setting out how commissioners in the NHS and local authorities, working with providers, the voluntary, community and social enterprise (VCSE) sector, and other partners, can deliver more joined-up, preventative, and person-centred care for their whole population, and across the life course. The integrated care strategy presents an opportunity to do things differently to before, such as reaching beyond ‘traditional’ health and social care services to consider the wider determinants of health or joining-up health, social care and wider services, and to take an approach based on health creation (see glossary in annex B), in addition to addressing deficits.

The development of the integrated care strategy can be used to agree the steps that partners, working closely with local people and communities, will take together to deliver system-level, evidence-based priorities in the short, medium and long term. These priorities should drive a unified focus on the challenges and opportunities to improve health and wellbeing of people and communities throughout the area of the ICP and should include consideration of using a ‘life course’ approach, from conception through to palliative and end of life care. These priorities should address how areas will contribute to the ambitions to reduce geographic disparities in wellbeing and healthy life expectancy, as set out in Levelling up the United Kingdom. They should also include how areas will put personalised care and support at the heart of adult social care, help everyone to access outstanding quality care that supports choice, control and independent living as set out in People at the Heart of Care, and put the prevention of mental and physical health problems at the heart of systems’ approaches. They can also include how areas will help deliver reforms to children’s social care and special educational needs and alternative provision (SEND-AP) systems as set out in the government’s Stable homes, built on love strategy and SEND-AP improvement plan.

ICPs and the wider system

The make-up of the ICP

The Health and Care Act 2022 establishes ICBs and requires them to form a joint committee with each responsible local authority in their area. This committee is the ICP as demonstrated in Figure 1 below. In some cases, local authorities might be involved in more than one ICP. Lower tier local authorities - for example, district councils - are not statutory members of the ICP. However, we recognise that such local authorities have an important role in the wider determinants of health and have close connections with local communities. Therefore, in 2-tier local authority areas, district councils should be closely involved in the preparation of integrated care strategies because they have a range of strategic and delivery responsibilities for services including housing, homelessness services, planning and spatial development, and leisure services.

The ICP should appoint additional members and determine its own procedures, including the processes for agreeing the integrated care strategy. The power to appoint additional members should also be used by the ICP to ensure that multiple perspectives shape the integrated care strategy. For example, ICPs may wish to appoint representatives from adult social care providers and the VCSE sector. When drafting the integrated care strategy, ICPs should consider organisations whose work may be relevant, including those in the VCSE sector, but who may not have a presence in the area of the ICP. Some ICPs have used their powers to appoint additional members to include representatives from district councils in their membership - for example, the Hampshire and Isle of Wight ICP.

Figure 1: the make-up of the ICP

The purpose of the integrated care strategy

The integrated care strategy is an opportunity to work with a wide range of people, communities and organisations to develop evidence-based, system-wide priorities that will improve the public’s health and wellbeing and reduce health inequalities. The integrated care strategy must set out how the assessed needs (identified in the joint strategic needs assessments produced by the health and wellbeing boards) of the local population are to be met by the ICB, responsible local authorities and NHSE (when commissioning in that area - for example, when NHSE is working with the ICB or a partnership of ICBs to commission specialised services). Where relevant, these commissioners must have regard to the integrated care strategy when exercising any of their functions.^{[footnote 2]} This includes their commissioning functions, plans and strategies. The 5-year joint forward plan (produced by the ICB and NHS trusts and foundation trusts) should be used as a mechanism for delivering the integrated care strategy.

The process of developing and revising an integrated care strategy is itself an opportunity for partners to work together, including those who have not always historically been directly involved in developing health and wellbeing strategies, such as, but not limited to, social care providers. Once a strategy is published, ICPs should continue to consider how it is implemented and evaluated. The strategy could include important strategic priorities for system-level action, to tackle the needs identified in the joint strategic needs assessments, complementing what is already being done at ‘place’ (see glossary in annex B). This is not about taking action on everything at once, nor should the strategic priorities for system-level action be overly prescriptive on what is occurring locally - for example, in health and wellbeing boards. It should aim to build upon previous system-level plans and strategies.

The Care Quality Commission’s (CQC’s) reviews will assess how the integrated care strategy is used to inform the commissioning and provision of quality and safe services across all partners within the ICS. This could include, for example, the equal partnership between the ICB and the ICP. The Secretary of State has also set integration as a priority for these reviews to understand how effectively the organisations within each ICS are forming strong partnerships and integrating their leadership arrangements.

Place, health and wellbeing boards and subsidiarity

Health and wellbeing boards are an important mechanism for driving joined up working at place level. The health and wellbeing board remains responsible for producing both the joint strategic needs assessment and the joint local health and wellbeing strategy (see glossary in annex B). The integrated care strategy should complement the production of these local strategies. It should identify where needs could be better addressed at ICS level and bring learning from across places and the system to drive improvement and innovation, for example challenges that could be met by integrating the workforce or considering population health and care needs and services over this larger area. It should not replace or supersede the joint local health and wellbeing strategies, which will continue to have a vital role at place. DHSC published guidance on health and wellbeing boards which considers how ICPs and health and wellbeing boards should work together.

The integrated care strategy should reflect and complement, not supersede, any other place-based plans and strategies - for example, shared outcomes frameworks being developed by place partnerships. In cases where the geographical area covered by a place-based arrangement is coterminous with that of a health and wellbeing board, the joint local health and wellbeing strategy produced by the health and wellbeing board may act as the shared outcomes framework the government expects place partnerships to develop. For more information about shared outcomes, see the ‘Approaches and mechanisms’ section below.

The ICP must consider refreshing the integrated care strategy when it receives a new joint strategic needs assessment. The ICP should continue to consider how its integrated care strategy aligns with shared outcomes frameworks produced by places within its geographical area, and in light of any new policy announcements. A health and wellbeing board is required to consider revising the joint local health and wellbeing strategy on receiving a new integrated care strategy, but need not produce a new strategy if it considers the existing strategy sufficient.

There should be alignment between system and place level strategies and plans. Figure 2 highlights that the integrated care strategy, as a system-level strategy, should complement the place-level joint strategic needs assessment, joint local health and wellbeing strategy, and any place-based shared outcomes framework.

Figure 2: plans and strategies at system and place level within ICSs

Text description for Figure 2

At place level, joint strategic needs assessments are produced by health and wellbeing boards and set out the needs of the local authority’s population. These in turn shape joint local health and wellbeing strategies, also produced by health and wellbeing boards, which set out how these needs will be met. They may also shape place-based shared outcomes frameworks.

At system level, joint strategic needs assessments produced by health and wellbeing boards shape the integrated care strategy produced by the ICP. The strategy should set the overall strategic direction for the system as a whole, including by shaping the 5-year joint forward plan produced by ICBs and their partner trusts and foundation trusts. Health and wellbeing boards are required to consider revising their joint local health and wellbeing strategies on receiving a new integrated care strategy produced by the ICP.

The ICP should ensure that it builds the principle of subsidiarity in the system, encouraging partners to reflect on whether decisions and delivery are happening at the right level when they produce the integrated care strategy. This can be achieved by having regard for the priorities and outcomes set at place to inform the strategic direction for systems as a whole.

For a few ICPs, there will be just one joint local health and wellbeing strategy in their area. It is up to the health and wellbeing board and ICP to determine how the joint local health and wellbeing strategy and the integrated care strategy will complement each other and ensure that the assessed needs are addressed between them. For example, the integrated care strategy could focus on integration with health-related services, sharing best practice and encouraging innovation across the system, bringing a wide set of data or evidence from research and practice to complement the joint strategic needs assessment or on issues that span multiple ICPs such as the provision of ambulance or specialist services.

Legal requirements and definition of terms

Definitions of terms

Where ‘must’ is used, this indicates that there is a statutory requirement. ‘May’ indicates that action could be taken, but it is not a requirement to do so. Where ‘should’ is used it indicates that something is not a legal requirement, however, note the section on ‘Legal duties and powers of the ICP’ which is relevant to the statutory components of this guidance.

Annex B contains a glossary of terms commonly used in this document.

Legal duties and powers of the ICP

In preparing the integrated care strategy each ICP must have regard to guidance issued by the Secretary of State (including this guidance or future guidance on the preparation of the integrated care strategy). Alongside this requirement, ICPs, when preparing an integrated care strategy, must also consider the areas set out in the following table, cross-referenced to the appropriate points in the guidance.

Legal duties and powers - where to find more information in this guidance

Statutory requirements	Further detail in this guidance
The integrated care strategy must set out how the ‘assessed needs’ from the joint strategic needs assessments in relation to its area are to be met by the functions of ICBs for its area, NHSE, or responsible local authorities.	See ‘Evidence of need and the integrated care strategy’ for detail on evidence of need. See ‘Content of the integrated care strategy’ for a non-exhaustive selection of topics for the ICP to consider, including: - shared outcomes - quality improvement - joint working and section 75 of the NHS Act 2006 - personalised care - disparities in health and social care - population health and prevention - health protection - babies, children, young people and their families, and healthy ageing - workforce - research and innovation - ‘health-related services’ such as housing and domestic and sexual abuse services - data and information sharing
In preparing the integrated care strategy, the ICP must, in particular, consider whether the needs could be more effectively met with an arrangement under section 75 of the NHS Act 2006.	See ‘Joint working and Section 75 of the NHS Act 2006’ in this document for further detail on this requirement.
The ICP may include a statement on better integration of health or social care services with ‘health-related’ services in the integrated care strategy.	See ‘Health-related services’ in this document for further detail on this power.
The ICP must have regard to the NHS mandate in preparing the integrated care strategy.	See the section in this document on the ‘NHS mandate’ for further detail on this requirement.
The ICP must involve in the preparation of the integrated care strategy: local Healthwatch organisations whose areas coincide with, or fall wholly or partly within the ICP’s area; and people who live and work in the area.	See the section on ‘Involving people and organisations in the strategy’ for further detail on involving people and groups for the ICP to consider, including: - local Healthwatch - people and communities - providers of health and social care services - the VCSE sector - local authority and ICB leaders - wider organisations - other partnerships and forums
The ICP must publish the integrated care strategy and give a copy to each responsible local authority and each ICB that is a partner to one of those local authorities.	See the section on ‘Publication and review’ for further detail on this requirement.
ICPs must consider revising the integrated care strategy whenever they receive a joint strategic needs assessment.	See the section on ‘Publication and review’ for further detail on this requirement.

NHS mandate

The government sets objectives for NHSE through a statutory mandate. The ICP must have regard to the mandate, alongside the guidance from the Secretary of State, when preparing their integrated care strategy.

For ICPs, having regard to the mandate means following the mandate unless there are compelling or exceptional reasons not to do so. In practical terms, ICPs should ensure they act in accordance with the mandate, where its content is applicable to their context. The mandate will also be reflected in NHSE’s own strategic documents and planning guidance.

Transitional period

We recognise that 2022 to 2023 was a transition period for ICSs. ICPs are at different levels of maturity, and this may be reflected in the breadth and depth of work undertaken to develop the initial strategy. The timeframes for ICPs to publish an initial strategy by December 2022 may mean it was difficult to engage with all groups in its development as intended.

Moving forward, we expect that ICPs will have more time to refresh and develop their integrated care strategy as they grow and mature. Integrated care strategies should continue to influence the 5-year joint forward plans produced by ICBs and NHS trusts and foundation trusts which are to be published by 31 March each year. Where relevant, commissioners must have regard to the relevant integrated care strategy when exercising any of their functions.

Question 2

Producing an integrated care strategy

Accepted Answer

Responsibility for developing the strategy

The ICP is responsible for preparing the integrated care strategy, so ICBs and responsible local authorities should engage, co-operate and provide the necessary resources for the preparation for the strategy. Other partners that are appointed to the ICP should participate fully. The integrated care strategy is an opportunity to consider challenges in the short-, medium-, and long-term about how assessed needs can be met.

As part of establishing their procedures, ICPs should agree their processes for finalising and signing off the strategy. There is more information about the requirements relating to the publication of the strategy later on.

Evidence of need and the integrated care strategy

The integrated care strategy is intended to meet the needs of local people of all ages identified in the relevant health and wellbeing boards’ joint strategic needs assessments. These assessments relate to all health (physical and mental), and social care needs of the whole population. ICPs should use these assessments to explore gaps in care, unwarranted variation, and disparities in health and care outcomes and experiences between parts of the population and understand opportunities where system-wide action could be effective in improving these, including addressing the wider determinants of health and wellbeing, and preventing ill-health and future care and support needs.

However, ICPs should aim to go further, drawing on additional intelligence such as:

assessments of local communities^{[footnote 3]} and needs developed by providers
the perspectives of local communities
the priorities and needs as identified within their local multi-agency safeguarding structures and partnerships
evidence from research and practice

This intelligence can help ICPs to build on their understanding of health and care needs and further articulate how those needs can be met. ICPs should take an asset-based approach, looking at what communities are already doing well in addition to where there are health deficits, and seek to work alongside local people to build physically and mentally healthy communities.

Groups who can be under-represented in assessments of need

While joint strategic needs assessments are useful to understand assessed needs, they will not always be able to offer a comprehensive overview of all population health and care needs, due to limitations in data and information. Some people, such as but not limited to unpaid carers (including young carers), victims of domestic abuse and sexual violence, those in inclusion health groups (see the definition below) and others who face social exclusion, can be systematically missed in data sources that feed into assessments. This is because, for example:

they are not registered to receive health services
they are not visible in health and care datasets
they or others do not recognise that they have a health or care need

ICPs should consider support for both child and adult victims of abuse and neglect, including domestic and sexual abuse, to prevent and reduce incidence and any associated risk factors through early intervention and prevention. This should include identifying support which enables seamless service provision within health-based settings and the community.

Inclusion health

‘Inclusion health’ describes action to improve health and care for people who are socially excluded, experience multiple overlapping risk factors for poor health (such as poverty, violence and complex trauma) and stigma and discrimination. They are not consistently accounted for in electronic health databases, which makes them effectively ‘invisible’ in health and care needs assessments. These experiences frequently lead to barriers in access to healthcare and extremely poor health outcomes, contributing considerably to health disparities. Inclusion health groups typically include people experiencing homelessness, including people who sleep rough, vulnerable migrants, refugees, Gypsy, Roma, and Traveller communities and sex workers, as well as victims of modern slavery and abuse, people with drug and alcohol dependency and people in touch with the criminal justice system.

Paucity of data and other evidence can itself be a significant barrier to the provision of effective, integrated care. The integrated care strategy should identify opportunities for improvement and research where there are gaps in evidence either of health and care need or gaps in how those needs might be effectively met (see ‘Evidence of need and the integrated care strategy’).

The Health and Care Act 2022 amends the National Health Service Act 2006 to require ICBs to have regard to the need to reduce inequalities between persons, not just patients, in respect to access to health services. ICPs should consider groups which may have the greatest need for services, but the greatest difficulty in accessing them, and take steps to remove barriers and improve provision.

The integrated care strategy should ensure that the needs of underserved populations, not only patients, are identified and met through the ICB, NHSE or responsible local authorities exercising their functions. This may involve taking steps that are not traditionally seen as healthcare interventions, but which are necessary to help mitigate inequalities. Best practice from meeting the needs of underserved populations could be extended to the wider population.

North West London (NWL) Homeless Health programme

NWL Homeless Health programme brings together local authority housing leads, the voluntary sector, specialist health services and delivery leads from across the integrated care system. The NWL Homeless Health dashboard extracts primary and secondary healthcare, homelessness and rough sleeping data, to drive a population health approach, while local multi-agency Homeless Health partnership groups develop tailored local plans. Deliverables include:

100% implementation and accreditation of safe surgeries in Brent
primary care homelessness community of practice led by a specialist GP
homelessness resources linking primary care to electronic patient record systems
a pilot nurse-led case management approach in Hammersmith

Lancashire’s ‘Changing Futures’ programme

Lancashire’s ‘Changing Futures’ programme works through 4 Enhanced Service Hubs, bringing together health, housing, substance misuse, social care and probation support around people experiencing multiple disadvantage and repeated, ineffective contacts with public services.

Regular local strategic meetings across the partners work flexibly to provide oversight and problem-solving to address long-standing barriers to co-ordination like data sharing, and feed up to a Lancashire-wide multiple deprivation board co-ordinated through the integrated care system which aims to drive earlier intervention and sustainability of changes across the county.

The approach is leading to more effective engagement with health and wider support services for adults experiencing multiple disadvantage, and reducing repeated demand on A&E and crisis services.

Involving people and organisations in the strategy

In the preparation of the integrated care strategy, ICPs must involve the people who live and work in the area covered by the ICP.

The process of engagement, and co-production with a wide range of people and organisations drawing on best practice and guidance will strengthen the strategy. Local authorities and NHS bodies have established arrangements for involving people and organisations and typically will have worked together for a number of years in developing this engagement. The ICP will want to build on this existing work and discuss how to plan and resource engagement across the system that makes sense to those being engaged.

ICPs should explore which other local partners and stakeholders they will need to engage in the development of the integrated care strategy either directly or indirectly through other organisations. These will vary between areas. Annex A contains a non-exhaustive list of people and organisations that the ICP should consider engaging in the production of the integrated care strategy. The Secretary of State has set a priority on the theme of integration for CQC’s ICS assessments. Each assessment should explore how effectively the organisations within each ICS are forming strong partnerships and integrating their leadership arrangements.

It will be, at times, more appropriate for the individuals or organisations to be involved directly at a local level in their neighbourhoods and communities rather than at the level of the ICP. The ICP should complement and champion this place-based and neighbourhood engagement and ensure that there are mechanisms for relevant local insights, including priorities identified through multi-agency safeguarding arrangements and structures, to inform the integrated care strategy. They should also consider the time and capability of partners to be involved, and how that is most effectively used.

ICPs should also ensure that any engagement or involvement opportunities:

are accessible
are locally available
allow for reasonable adjustments
where appropriate, provide resources and training to build capability and capacity to enable effective participation

The NHSE and DHSC Working in partnership with people and communities guidance contains effective strategies and techniques for engaging people and communities in the development of the integrated care strategy.

The ICP should also be transparent about the process for preparing the strategy from the outset and be clear about those responsible for the strategy, including a publicly available contact details to ensure people and groups can pro-actively engage in the development of the strategy. The integrated care strategy is an opportunity to set out expectations as to how people should be involved across the system. ICPs should ensure that the results of engagement are shared with those who have been involved.

Finally, we recognise that 2022 to 2023 was a transition year, and the level of engagement varied according to the time and resource available to engage people and organisations in the preparation of the initial integrated care strategy. However, we now expect this engagement to be meaningfully embedded as the ICPs mature and integrated care strategies develop.

The following section sets out particular people and organisations to be involved in the production of the integrated care strategy.

Healthwatch

ICPs must involve local Healthwatch organisations in the production of the integrated care strategy and can determine locally what form that involvement takes. ICPs should involve Healthwatch at an early stage in the development of the strategies so they can assist in the development of the engagement approach and strategy.

This might be done individually with each Healthwatch or through a larger network, which many local Healthwatch organisations are forming. Local Healthwatch organisations could contribute in different ways to support the ICP through their statutory functions including:

collating and sharing existing insight about people’s experience of health and care services
undertaking additional research and engagement in support of development or delivery of the strategy to gather the views and experiences of local people, including those from marginalised groups who are seldom heard (including those in inclusion health groups)
providing advice and expertise to support the ICP to undertake and commission community engagement to a high standard
supporting the ICP to collaborate with people with lived experience of inequality to carry out monitoring processes

People and communities

ICPs should consider how a wide range of people are able to engage and input into the strategy. This should include, but is not limited to, proactively involving people with a range of lived experiences of accessing health and or social care services, including:

children in care and care leavers or having a mental or physical health condition
seldom heard voices (such as, but not limited to, children and young people, asylum seekers, refugees, and people with English as a second language)
people experiencing, or at risk of, homelessness
those who commissioners have a responsibility for, but reside outside of the area of the ICB and ICP, such as people providing unpaid care at a distance
those receiving specialist services outside the ICP area

Additionally, ICPs should ensure that this engagement is inclusive of all children, young people and their families and carers (including new and expectant parents).

This engagement should include facilitating the involvement of people who might face additional challenges such as severe mental illness, learning disabilities, or those who face digital exclusion. This should include consideration of people, and organisations who both formally and informally advocate on behalf of people who cannot otherwise easily engage. This engagement should be achieved through involvement and co-production in the preparation of the integrated care strategy. To achieve this, ICPs should draw upon local experience - for example, from local government, providers or VCSE groups (including by and for organisations) to support this engagement. These organisations, like Healthwatch organisations will have existing co-production and citizen engagement mechanisms which ICPs can use and build upon.

The Health and Care Act 2022 amends the National Health Service Act 2006 to require ICBs to promote the involvement of patients, carers and their representatives - for example, local carer organisations - in the exercise of their functions when it relates to the prevention or diagnosis of illness in patients or their care and treatment and ensure that they are involved in the planning, development and operation of commissioning arrangements.^{[footnote 4]} ICPs should also promote this involvement in the development of the integrated care strategy, and consider how the strategy supports personalised care and support (see ‘Personalised care’). ICPs should promote the involvement of all carers, including unpaid and young carers.

NHSE has published ‘Working in partnership with people and communities: statutory guidance’ to support effective partnership working, improve services and meet public involvement legal duties.

Surrey Heartlands integrated care system: an integrated approach to supporting carers

Surrey Heartlands integrated care system has worked closely with the local health and wellbeing board to develop a carers strategy for 2021 to 2024 in partnership with carers that will improve carer identification, outcomes, experience and quality throughout the ICS.

This system-wide, integrated approach to the strategy will set up a ‘carer friendly’ system to support all carers, regardless of background – for instance, identifying young carers across the health and social care system in Surrey Heartlands, then assessing and satisfying their health and wellbeing needs.

Providers of adult and children’s social care, primary care (including general practice, pharmacy, eye care, dental and audiology services), community health services, secondary care, and public health (including public mental health) services will have important insights into how the needs of local people can be met due to their knowledge, experience and direct links with people who draw on health and social care. The ICP should map out the different types of providers and practitioners who should be engaged in the development of the refresh of the strategy. This mapping should be inclusive of VCSE and independent sector providers. In larger systems, it might be necessary for each place to gather this information and share it upwards with the ICP to ensure full coverage.

It is also important for VCSE and independent sector organisations and providers to have clear access to the ICP. The necessary contact information should be publicly available, with clear ways in which providers, and the independent and VCSE sectors, can support the development of the strategy and beyond.

ICPs should gather input from providers, including through place-based and neighbourhood-level areas (see glossary in annex B). This input should come from a broad spectrum of health and care providers as strategic partners in the preparation of the integrated care strategy. ICPs should recognise that the adult social care provider landscape in particular contains a diverse range and type of providers, many of which are small to medium-sized enterprises, that will be closely tied to the communities they serve and will have important insights to inform the integrated care strategy. The ICP should take into account that these providers will face competing priorities and have differing capacities, and resources to engage in its activities. Nonetheless, the ICP should engage a diversity of perspectives in the strategy, and not assume that the commissioners are adequate proxies for the provider voice. For example, for adult social care providers, ICPs could draw on care associations or similar local, regional or national networks, such as registered managers and individuals networks. When engaging with adult social care providers, the ICP should use the guidance on the expected ways of working for ICPs and adult social care providers to ensure that they are appropriately engaged in the development of the integrated care strategy. When engaging with either children’s or adults’ social care providers and systems, the ICP should refer to the local multi-agency safeguarding arrangements and any sub-boards, which include education settings and other relevant agencies.

ICPs should ensure communications and involvement are appropriate to the providers, make clear the value and purpose of their involvement and the ways in which the development of the integrated care strategy is relevant for them, and how their perspectives and expertise will be used. Conversely, some providers span multiple ICPs. In such cases, ICPs should consider working together to facilitate this engagement.

Greater Manchester Oral Health Sustainability and Transformation Programme

The Greater Manchester Health and Social Care Partnership funded a 3-year £1.5 million Oral Health Sustainability and Transformation Programme, targeting the 4 localities within Greater Manchester with the poorest oral health in children. The programme included daily supervised fluoride toothbrushing programmes in all early years settings, and universal distribution of free fluoride toothbrushing packs and oral health advice by health visitors. It also fostered links between health visiting teams and dental practices to encourage early dental attendance. This system-level approach to oral health was informed by strong evidence of cost effectiveness and was well integrated into early years provision. Some of the main benefits include reductions in primary and secondary care service use.

When engaging with primary care providers and primary care networks to develop the integrated care strategy, the ICP could consider whether it is appropriate to engage with any primary care forums or networks established at system level that represent a breadth of views across primary care, as well as drawing on primary care expertise on place-based boards.

Sheffield primary care mental health transformation

A collaboration between Sheffield Health and Social Care NHS Trust, Primary Care Sheffield, NHS Sheffield Clinical Commissioning Group, Sheffield City Council, Sheffield Mind and Rethink Mental Illness has created a responsive mental health service that has helped to reduce mental health inequalities and delivered person-centred care closer to home. These organisations came together with a pooled transformation budget to develop the primary care and mental health transformation programme. They adopted a novel approach to bring care closer to home, allowing the project to work closer with communities and tap into unmet demand. As a result, in some of the primary care networks they doubled the mental health access rate for minority ethnic groups presenting to secondary care, increasing from 11.6% to 22%.

As well as involving providers, the ICP should involve clinical and care professionals, including those working on the front-line in health and social care as they will have important expertise on how services can be constructed and successfully delivered. To achieve this, they can work through the existing infrastructure that supports clinical and care leadership, to help ensure the widest possible range of clinical and social care leaders are able to contribute.

VCSE sector

The VCSE sector covers a wide variety of organisations with an equally wide range of experience and insights.

There are a wide range of VCSE organisations tackling disparities in health and care and influencing the wider determinants of health. They fulfil a variety of roles including, but not limited to:

organisations led by people with lived experience
service providers (including for social prescribing provision, palliative and end of life care, and housing for people experiencing homelessness)
advice and advocacy services
funders of research

VCSE organisations often offer a practical route to understanding the experiences of the groups who are most minoritised and whose voices are most seldom heard.

VCSE alliances, or similar entities, are present in each area, and will be important from the outset in the production of the integrated care strategy. ICPs should also consider the different roles VCSE organisations can play and facilitate their involvement when relevant - for example, when involving people and communities or providers. This may include consideration of opportunities to work jointly with VCSE organisations to reduce disparities in health outcomes, particularly within inclusion groups.

The decision to involve, and map, VCSE sector members should be reflective of how the organisation can support local population needs, and not be based on whether VCSE organisations work on a national, regional or local basis.

Connections over coffee

NHS Devon has a buddying scheme where 16 leaders from the voluntary and community sector link with 16 leaders from the wider system including the CCG, local authorities and NHS trusts. They spend 12 months getting to know each other through 6 weekly phone calls or cups of tea and learn how their role fits into the overall care picture for Devon. It has facilitated those vital connections that help to reduce the invisible barrier that sometimes occurs between sectors.

NHSE has published guidance on how to embed VCSE sector partnerships in ICSs.

Local authority and ICB leaders

ICPs should involve chairs of health and wellbeing boards, local authority directors of children’s services, adult social services, statutory safeguarding partners, and public health and their teams in the production of the integrated care strategy. While the individuals holding these roles may not be statutory members of the ICP, they are statutory members of health and wellbeing boards, and will be involved in the development of joint local health and wellbeing strategies. This gives them an important role in ensuring coherence across the priorities and objectives.

These directors and their teams also have multiple roles within ICSs, including as leaders at place, in supporting system aims and in helping to inform fulfilment of other legal duties. ICPs should draw on their expertise and guidance, and involve them when considering other sources of relevant expertise. In particular, directors of public health and their teams can provide expertise and guidance on how system partners can work together to improve physical and mental health and care outcomes and experiences across the whole population.

ICPs should engage ICB leads for areas including people, workforce and digital and data, children and young people and those with delegated responsibility for statutory duties, such as the executive leads for children and young people with special educational needs and disabilities (SEND), child safeguarding, vulnerable adults and adult safeguarding.

Engaging ICB leads with responsibilities related to children and young people, combined with directors of public health and directors of children’s services, will give local children’s leadership the opportunity to ensure the strategy meets the assessed needs of babies, children and young people and their families, including:

children with SEND
children involved in Child in Need and child protection procedures
children in care
care leavers

ICPs should also engage with SEND and AP partnerships that will be responsible for producing a local area inclusion plan which sets out how the needs of the local 0 to 25 population with SEND will be met. ICPs and local authorities also need to work together to manage the current and future need for speech and language therapists, who play an important role in supporting children with special educational needs. They will also need to work together to ensure autistic children and young people are supported well, both through the process of formal diagnosis and by having their special educational needs met.

While engagement with these individuals is important, it should not be seen as a proxy for the involvement of relevant providers, people who use services, or the wider workforce.

Wider organisations

The integrated care strategy may include a statement on integration with other services that impact upon people’s health and wellbeing but are not health and care services. Examples will include:

housing and homelessness services
employment support
domestic abuse and sexual violence services
leisure services

See ‘Health-related services’ below for more information.

Some of these services may be provided by local authorities. The NHS Act 2006 imposes on NHS bodies and local authorities a duty to co-operate when exercising their functions in order to secure and advance the health and welfare of people in England and Wales. Section 6 of the Care Act imposes a general duty to co-operate on local authorities and their partners which have functions relevant to care and support, and carers.

ICPs should involve representatives from these other services, and those who commission these services, in the production of the integrated care strategy to understand how these services can be better integrated with health and care services to achieve joined-up, person-centred care and preventative interventions for their population. This should be inclusive of those providers in the VCSE or independent sector.

In 2-tier local authorities, district councils should be closely involved in the preparation of integrated care strategies – because they have a range of strategic and delivery responsibilities for services including housing, homelessness services, planning and spatial development, and leisure services.

Furthermore, other groups such as businesses, employers, schools, colleges, housing providers (particularly registered providers of social housing) and local planning services play a critical role in supporting the health and wellbeing of the local community. Engaging and involving them can identify new opportunities and innovative ways to improve population health.

Improving population health programme in West Yorkshire

West Yorkshire Health and Care Partnership’s ‘Improving Population Health Programme’ has an established partnership with the West Yorkshire Violence Reduction Unit since 2019. Working with public sector institutions and communities to help prevent and reduce violence with a particular focus on adversity, trauma, resilience, early intervention, education and partnership working. This programme brings together specialists from all sectors, including health, law enforcement, local government, education, voluntary and community services and others to understand and tackle the root causes of violent crime, trauma and adversity.

Other partnerships and forums

There will be a range of other partnerships and forums that operate at a system or regional level - for example, violence prevention partnerships and local criminal justice boards. ICPs should, where possible, engage and build relationships with these existing partnerships and forums rather than duplicate their work, and seek to align strategies and plans.

Question 3

Content of the integrated care strategy

Accepted Answer

The content and format of the integrated care strategy will vary from system to system. However, the strategy presents an opportunity to consider challenges, and solutions, across the short, medium and long term. The following section contains some of the areas the ICP should consider.

Approaches and mechanisms

Shared outcomes

Agreement by all actors within the ICS on priority outcomes is a powerful way for the integrated care strategy to bring focus to the system, galvanising joint working and driving progress on the most important outcomes for the local population. We expect this to be an important aspect of all integrated care strategies, which should also consider closing the gap between those at risk of the poorest outcomes and the rest of the population.

We also expect shared outcomes to play an important role in driving integrated working at place level within ICSs, and from March 2024, we expect all places to be able to evidence the work they are undertaking to develop their shared outcomes framework. To support this, DHSC has published a shared outcomes toolkit containing case studies of good practice, suggestions for overcoming challenges, and example frameworks. Although developed with place level in mind, the toolkit can be used at all levels of ICSs to inform the development of shared outcomes. The ICP should continue to consider how its integrated care strategy aligns with shared outcomes frameworks produced by places within its geographical area.

Quality improvement

ICPs should consider how they can meet assessed needs, together with how they can secure continuous and sustainable improvement in care quality and outcomes when preparing the integrated care strategy. This is integral to the ICS becoming ‘self-improving’, as set out in the Hewitt Review. National and regional organisations will also support this aim. The National Quality Board (NQB) has issued a suite of publications to support the development of quality functions in ICSs. CQC also has 2 new functions:

review the exercise of regulated care functions (part 1 of the Care Act 2014) by English local authorities, assess performance of those local authorities and publish a report
review the provision of health and adult social care within each ICB area, assess how well the ICS functions in providing health and adult social care and publish a report

The findings of these new assessments will drive improvements in quality. ICPs should also use established peer support networks to facilitate the sharing of best practice.

Joint working and section 75 of the National Health Service Act 2006

In preparing the integrated care strategy, the ICP must consider whether needs could be better met through an arrangement, such as the pooling of budgets, under section 75 of the NHS Act 2006 (see box). Section 75 is an important tool to enable integration, and ICPs must consider the benefits of section 75 arrangements as part of preparing their integrated care strategies. However, individual section 75 agreements remain the responsibility of the partners involved.

Section 75 of the National Health Service Act 2006 and the Better Care Fund

This is a long-standing mechanism to allow one or more NHS body (for example, NHSE, an NHS trust or NHS foundation trust, or an ICB) to work in partnership with one or more local or combined authorities. These partnerships can include the delegation or joint exercise of prescribed (in regulations) functions, the pooling of budgets, and the formation of joint committees. Section 75 is also the legal mechanism that underpins the Better Care Fund (BCF). BCF plans are jointly agreed by ICBs and local authorities and signed off by local health and wellbeing boards. BCF plans, including narrative plans, include agreement on how these bodies will deliver integrated health and social care services and how a locally pooled fund will be used to support this. BCF plans, including demand and capacity plans, should be considered by the ICP.

As well as formal joint working mechanisms there are a range of other approaches that facilitate joint working - for example:

joint appointments between partners
better data sharing
the co-location of services
integrated teams
joint strategies and plans
aligning budgets

The ICP should consider these in the production of the integrated care strategy (and could be included in the joint forward plan).

Areas to consider in the integrated care strategy

Personalised care

Further integration provides an opportunity to enhance personalisation, choice and flexibility for people who draw on health and adult social care services, and the people that provide them. ICPs should set out how they can support the delivery of personalised care that enhances quality of life and promotes independence across health and social care. This should identify solutions to enable services to join up around the individual holistically, so that their care is tailored to them to meet their current and future needs.

The integrated care strategy could consider how specific types of support can enhance integration of services, such as the role that personalised advice can play in helping people to navigate the system; the use of self-directed support or highlighting ways of enhancing personalisation of care such as exploring new technologies and innovative models of care that can support a highly integrated and personalised experience of care, and pro-actively identify areas for improvement.

The ICP should set out how to address unwarranted variations in population health, including mental health, and disparities in access, outcomes, and experience of health and social care across their population throughout the integrated care strategy. ICBs have duties as to reducing inequalities in access to, and outcomes from, health services. The outcomes achieved also includes patient experience.^{[footnote 5]} Constituent organisations of the ICP that are public bodies are subject to the public sector equality duty.^{[footnote 6]}

ICPs should consider how their integrated care strategy will address unwarranted variation in population health and disparities in health and wellbeing outcomes, access and experience from conception through to end of life. This should also address the drivers of these variations and disparities. In addition, certain groups, such as refugees and asylum seekers, inclusion health groups or people with trauma from violence or abuse (including domestic abuse – see Domestic abuse: statutory guidance), can face multiple disadvantage and multiple barriers to accessing the health, care and support they need. Strategies could include a focus on what specifically could be done to join up services for those experiencing significant and multiple disadvantage to facilitate better outcomes, access and experience. This could include, for example, health, care and housing and other wider determinants of health.

Increasing access to health services in Hertfordshire

To increase access to health services by inclusion health groups, a Hertfordshire GP practice is providing drop-in clinics and community support with a multidisciplinary ‘complex needs team’ in partnership with local authorities and local VCSE partners. They build trust and confidence with people who haven’t been reached before by making it clear that identification or proof of address is not needed for registration and any details shared are confidential, supporting socially excluded people to register. Community navigators help people access wider community support services to meet their needs, such as local physical and mental health initiatives, welfare, housing and education.

Population health and prevention

ICPs should consider how to improve health and wellbeing and how to support prevention of physical and mental ill-health, future care and support needs, the loss of independence and premature mortality (see box for definition). Under Section 2 of the Care Act 2014, local authorities have a specific duty to take steps that contribute to preventing or delaying needs for care and support by adults and their carers in their areas.

Definition of prevention

There is no single definition for what constitutes preventative activity. This can range from wide-scale whole-population measures aimed at promoting health and wellbeing, including the wider determinants of health, to more targeted, individual interventions aimed at improving skills or functioning for one person, or particular groups including carers. At its earliest, prevention activity involves a focus on pre-conception support, pregnancy support, and a focus on the earliest days of life. There are 3 categories of prevention activity, all of which are essential:

primary prevention: population-wide interventions to support wellbeing and mental health or prevent disease or ill-health before it occurs - for example, smoking cessation, social prescribing, reducing loneliness or isolation
secondary prevention: early intervention that slows down or reduces any further deterioration including through detection of early disease and preventing disease progression, reoccurrence or relapse by reducing the impact of a disease that has already occurred (including screening), for example home adaptations, cancer screening, and addiction services
tertiary prevention: formal intervention aimed at managing or reducing the impact of lasting illness or injury for example chronic disease management programmes and services, rehabilitations and reablement or supporting their carers

Definition of population health management

Evidence-based, proactive, data-driven population health management techniques such as targeted predictive prevention and tackling long-term challenges through addressing the wider determinants of health are an important part of the broader task of improving population health. ICPs, when considering how they can address health and social care needs, should consider whether population health management approaches could support people in staying healthy, avoiding illness, and the impact this can have on their and their families’ lives.

Patients with chronic conditions offered personalised care through population health management

Valens Primary Care Network, part of North East and North Cumbria ICS, set up a public health management approach to identify patients at high risk of becoming unwell due to both chronic physical health problems and depression. This was to start proactive, personalised support to improve their health and wellbeing. They set up a working group of health and care professionals including a public health consultant, GPs, a social prescribing link worker and the clinical commissioning group’s Medical Director to analyse the GP surgeries’ SystmOne database and identify people likely to be at high risk of becoming unwell.

Those who met the criteria were proactively contacted by a social prescribing link worker to ask if there were any environmental factors making it more difficult to manage their conditions.

ICPs should ensure the full utilisation of public health expertise and leadership, centring on the local directors of public health. The strategy should include measures to improve health and wellbeing outcomes and experiences across the whole population, including addressing the wider determinants of health and wellbeing. This should include consideration of opportunities to work jointly and use collective resources, particularly where commissioning responsibility is shared between partners, to enable a system-wide approach, including to pursue improved healthy life expectancy and reduced health disparities (see ‘Disparities in health and care’ section).

Warwickshire Care Collaborative

The Warwickshire Care Collaborative has been identified as a discharge front-runner site in the Intermediate care framework for rehabilitation, reablement and recovery following hospital discharge. Health and social care partners across Warwickshire have been working together to improve intermediate care services at home. The collaborative developed and launched a new Community Recovery Service in April 2023 that enables more people to access rehabilitation and recovery services after a hospital stay, with the aim of reducing length of stay in acute hospitals and maximising the home first approach.

Integrated care strategies should explore the role that local government, NHS, other large employers, providers and partners can play as anchor institutions (see the glossary in annex B for a definition), and the potential to use their spending power and significant assets to benefit communities and enhance socio-economic conditions. ICSs are increasingly acting as ‘anchor systems’, working with individual NHS organisations to support their anchor ambitions.

Read more about anchors on the NHSE website

ICPs should consider evidence-based prevention measures in the integrated care strategy to: prevent and reduce mental and physical ill health and their risk factors; hospitalisation and rehospitalisation; the loss of independence; avoidable and premature mortality; long-term ill-health; and future care and support needs. This requires early identification of risk factors and illness and acting early to reduce their impact on individuals once identified.

Preventative action takes many forms, including:

commissioning of prevention services
promotion of health and wellbeing
population health management
intermediate care services
measures to prevent harm, including self-harm, suicide, violence and abuse, including through the safeguarding of adults and children
adopting a broad-based approach which includes action on social and economic drivers of health and wellbeing

Tobacco treatment and prevention in Humber and North Yorkshire ICS

Tobacco treatment and prevention is the number one prevention priority for Humber and North Yorkshire ICS. To do this the ICS set up a multi-agency tobacco steering group chaired by a consultant in public health, which explored and then presented options for implementation of the long-term plan to the board. Once the board agreed the way forward, the steering group became the programme board and refocused on delivery. The ICS appointed a programme manager to co-ordinate and lead the group and ensure coherence across the system and has invested in a communications campaign to increase the likelihood that people who attend hospital are aware that sites are Smokefree and that help is available and will be offered.

Integrated care strategies should also consider how the ICP will work with system partners to achieve a ‘life course’ approach. This includes addressing disadvantages early and better integrated health and care for people of all ages at the critical stages, such as conception through to early years, transitions between life phases, and palliative and end of life care. Ensuring babies children and their families and carers have access to the care and support they need during the critical 1,001 days from conception to age 2 is important for the integrated care strategy to include (see The best start for life: a vision for the 1,001 critical days). This requires focus across the system on Start for Life services and the wider determinants of health.

Similarly, the integrated care strategy should ensure people of all ages with palliative and end of life care needs have access to the care and support they need in accordance with the statutory guidance for palliative and end of life care for ICBs.

Integrated Mersey Palliative Care Team (IMPaCT)

The Integrated Mersey Palliative Care Team model (IMPaCT) is a consultant-led service supporting patients nearing the end of life, and was developed by re-organising existing services with stakeholder involvement. Before it was introduced, services were fragmented and difficult to navigate with more than 40 services involved.

A designated 24/7 phone line drawing on the underlying collaboration between health, care and voluntary sector services enables specialist triage, rapid access to advice and support, and effective information sharing.

As a result, in the first year of operation, it achieved:

a 38% increase in the proportion of people on the supportive care register
fewer deaths in hospital
a 44% reduction in unplanned emergency admissions in the last 90 days of life

Proactive care and integrated neighbourhood teams

ICPs should consider how a proactive care approach can be embedded in the delivery of care for people with complex needs, and the facilitators of this approach. ICBs hold overall responsibility for ensuring implementation of proactive care. Working with relevant partner organisations, primary care networks will be well placed to identify the proactive care population cohort, with multi-professional support and interventions delivered through integrated neighbourhood teams. Integrated neighbourhood teams will likely include professionals from primary care, community services, mental health, secondary care, and the voluntary sector.

There are 5 core components of the proactive care approach:

identifying the target cohort for whom there is the greatest potential impact on health and system outcomes
carrying out holistic assessments, such as a Comprehensive Geriatric Assessment
developing a personalised care and support plan
delivering co-ordinated multi-professional interventions to address the person’s range of needs
providing a clear plan for continuity of care, including an agreed schedule of follow-ups

NHSE has published a proactive care framework which contains more information.

Health protection

ICPs should consider health protection in their integrated care strategy, with system partners including the UK Health Security Agency, local authorities and the NHS who, among other bodies, have health protection responsibilities to deliver improved outcomes for the population and communities served. Health protection includes:

infection and prevention control (IPC) arrangements within health and social care settings
tackling antimicrobial resistance
reducing vaccine-preventable diseases through immunisation
prevention activities related to health protection hazards such as needle exchanges for blood-borne viruses (BBVs)
commissioning of services for response to health protection hazards (such as testing, vaccination and prophylaxis) and to tackle health protection priorities (such as tuberculosis or BBV services)
emergency preparedness, resilience and response (EPRR) across all hazards
other health threats determined as priorities

Babies, children, young people, their families and healthy ageing

Partnership working in Doncaster to support children and young people’s mental health

The Doncaster Children’s Partnership set up the multi-agency Social and Emotional Mental Health (SEMH) Group, which brings together important influencers and decision-makers from the clinical commissioning group, local authority, children and young people’s mental health service provider and other partners including the police. The SEMH Group promotes better joint assessments, planning and service delivery for vulnerable young people in need of care, which has led to reduced delays and improved access to appropriate help and support for children and young people in the local area.

People’s health and social care needs change over their lifetime, and ICPs should produce an integrated care strategy that relates to the needs of the whole population of their area including those of different ages.

The ICP should consider how the needs and health and wellbeing outcomes of babies, children, young people and families can be met and improved. These outcomes are shared by many partners across health, social care, education and other services impacting on the wider determinants of health, in local authorities, the NHS, VCSE and others.

The strategy should consider the integration of children’s services and, for example, whether joint commissioning and the pooling of funding under section 75 of the NHS Act 2006 would meet their needs more effectively.

The ICP has a role to improve outcomes for children and young people who are in complex and/or vulnerable situations and are currently, or at risk of, being deprived of their liberty, by ensuring that health and local authority partners work jointly to commission and deliver the best possible models of care.

The ICP should consider how to use joint funding and resources to ensure that there is suitable treatment and provision available for these vulnerable children and young people.

The integrated care strategy could also consider approaches to sharing information across different partners to ensure the best outcomes for the individual. ICB executive leads, including for children and young people, should be involved in these considerations.

The ongoing development of family hub networks in many local areas should be considered as an important opportunity to integrate with wider health-related services and provide better outcomes and experiences for families.

Family hubs

Family hubs are a way of joining up locally to bring existing family services across the health, education and care landscape together to:

improve access
improve the connections between families, professionals, services and providers
put relationships at the heart of family support

The family hub model is for families with children of all ages (0 to 19) or up to 25 with SEND, with a ‘Start for Life offer’ (0 to 2) (see ‘The best start for life: a vision for the 1,001 critical days’) at its core. The government is investing over £300 million across 2022 to 2025 to develop family hubs in 87 local authorities.

For more information, see the Family Hub Model Framework and resources provided by the National Centre for Family Hubs.

The integrated care strategy could take a whole-family approach, recognising that children’s and their wider families’ physical and mental health needs are inter-connected, and that co-ordination between children’s and adults’ services can support improved outcomes for the whole family. For example, it could consider how the provision of adults’ services can have a knock-on impact on the health and wellbeing of children and young people, and vice-versa particularly if the young person is caring for a parent or other adult.

ICPs should also consider what action can be taken at system level to strengthen the multi-agency safeguarding of children through their local arrangements. This should include identifying how safeguarding partners and relevant agencies, including education settings, could address cultural and technological barriers to the safe and appropriate sharing of information between professionals in different agencies for child safeguarding purposes. Members of the ICP, including the ICB and local authorities, have separate statutory duties as a safeguarding partner. The ICP could support local safeguarding work, but the safeguarding partners retain the statutory responsibilities for safeguarding children in their local area, as set out in Working together to safeguard children.

ICPs could also consider the expectations for practice and the outcomes and enablers set out in the Children’s social care national framework, alongside ‘Working together to safeguard children’. The national framework describes the outcomes that children’s social care should achieve, and multi-agency working, including between ICPs and local authorities, and is an important enabler that is essential to facilitating good outcomes comes for children, young people and families.

Furthermore, ICPs should consider emerging learning from the Families first for children pathfinder, which will design and test major reforms to children’s services, from family help to the edge of care in a number of local areas. These pathfinder areas will design and test important multi-agency reforms relating to family help, child protection, the role of safeguarding partners and greater use of family networks.

The integrated care strategy should also consider healthy ageing, recognising that older adults experience the largest burden of non-communicable disease, including cancer, dementia, and cardiovascular disease. Consideration should be made as to how the needs and health and wellbeing outcomes of older adults can be prevented met and improved, including through mechanisms such as improved housing and technological solutions; and how unpaid carers can be supported in accessing services which will improve outcomes for those in their care and carers themselves.

Healthy ageing also includes ensuring that everyone in later life can experience:

good physical health and mental wellbeing
financial security and independence
a sense of meaning and purpose
social connectedness
better resilience

Integrated care strategies could address these through considering healthy ageing when addressing the wider determinants of health and wellbeing, or through the promotion of health and wellbeing, early intervention, or health screenings.

ICPs should consider important transition points and continuity of care which can cause complications for some people’s health and care. This should include:

becoming a parent
transitioning from maternity to children’s services
moves from primary to secondary and further to higher education
transitioning into and from children’s social care to adult social care
transitioning from children’s to adult services (at age 25) for children and young people with SEND
transitioning from children and young people’s health and mental health services to adult services
entering employment
leaving a secure setting and re-entering the community
receiving adult social care for the first time

Workforce

Meeting the needs identified by joint strategic needs assessments requires effective system-wide co-ordination of the recruitment, planning and development of ‘one workforce’.^{[footnote 7]} ICPs should therefore work with provider organisations to build a workforce that can deliver new ways of working that meet population health and wellbeing needs and wrap care and support around the person. This should apply to the workforces that work across health and social care.

In June 2023, NHSE published the first NHS Long Term Workforce Plan (LTWP), setting out how the NHS will address existing vacancies and meet the evolving needs of a growing and ageing population over the next 15 years. The plan, supported by the government, sets national-level ambitions across 3 areas:

growing the workforce through training
retaining existing talent
working and training differently

As such, refreshed integrated care strategies should reflect these LTWP ambitions, demonstrating a commitment to workforce transformation at a system and place level.

A system approach to apprenticeships in Staffordshire and Stoke on Trent

Staffordshire and Stoke on Trent ICS and partners, as part of their programme to increase the participation of young people from diverse and hard to reach backgrounds in health and care careers, created a rotational apprenticeships across different providers in the ICS. This gives young people a clearly defined vocational pathway from school into a registered profession that does not require them to participate in full time education after the age of 18 or pay university tuition fees.

Participants can work at their own pace to achieve qualifications over a number of years by pausing following the completion of the NVQ level 3 Health and Care Apprenticeship or go straight onto applying for TNA or Registered qualification places. Over the course of the programme, the team worked with different partners in the ICS – including acute, mental health and community trusts, primary care, the local skills council, local authorities – to agree a joint approach to developing people from the local communities to step into health and care careers through rotational apprenticeships, with all partners agreed to provide funding and support for apprenticeship placements.

This will allow apprentices to gain experience of working in a number of different settings and pathways, allowing them to work across a number of different health and care settings. As a result of this initiative, 40 apprentices have been recruited since the scheme was created with 72% of these remaining in health or social care or pursuing higher level qualifications.

To support this ambition, integrated care strategies should highlight the next steps needed to create an integrated workforce across health and adult social care. This should be informed by joined-up workforce planning, talent management and skills development. This could include areas such as:

ensuring there is sufficient high-quality clinical placement capacity, including educator and trainer capacity
promoting and developing more flexible and inclusive careers, supported by joint training and development pathways and the role of anchor institutions
developing system-level data that will help enable integrated workforce planning
developing shared values and common standards^{[footnote 8]}
developing new cross-system ways of working, including through new roles that help enable this
adopting system-wide approaches to recruitment and deployment and bringing teams together - for example, through co-location or creating multi-professional teams
commissioning joint or enhanced health and care roles
delegated healthcare activities with appropriate funding for training and supervision

Joined up careers in Derbyshire ICS

In Derbyshire ICS, the ICS workforce team worked with Joined Up Careers, along with the Department for Work and Pensions, Jobcentre Plus and Futures for Business, to boost recruitment to the Sector-based Work Academy Programme (SWAP). The programme, led by the local City Council, prepares and places new entrants into the health and social care sector in Derby and Derbyshire, particularly targeting support to increase the employment rate for individuals unemployed and or on Universal Credit who are disabled, people aged 50 and over, ethnic minorities and women. As a result of this programme, A total of 299 participants signed onto the pathways into health and social care employment project, many of whom were previously unemployed or economically inactive.

NHSE guidance on Building strong integrated care systems everywhere: guidance on the integrated care system people function further sets out how ICBs can work with ICPs and wider partners to support the delivery of its 10 outcome-based functions, which ICPs could use to support the preparation and revision of their integrated care strategies.

Research and innovation

ICPs should include consideration of research and practice-based evidence in their integrated care strategies, either to address challenges for health and wellbeing boards in assessing need or to improve the understanding of how those needs can be effectively met through the use of evidence from research or from further research. Similarly, the adoption and spread of proven innovation, can be an effective way to address the population needs and reduce disparities in access, outcomes, and experience. For both research and innovation, ICPs should consider involving wider partners (a non-exhaustive list is included in annex A).

Some services will have a substantial impact on health and wellbeing but are not provided by a health or social care provider. For example, victims often access health settings as trusted environments and addressing their wider wellbeing needs is often crucial to aiding recovery from health conditions. Health-related services are defined for the purposes of the integrated care strategy as services that could have an effect on the health of individuals, but are not health services or social care services.^{[footnote 9]} This includes those impacting on wider determinants, such as employment, crime and housing. Integrated care strategies should encourage closer working between commissioners and providers of health-related services and health and social care services. The integrated care strategy may include a statement of its views on how ‘health-related’ services and health and social care services can be more closely integrated. A non-exhaustive set of examples for health-related services are in annex A.

Mental health support for children and young people in Milton Keynes

The Bridge, a primary care network in Milton Keynes, has created a programme with system partners to improve mental health support for children and young people. Taking a bottom-up approach, they worked with several local partners including the public health team, the parish council, local schools, and voluntary and community sector organisations. This included setting up ‘Talk for Sport’, an exercise-based therapy programme which provides 8 weekly gym sessions for young people aged 11 to 18 with low to moderate mental health issues. As a result of this, the post-course questionnaire found that 100% had reached the minimum recommended amount of exercise per week, 69% had improved their mental wellbeing and 76% made new friends.

For those who draw on care and support, the right housing arrangements can be critical to supporting independent living outside of residential and institutional settings. The development of integrated care strategies should therefore explore the opportunities by having a joined-up approach to the planning, commissioning and delivery of housing and broader support services related to housing, and victims, when setting out how they will meet assessed needs.

Improving Access to Psychological Therapies service in Hackney and the City of London

In the London Borough of Hackney and the City of London, employment advisers (EAs) are embedded in the Talk Changes – Improving Access to Psychological Therapies (IAPT) service. They work alongside therapists to support people with depression and anxiety disorders. The EAs - who like their therapist colleagues are employed by Homerton Healthcare NHS Foundation Trust - enable the service to deliver combined employment support and psychological treatment to all IAPT clients who choose this offer. The EAs and therapists work together with clients to develop and deliver personalised plans to enable clients to improve their mental health, find work, return to work and stay in work.

The ICP should explore how data and information is shared safely and appropriately between system partners, and across systems, and how effectively health, care and health-related service data is captured and linked. The strategy could identify opportunities for improved safe and appropriate data and information sharing to meet assessed needs. This could include:

developing the right digital and data infrastructure to combine and link data to improve direct care, build better analytics for population health management and enable and support research and innovation, including data relating to the wider determinants of health, as well as making improvements to overcome data paucity where it exists
identifying opportunities to use workforce, financial and operational capacity data to improve productivity and support better use of scarce resources
exploring opportunities to build data and digital capability among commissioners and providers to inform decision making; improving waiting list management or delivering more personalised and predictive care
building public trust in the use of data by ensuring compliance with the common law duty of confidentiality and data protection obligations for the use and sharing of personal data and transparency and awareness about the use of personal and patient data – for both direct care and secondary health and care purposes – through information materials and sustained communications to people and communities

Question 4

Publication and review

Accepted Answer

Legal basis

This section relates to the publication of the integrated care strategy. This section is not statutory guidance.

Publication

Under the Health and Care Act 2022, the ICP must give a copy of the integrated care strategy to each responsible local authority and each partner ICB of those responsible local authorities. It must also publish the integrated care strategy. Each ICP will need to establish how this is done through their procedures. We expect ICPs to ensure, likely through their constituent organisations, that this strategy is readily available to people throughout the ICS through routes that are most meaningful to people, including those with accessibility needs and low levels of health and care literacy. It is important that the people, their communities, and organisations who have contributed to the strategy are able to see the impact of their contributions reflected in the strategy and, in turn, the effect of their contributions on the provision of services. ICPs should establish clear mechanisms through which these groups and the wider population can give feedback on the strategy and receive further information.

Refreshing the integrated care strategy

Whenever the ICP receives a new joint strategic needs assessment from a health and wellbeing board, it must consider whether the integrated care strategy needs to be revised. Where possible, we suggest that ICPs work with health and wellbeing boards, local authorities and the ICB to align the timelines of their strategies and assessments with the 5-year joint forward plan, which must be published in April each year, and with relevant local authority plans and strategies. ICPs should also consider any changes in their wider context including new or changed policies or guidance when refreshing their strategies. To be transparent and enable wide participation, ICPs should be clear with their partners and the community about their timing cycles and when outputs will be published.

Review and evaluation

When refreshing the integrated care strategy and as part of its ongoing role in the system we expect the ICP to consider whether the strategy is being delivered by the ICB, NHSE and local authorities. This can include, if appropriate, identifying, and evaluating the impact that the strategy has had on population health outcomes, commissioning and delivery decisions. ICPs should consider this impact from multiple perspectives, including providers, local people and communities and those engaged in the production of the strategy.

Section 116ZB(3)(b) of the Local Government and Public Involvement in Health Act 2007. ↩
For NHSE, this only applies when they are exercising any functions in arranging for the provision of health services in the area of a responsible local authority (more than 90% of health services are commissioned by ICBs and very few services are commissioned by NHSE). ↩
This includes, for example, strategic needs assessments produced under the Serious Violence Duty. ↩
Sections 14Z36 and 14Z45 of the National Health Service Act 2006. ↩
Sections 14Z34 and 14Z35 of the National Health Service Act 2006. ↩
Section 149 of the Equality Act 2010. ↩
The ‘one workforce’, as set out in the NHSE ICS Design Framework and the NHSE ICS people function guidance (‘Building strong integrated care systems everywhere: guidance on the integrated care system people function’), is the totality of staff working in health and care across each ICS. It includes those employed by and working in NHS organisations (acute, mental health, community and primary care), in social care, in the VCSE sector, as well as those employed by future ICBs. ↩
This should, where relevant, include values and standards raised in: Leadership for a collaborative and inclusive future, Next steps for integrating primary care: Fuller stocktake report (NHSE), Final report of the Ockenden review, A review of the fit and proper person test and the Sexual safety in healthcare - organisational charter (NHSE). ↩
See section 116ZB(8)(c) of the Local Government and Public Involvement in Health Act 2007 which outlines that ‘health-related services’ has the same meaning as section 195 of the Health and Social Care Act 2012. ↩

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Applies to England