Policy paper

Integrated care systems boundaries review: decision summary

Published 22 July 2021

Applies to England

Overview

The Department of Health and Social Care (DHSC) and NHS England have been supporting and developing proposals for integrated care over a number of years, looking at both the operational and legislative opportunities to deliver enhanced integration across the health and care system.

One of the key mechanisms for supporting integration is system working. Since 2018, integrated care systems (ICSs) have developed from pre-existing sustainability and transformation partnerships. They currently exist as non-statutory partnerships between the organisations that meet health and care needs across an area, to coordinate services and to plan in a way that improves population health and reduces inequalities between different groups.

Part of the policy proposed in the Health and Care Bill is for a statutory body to be created to drive forward the progress on integration and continue to strengthen relationships between organisation in an area. The statutory body will be known as an integrated care board (ICB), and it is intended that the area for each ICB, once established, matches the area for the existing non-statutory integrated care system.

This work being done now to review and update the ICS boundaries will:

• ensure those areas are appropriate
• allow any necessary clinical commissioning group (CCG) mergers to take place
• improve patient outcomes by achieving coterminosity where possible
• allow the smooth transition to the statutory regime proposed by the Bill

Subject to successful passage through Parliament, once the policy proposed in the Bill has been implemented, the ICB, integrated care partnership (ICP), local authorities and NHS trusts and foundation trusts, as well as other local health and care stakeholders in an area working together, will continue to be described as an integrated care system – to carry forward the understanding that joint working is key to providing integrated care.

Several helpful factors have been found key to the fostering of stronger partnerships between the NHS and local authorities, and one key driver is coterminosity of boundaries with one or more upper-tier local authority. Around 70% of ICSs are already coterminous with upper-tier local authority boundaries.

Therefore, earlier this year, DHSC asked NHS England to set out options for boundary alignment in ICS in specific geographies where upper-tier local authorities currently have to work across more than one ICS footprint and to assess the impact of changes to deliver alignment in each case. Over the last 6 months NHS England has worked with stakeholders to develop advice and analysis for each of the affected areas to inform the Secretary of State’s decision.

This work has now concluded, with advice provided to the Secretary of State for Health and Social care. A final decision has been taken for the areas in scope:

• East of England

• Frimley

• Bassetlaw

• Glossop

• West Birmingham

• North Northamptonshire

Cumbria and North Yorkshire were also identified as areas with non-coterminous boundaries. However, due to the ongoing local government unitarisation consultation and process conducted by the Ministry of Housing, Communities and Local Government (MHCLG) in these 2 areas, they were deemed out of scope of this review. This was due to the possibility of changing local authority boundaries affecting timings of the review’s conclusion.

Coterminosity

This work has been underpinned by the principle that coterminous boundaries deliver clear benefits in integration between local authorities and NHS organisations. As approaches to integrated care develop it is crucial that we have a system that helps support closer working both across NHS organisations and between the NHS and local government.

It is envisaged that local authorities, through the Health and Care Bill, subject to its parliamentary passage, will have a statutory seat on ICBs and will play a key role in establishing and leading ICPs. As such it is important that once established in legislation ICBs and ICPs have the best opportunities to build strong relationships between NHS and local authority stakeholders.

On the ground, coterminous boundaries can also improve joined-up decision making on delivery of services for patients. Improved alignment can allow areas to build joint care models around a wide variety of services including children’s and adult social care services, public health, as well as community and mental health services which are often also aligned along local authority footprints.

This alignment can also help deliver more cohesive targeting of population health management interventions through public health and NHS alignment to support reduction in health inequalities across local authority footprints and aims to improve outcomes for patients.

There has therefore been a strong presumption of moving towards coterminosity, save for in exceptional circumstances where there were strong reasons for not doing so.

ICS boundary review process

Since the initial request, NHS England regional teams have conducted robust engagement activity with local stakeholder organisations to develop analysis of the risks, mitigations and benefits for any options for coterminous boundaries in the affected areas. This engagement has included roundtables with local NHS organisations, including the ICSs themselves as well as providers, commissioners and local authorities.

DHSC has engaged at ministerial level with parliamentarians as well as national organisations such as NHS Providers and the Local Government Association to ensure their views were reflected in the final advice to the Secretary of State and they had an opportunity to feed into the development of this work.

Where members of the public have written to DHSC or NHS England regarding this work their views have been taken into account as part of the recommendations and advice to the Secretary of State.

Final decision process

As set out at the beginning of the process the principle underpinning these decisions was one of moving to coterminous boundaries, with a non-coterminous status quo being maintained only in exceptional circumstances.

The Secretary of State for Health and Social Care’s decision process has involved careful consideration of a wide range of issues, perspectives and interests and a careful weighing up of risks and benefits, outlined in the analysis provided by NHS England for each area. These have been considered on an case-by-case basis for each area. Where NHS England has made a recommendation based on broad (not universal) local consensus, including a recommendation to retain the status quo, the Secretary of State has listened and has accepted these recommendations. There was not a broad local consensus for 3 of the areas within this review and as such no recommendations were made by NHS England. In these areas a balanced judgement was taken by the Secretary of State, weighing up the risks and benefits of a change in boundaries and having regard to his legal duties including his public sector equalities duty.

Final decisions for affected areas

East of England

The areas in the East of England affected by the review are considered an appropriate exception to the principle of coterminosity. No changes will be made to existing boundaries.

The Secretary of State appreciated the significant work that had been done in the area to develop a joint paper across NHS and local authority bodies to inform the decision. There was no local consensus in this area and so the decision was taken based on a consideration that the benefits of the status quo outweighed the risks of moving to coterminous boundaries.

The considerable progress already being made with integration at a local level was noted as a key benefit of the status quo with respect to partnership working and system recovery. The importance of recognising the concerns regarding different types of local authority and their representation in the potential proposed new boundaries for ICSs was also noted.

It is hoped though that learning from this review and analysis which developed suitable mitigations to any risks to integration arising from the status quo option can continue to be developed by the systems affected, particularly in the 4 key areas identified in this analysis including:

• governance and system working arrangements
• population health and wellbeing focus
• development and provision of health and care services
• relationships, trust and ways of working

As we move towards the next stage of development of statutory ICBs and ICPs it will be important that appropriate changes are made to system working to ensure even stronger relationships can be developed with local authority partners in this region.

Frimley

Frimley ICS is considered an appropriate exception to the principle of coterminosity. No changes will be made to existing boundaries.

This is in line with NHS England’s recommendations for this area as well as the vast majority of stakeholder feedback from local authorities, NHS organisations, representatives of primary care and parliamentarians.

It was also evident that this high-performing ICS is delivering very effective outcomes for its residents and has already undertaken significant work to reduce the issues non-coterminous boundaries may have for patients in the area. This includes undertaking an independent review in 2020 to this effect. The status quo position allows Frimley the opportunity to continue to implement the conclusion of this review and develop:

• clear collaborative partnership arrangements with bordering ICSs and local authorities on populations of joint interest

• the development of a provider collaborative in Frimley to drive service development and redesign with further ambition

• the further development of arrangements in ‘place’ with the 5 local authorities Frimley works closely with, and indeed by extension the district authorities

It was also clear that there was no alternative option to the status quo that would provide a naturally coterminous outcome for Frimley that would not result in a significant disbenefit to one or more stakeholders in the system. As such, it was concluded that there was enough evidence to qualify Frimley as an exception to coterminous boundaries.

Bassetlaw

The decision has been taken to move the area of Bassetlaw from South Yorkshire and Bassetlaw ICS into Nottingham and Nottinghamshire ICS.

There was no local consensus in this area and so the decision was taken based on a consideration that the benefits of coterminous boundaries outweighed the challenges.

The benefits of the decision are that coterminous boundaries deliver not just alignment with local authority services but also community, mental health and ambulance services provided on a county-wide footprint and alignment in this manner also enables the development of strategic plans for prevention, population health and tackling inequalities. But in taking this decision the Secretary of State considered a wide range of factors, including:

• alignment of health and care services
• acute provider patient flows
• opportunities to develop strong place-based arrangements

He also considered the extent to which any concerns raised could be mitigated and the plans in place for such mitigations following a decision.

It important to stress that for this and any other areas a decision on these boundaries will not impact a patient’s right to choose or use services outside of their ICS, nor do ICS changes mean any local services to patients and residents will change, including Bassetlaw Hospital. Once established, subject to Parliamentary passage of the Health and Care Bill, the allocation of resources to each ICB (which will align with ICS areas) will continue to be determined by NHS England, based on longstanding principles of ensuring equal opportunity of access for equal need and contributing to the reduction of health inequalities.

Glossop

The decision has been taken to move the area of Glossop from Greater Manchester ICS into Derbyshire ICS.

There was no local consensus in this area and while the historic partnership and strong relationships developed in Tameside and Glossop were noted, the decision was taken based on a consideration that the benefits of coterminous boundaries outweighed the challenges.

The benefits of the decision are that alignment enables more opportunities for joined-up working with the local authority and the creation of joined-up plans for prevention and population health to improve provision for local people as well as greater alignment between community, mental health and ambulance service provision which provide a county-wide service.

As with Bassetlaw it is important to stress that this decision will not impact any individual patient’s right to choose or use services outside of their ICS, nor do ICS changes mean any local services to patients and residents will change. It will also be important that all parties work together in the region to implement this change in a way that retains the learning and relationships developed as part of Greater Manchester ICS and incorporates all mitigations required to ensure a smooth transition.

West Birmingham

The decision has been taken to move West Birmingham from the Black Country and West Birmingham ICS into Birmingham and Solihull ICS, thus delivering coterminous boundaries for the area.

Ensuring all of Birmingham City Council is now aligned with Birmingham and Solihull ICS will support greater opportunities for the area to strengthen partnership working between the NHS, local government, public health and social care.

We are aware the affected systems have also expressed some important conditions for success that need to be delivered through the implementation process in order to ensure the transition to coterminous boundaries is successful. It will be important that stakeholders work together to implement these changes.

North Northamptonshire

The decision has been taken to move the Lakeside Healthcare GP practice (Oundle) into Northamptonshire ICS and retain the Wansford and Kings Cliffe GP Practice in Cambridgeshire and Peterborough ICS.

This is in line with NHS England’s recommendations for the area. The Oundle practice serves a population of largely North Northamptonshire residents. By including this practice in Northamptonshire ICS, we will enable those who reside in the new North Northamptonshire Council geography to enjoy better alignment of local place relationships and community service flows in North Northamptonshire.

For Wansford and Kings Cliffe GP Practice it was considered that this practice has a main surgery (Wansford) that serves a population of largely Peterborough residents that is located immediately adjacent to the border (on the North Northamptonshire side) and a branch surgery serves a population in North Northamptonshire. As such it was deemed appropriate that it retains its inclusion in Cambridgeshire and Peterborough ICS to continue to align with other health and community services for the people of Peterborough who are the main group served by the practice.

Conclusions

With thanks to the work of NHS England and all of the stakeholders who have contributed to the careful assessment of options, the boundary review process has generated crucial insights that will help different areas to develop closer relationships between NHS organisations and local authorities both in areas that will move towards coterminosity and those that have been considered exceptions.

This learning will be crucial to embed into systems as we move towards statutory ICBs and ICPs, subject to parliamentary passage of the Health and Care Bill, currently anticipated by April 2022.

A decision has been taken now to provide certainty to these affected areas and allow them to continue to build strong relationships and begin work to implement any changes needed as part of the proposed legislative reforms in advance of April 2022.

It is important to note that changes generated from these decisions in any of the affected areas will not impact any individual patient’s right to choose and use services outside of their ICS geography. Once established, subject to Parliamentary passage of the Health and Care Bill, the allocation of resources to each ICB will continue to be determined by NHS England, based on longstanding principles of ensuring equal opportunity of access for equal need and contributing to the reduction of health inequalities.

NHS England has also made an employment commitment for colleagues impacted by this legislation. The HR framework developed by NHS England will also provide guidance on the process to follow for CCGs affected by boundary changes to ensure the appropriate transfer of people in line with this employment commitment. This guidance is designed for leaders and HR colleagues and is due to be published in due course.

Local areas may still wish to keep under review how their boundaries are working in the light of any new legislative framework. Therefore, this decision does not preclude the important work many systems undertake naturally to ensure they have a system and boundaries that best suit local needs. We have already heard such requests from local stakeholders around Cheshire and Merseyside ICS, as such the Secretary of State has also announced his intention to review this system. The Secretary of State also intends to review the areas of Cumbria and North Yorkshire, as we are now aware they will remain non-coterminous following the conclusion of MHCLG’s unitarisation process. These reviews will take place in 2 years, following the implementation, subject to parliamentary passage, of the Health and Care Bill.