ICPs: Scope for improvement

Integrated care partnerships risk becoming an additional layer of bureaucracy, Deirdre Heenan and Derek Birrell write. The model must have a strong focus on the needs of people using the service and ensure that social care is fairly represented.

A key element of the 2011 strategic review of health and social care in Northern Ireland, Transforming Your Care was the establishment of 17 integrated care partnerships (ICPs) to join together the full range of health and social care services, including GPs, community health and social care providers, hospital specialists and representatives of the independent and voluntary sectors.

It was envisaged that these ICPs would be collaborative networks of care providers, determining the needs of the local population, and planning and delivering integrated services.

The pressures on health and social care including increasing expectations and demands and an ageing and growing population, alongside shrinking resources, mean that radical change in the configuration of the system is essential, if it is to be sustainable, this type of transformation requires radical thinking and fundamental change. Will ICPs deliver this type of change?

Significantly, an ICP was defined as a collaborative network rather than an organisation and did not have any separate statutory existence. ICPs were not set up as a delivery mechanism for services and they sit outside the formal commissioner-provider structure in Northern Ireland of a Health and Social Care Board, advised by five local committees (the local commissioning groups) and five delivery health and social care trusts.

Throughout these documents, the strategic role of ICPs is described as designing care pathways, ensuring local effectiveness and improving how services are planned and delivered. Under these arrangements, if proposals for new services require additional resources then a case must be made to commissioning bodies. The ICP must complete an investment proposal template, which is essentially a business case outlining the rationale, aims, objectives, costs, timescales and benefits. This rather laborious system is required as the ICPs have no budget, no ability to commission services and no legal status.

An examination of the background and the process of implementation of integrated care partnerships does give rise to a number of key issues and questions about the efficacy of the whole process. Seven such key issues are identified:

1. ICPs and the principle of the integration of health and social care

It is not explained how ICPs relate to the existing integrated structures e.g. integrated programmes of care, integrated teams or new reablement strategies. There is an absence of comment on the experience of Northern Ireland’s integrated services and its relevance to setting up ICPs and the narratives in the documentation say little about the value of integrating health and social care.

2. Are ICPs mainly about integrating health care?

The origins of ICPs lie in an initiative to establish primary care partnerships (PCPs) and this is a significant background. Whilst PCPs purported to be concerned with health and social care, their focus was almost entirely health-related. A major consideration is the small representation of social work and care on the partnership committees, which would seem to mean a small voice for social care – this is exemplified most by the presence of one social work representative but two pharmacists. The priority areas identified for ICPs to focus on, with one exception, are strongly medicalised areas.

3. To what extent do ICPs represent partnerships?

The use of the term partnership in ICPs may be somewhat misleading in several senses. ICPs are not a partnership between health and social care in a way the term is used, for example, in Scotland. In Northern Ireland, health and social care are part of the same organisation – as is most of primary care and secondary care – so they cannot form a partnership with themselves.

4. To what extent can they be considered networks?

ICPs are described as collaborative networks rather than organisations. However, as implemented, they appear limited in the context of the usual meaning of networks. Networks usually imply the involvement of a wide range of bodies.

5. User and public involvement

The principles of user and public involvement have emerged as key issues in the delivery of adult social care and integrated care. This relates to input into policy-making, implementation, delivery, training, research and evaluation and has led to developments in co-production, direct control and personalisation. These issues receive almost no attention in the narratives relating to ICPs. User involvement in ICPs is limited to one individual on each ICP committee.

6. Localism

The establishment of 17 ICPs may indicate a focus on a more localised approach in health and social care structures in Northern Ireland.

However, the documentation on ICPs makes very little comment on the promotion of localism, other than a limited reference to ICPs taking account of local needs and local flexibility.

Much more comment seems focused on encouraging conformity, with the policy implementation framework referring to “the avoidance of unsuitable divergence in ICP working in different geographical localities” and to promoting equity of services.

7. Top-down managerialism

A criticism made of health and social care systems in Northern Ireland is that they have a characteristic of managerialism, where top-down decision-making and line management systems dominate and hold power.

The role of managers an20-2d administrators, line management and bureaucratic accountability in the prescribed structures for ICPs would appear to align with this view.

The establishment of integrated care partnerships raises questions about the extent to which structural integration of health and social care has been fully exploited in Northern Ireland, if these additional vehicles are deemed necessary.

Additionally their power, remit, structure, operation and relationship to existing integrated structures and practices suggest they are unlikely to be able to affect any significant change.

If they become glorified ‘talking shops’ then they will have been a dismal failure, with key stakeholders inevitably walking away.

It will be necessary to monitor closely the progress, performance and outcomes of ICPs in order to assess the extent to which they can be an effective vehicle for reshaping services and ensure the focus is on the needs of service users rather than administrative boundaries.

Professors Deirdre Heenan and Derek Birrell lecture in social policy at the University of Ulster.