‘There is a high risk that ICSs will find it challenging to fulfil the high hopes many stakeholders have for them’. This is the verdict of the National Audit Office (NAO) in its assessment of where ICSs are starting from and the challenges and opportunities ahead (click here for full report).

The NAO is positive about the potential of ICSs but realistic about the context in which they are working. It is also unafraid to call out the Department of Health and Social Care (DHSC) and NHS England when it believes they could do more to support ICSs to deliver the strategic objectives they have been established to achieve. Its recommendations should help ICS leaders as they continue to develop their capabilities if the authorising environment in which they operate is willing to listen.

The challenges identified by the NAO are depressingly familiar: financial pressures including long standing deficits in many organisations and eye watering targets for efficiency savings; staffing shortages and the absence of a fully funded workforce plan to address these shortages; and the growing gap between the supply and demand for social care. Hardly surprising then that 31 out of 42 ICSs are in deficit even before the impact of higher than expected levels of inflation and future pay rises are factored in.

The NAO welcomes the opportunity for ICSs to work with partner organisations to integrate care and improve health outcomes but is critical of the failure to establish transparent arrangements across government to tackle the drivers of poor outcomes. It is equally critical of NHS England for not aligning its oversight of integrated care boards with the strategic objectives for ICSs. The focus on financial management and elective recovery crowds out work on prevention and population health, creating a risk that the work of integrated care partnerships within ICSs will be marginalised.

Sensibly, the NAO recommends that DHSC and NHSE should clarify ‘what a realistic set of medium-term objectives looks like under current circumstances’. Readers are left in no doubt that that these objectives should be small in number, include local as well as national priorities, and go beyond core NHS targets to include improvements in health outcomes. The NAO challenges DHSC and NHSE to tackle the financial and workforce pressures that require national level strategies and solutions to give ICSs a greater chance of success.

The need for realism is also emphasised in the NAO’s argument that it will take time for ICSs to demonstrate improvements in health outcomes. Based on a survey of senior ICS staff, the report suggests between three and ten years will be needed for these improvements to become visible. In part, this is because of the lag between intervening to improve population health and seeing the results, and in part because ICSs need time and expertise to establish health creating partnerships.

Work on a new operating framework for the NHS, the latest version of which was published last week (click here for access to the framework), offers an opportunity for NHSE to act on the NAO’s recommendations in conjunction with DHSC. Integration at a local level demands a joined-up approach at the centre and now is the time for DHSC and NHSE to show through their actions that they are in this together.

We have also created a summary snapshot of the new operating framework which can be found here.