The role and contribution of integrated care boards

NHSE's operating model and oversight framework aim to clarify the role of ICBs in the new context of system working, positioning them as the first line of oversight and performance management of trusts. The Hewitt Review also reflected on the role and responsibilities of ICBs, reemphasising the principles of the two frameworks and the importance of subsidiarity and effective co-design.

In our conversations with NHSE, and in our commentary on the Hewitt Review, we have highlighted the inherent tension in ICBs being positioned as convenors and equal partners within their systems, and in overseeing performance. We have identified the challenging position this puts both trusts and ICBs in, and the potential for conflicts of interest.

Figure 10 below reveals overwhelming support from trust leaders for ICBs’ role in fostering a sense of shared responsibility and collective endeavour among system partners (98% agreed), as well as in bringing system partners together to solve problems and share practice on patient care and outcomes (96% agreed). Trusts were also very supportive of ICBs’ constructive work with ICPs (94% agreed), their role in improvement and peer support (89% agreed), and their focus on system performance (85% agreed).

Views were markedly split on the role of ICBs as performance managers of trusts: only 37% were comfortable with this role, while just under a third (32%) disagreed. Acute trusts were the most sceptical, with 44% disagreeing.

While supportive of the aims of ICBs, many respondents said that it was too early to assess their impact and highlighted variable maturity across systems.

Several comments highlighted confusion and lack of clarity around the role of ICBs, with some saying that ICB leaders themselves were unclear.

Several respondents pointed out the importance of culture and behaviours.

A large number of comments reflected views on the optimal role for ICBs – there was a strong feeling that ICBs should focus on collaboration across a system.

There was scepticism around the role of the ICB as performance manager.

A couple of respondents pointed out the potential of provider collaboratives to improve system working, based on their current experience.

The introduction of ICBs was often associated with an increased burden, while the confusion and duplication between NHSE and ICBs was highlighted multiple times. Some trust leaders reported that requests from ICBs had been more onerous than those coming from the regulators themselves.

The past year has exposed trusts and system partners to unprecedented operational challenges, which have tested the resilience and adaptability of the NHS. Over the last 12 months, we have also seen the formal introduction of ICSs, and a set of vital but often competing responsibilities for ICBs. Regulators have been transforming their approaches to make them better suited to system working, and to the evolving expectations of the public and those they regulate.

In this challenging context, our survey shows that NHS providers remain optimistic about the benefits of system working and appreciative of regulators' commitments to cultural change, to alignment with a new system context, and to a more flexible, responsive and risk-informed approach.

However, trust leaders' experiences of regulation often do not meet their expectations. They report an increase in regulatory burden and ad hoc requests from the regulators and are disappointed by a continued regulatory focus on inputs and targets, rather than on outcomes and improvement. They continue to feel that regulators are often unaware of, or worse, that they actively disregard, the operational pressures that providers are facing. Some made concerning observations that, on balance, the focus of regulation does not helpfully prioritise quality and safety.

This year's survey undoubtedly makes for more challenging reading with regard to trust leaders' relationship with CQC. Trust leaders remain cautiously optimistic about the changes CQC has committed to, and about its new role in assessing systems and local authorities. But in this survey trusts have also shared some unsatisfactory experiences of inspections, raising questions about whether CQC is encouraging providers to collaborate and integrate care, and to adequately support innovation and the spread of good practice. Given the vital role that care quality regulation plays in any health system, it is very concerning that many

Trusts are mostly satisfied with the NHS oversight metrics, but still tend to think of the oversight framework as a performance management, rather than a support, tool. They also remain unconvinced that the new operating framework is yet having the desired impact on culture and behaviours. Trusts continue to feel there is a lack of clarity and unhelpful duplication between the roles of ICBs and NHSE, despite supporting the role of the ICB as a convenor and partner in systems.

The story of this year's regulation survey is therefore clear and powerful – change is needed and desirable; however, it needs to be underpinned by a clear shift in culture and behaviours, and must come with clarity on the purpose of regulation and the distinctive roles of CQC, NHSE and ICBs. Trusts recognise the importance and value of good, risk-based regulation, and they are receptive to a more open and collaborative regulatory approach by both CQC and NHSE. They are also firm believers in the potential offered by system working.

We will continue working with CQC and NHSE over the year ahead to discuss, test and refine their developing approaches, remaining a constructive critical friend. We will also continue to make the case for regulation that is meaningful for patients and service users, and that evolves to meet the changing needs of the system and of those regulated.