Integrated care systems (ICSs) must reform to improve patient care
Why we believe integrated care boards (ICBs) need to embrace optometry to deliver eye care services that meet the needs of local people, are high quality, and value for money
Executive summary
The policy aims of integrated care systems (ICSs) are positive: to provide health services that are high quality, affordable, and local. However, if the core aims of ICSs are to meet patient need, we first need to address: the prevalence of GPs on the core membership of integrated care boards (ICBs), being more inclusive of the wider primary care team; more consistency when commissioning eye care services; and greater investment in all of primary care, including optometry. Finding a considered balance of national and local planning is essential.
It is reassuring to see the new Labour government are undertaking an independent review of NHS systems and performance, with a view to making efficiency improvements, which will be led by Lord Darzi. The stated aim of a “greater focus on long termism, investment in prevention, managing demand, and increasing devolution and local integration of services” has the potential to address some of the recommendations we propose, such as an increased amount of funding for primary care. We look forward to the outcomes of the Darzi review and to working with the government to ensure effective implementation.
What’s the background?
As the title suggests, ICSs are partnerships that bring together NHS organisations, local authorities and others to take shared responsibility for planning services, improving health and reducing inequalities across geographical areas.
There are 42 ICSs across England. Each covers populations of around 500,000 to 3 million people.
Since 2016, informal integrated systems have existed in various guises, with The King’s Fund noting that they “largely operated as informal partnerships using soft power and influence to achieve their objectives”.
As part of the 2022 Health and Care Act, ICSs were legally established with statutory powers and responsibilities, as of 1 July 2022.
This meant clinical commissioning groups (CCGs), which were established as part of the Health and Social Care Act in 2012 to replace primary care trusts in April 2013, were replaced.
Covering all of England, the aim of ICSs is to:
- Improve outcomes in population health and healthcare
- Tackle inequalities in outcomes, experience and access
- Enhance productivity and value for money
- Help the NHS support the broader social and economic development.
Statutory ICSs comprise two key components:
- Integrated care partnerships (ICPs)
- ICBs.
NHS organisations and upper tier local authorities in each ICS run a joint committee called an integrated care partnership (ICP). The ICP is responsible for the long term strategy to improve health and social care services and the health and well-being of people in the area.
The ICB is an NHS organisation responsible for planning health services for the local population. There is one ICB per ICS; they manage the NHS budget and work with local providers of NHS services such as hospitals, GP practices and optometry practices.
The King's Fund note that formalising ICSs marked a significant moment for health care in England: “ICSs are the centrepiece of the reforms introduced through the 2022 Health and Care Act and are part of a fundamental shift in the way the English health and care system is organised. Following several decades during which the emphasis was on organisational autonomy, competition and the separation of commissioners and providers, ICSs are intended to depend instead on collaboration and a focus on places and local populations as the driving forces for improvement.”
What has happened in optometry?
Since 1 April 2023, NHS England has delegated responsibility for the General Ophthalmic Services (GOS) contract to ICBs; they now administer and quality assure the GOS contract, but the fee structure is still set at a national level.
Services such as minor eye conditions (MECS) or community urgent eyecare services (CUES) are commissioned at an ICB level; for these local enhanced services, the fees are determined and set by the ICB leading to variation in the remuneration based on location. Each ICB board should be made up of a range of members, primary medical services are represented, but unfortunately primary eyecare, dental and pharmacy services are not core members, meaning the wider primary care voice is diminished.
Based on this track record, we are concerned that the aim to use ICSs to plan how best to deliver services so that they meet the needs of local people, are high quality and are affordable, is not being achieved in eye care.
Most ICBs have some form of enhanced optometric service provision and commission a range of MECS and CUES, glaucoma shared care and other pathways, but often these services are not universally available across the whole ICB and still follow the previous CCG commissioning footprints.
Where these services are not commissioned, the reasons put forward behind the decision to not commission vary. In some areas, it appears that despite many years of evidence, ICBs remain unconvinced about the value that these services bring. We believe these instances are rare. Far more common is a desire by ICBs to commission, but have an inability to do so due to funding constraints. It is well documented that many ICBs are in deficit and are having to make significant savings; in these instances and despite the projected savings enhanced services could bring, they simply do not have the finances required to commission new services.
What needs to change?
In our view there are three changes that would improve the effectiveness of ICSs, patient outcomes, and cost efficiency for NHS England.
True representation of optometry on ICBs
It is essential to ensure there is representation from all parts of primary care at ICB level, including optometry, rather than the GP-centric approach which currently exists.
Our view is that without broader representation from primary care professionals, opportunities are being missed and the approach to service delivery will remain trapped in the status quo. This means that more money will continue to flow into NHS trusts, and GPs will remain the focus whenever primary care is discussed.
Community optometry offers a way to deliver care differently. There is a network of well-equipped optical practices and skilled regulated clinicians who should be enabled to deliver care closer to where patients live, freeing hospital capacity and improving patient experiences.
Investing in primary care
We welcome The King’s Fund report, Making care closer to home a reality, which calls for a “wholesale” shift in focus from hospitals to primary care: “The failure to grow and invest in primary and community health and care services ranks as one of the most significant and long-running failures of policy and implementation in the NHS and social care for more than 30 years”.
As an example, it shows that the number of hospital specialists grew four times faster than GPs between 2016/17 to 2021/22.
We argue the proportion of DHSC spending on primary care has to now increase. The report highlights that the proportion of DHSC spending on primary care has fallen from 8.9% in 2015–16 to 8.1% in 2021–22.
Evidenced-based approach to funding in primary care
A number of high profile funding commitments have been made in primary care:
- Pharmacy First will receive approximately £600m across two years
- The plan to tackle the problems in NHS dentistry will receive £200m.
While tackling important issues for patients, we argue that a more strategic approach is needed by ICBs, using an evaluation and risk stratification model for all health-based commissioning. This is important because it helps to avoid duplication of effort and unnecessary cost burdens.
We believe that adopting this approach would demonstrate why increased funding in optometry is beneficial.
For example, based on our modelling, we estimate that an additional £75m would enable NHS England to commission MECS/CUES across the whole of the UK. Furthermore, our cost analysis indicates that by utilising primary care optometry for glaucoma monitoring, in conjunction with schemes that look to reduce referrals into hospital eye services (HES), could achieve a cost saving of between £36m and £72m (based on 2020/21 glaucoma patient volumes). Using patient volume projections for 2030/31 these figures rise to between £46.5m and £93.5m.
Unlike other areas of primary and secondary care, additional funding to support the workforce, capital and revenue investment in technology, and estates, is not required. Operating as private sector, community optometry businesses continue to invest heavily in equipment including optical coherence tomography (OCT) to deliver high quality clinical care, locally.
The bigger picture – balancing national and local planning
One of the core policies of NHS England since the 2012 Health and Social Care Act has been commissioning locally, with local decisions for the needs of local people. There is much to recommend with this approach; enabling those who live and work in an area to make informed decisions about the local challenges.
However, our view is that more nuance is needed. Today, the NHS is dominated by two health factors: the scale of our growing ageing population, specifically those aged over 75; and the growing number of people living with chronic health conditions that need long-term management.
In this context, the benefits of thinking and acting locally are being outweighed by poor patient outcomes and a lack of value for money.
Our view is that local commissioning to tackle specific population challenges is essential. On a broader level, however, we conclude that some services should be commissioned nationally to reduce duplication of effort, remove variability, tackle the postcode lottery, and realise efficiencies.
In optometry, 42 variants of MECS/CUES , with 42 contract procurements, 42 contract managers, and 42 accounting and reporting leads, is in our view inefficient and costly. Instead this could be delivered via a national contract, negotiated and designed once, to be delivered to all.
In contrast, we believe that population-targeted interventions for specific at-risk groups can and should be delivered locally. For example, it is documented that the prevalence of glaucoma in African–Caribbean populations is higher, and that disease onset is often earlier than in a Caucasian population; however once diagnosed, treatment protocols are broadly the same as for all glaucoma patients. As the risk to this cohort of patients is higher, a targeted local approach to identify these patients would be an appropriate example of where local commissioning is needed, bringing value for money and improved health outcomes for patients.