NHS England has a legal duty, as set out in the Health and Care Act 2022, to undertake an annual assessment of Integrated Care Board (ICB) performance.
Before setting out the outcome of our assessment I would first like to express my thanks for, and acknowledgement of, all the work that you and your leadership team, and colleagues throughout the ICB, have put into securing the effective transition from the CCG and the establishment of the ICB, and the progress made in the first nine months of ICB delivery.
Integrated Care Boards were formally established on 1 July 2022 and this assessment sets out NHSE’s consideration of how the Integrated Care Board has discharged its key statutory duties since establishment through the 2022/23 financial year. In making this assessment we have sought to acknowledge the relative infancy of ICBs, having only been statutory bodies for nine months of the 2022/23 financial year. We are also mindful of the developing local strategic aims of the Integrated care System (ICS) as set out in the Integrated Care Strategy for the system and articulated through the developing Joint Forward Plan for the ICB.
For 2022/23 NHS England has undertaken a narrative based assessment of Integrated Care Boards. This letter provides a summary assessment of South East London (SEL) ICB’s delivery of its functions aligned to the four core objectives of an ICS, and its key duties. It also covers the ICB’s role in providing and supporting leadership and effective governance across the system. In support of our assessment, we have also sought views from the relevant Health and Wellbeing Boards (HWB) and from the Integrated Care Partnership (ICP), and their input is reflected in the assessment as appropriate.
We appreciate the work that has taken place in this period to manage the transition and to establish the South East London (SEL) ICB on a sound footing. Building on these foundations we also acknowledge the ongoing work as the ICB addresses the challenges to implement a sustainable and effective structure and operating model, and its work to establish effective relationships with key partners across the system, in order to deliver the national and local priorities for health.
The ICB has been positively engaged in the development and production of two key outputs that set the strategic approach to, and plans for, improving the quality of services and outcomes for the population it serves. The Integrated Care Partnership Strategy, which was based on extensive engagement with communities and with relevant partners, sets out the vision and mission for care delivery, and establishes five strategic priorities. This strategy is complemented and supplemented by the ICB’s Joint Forward Plan which sets out how the ICB will look to play its part in the delivery of NHS elements of the strategy, and the ICB’s own objectives for the next five years.
The South East London ICP has commented positively on how the ICB has provided effective and supportive leadership, and on its inclusive approach, referencing the ICB’s work in building a broad cross-system partnership, including local authorities, the Voluntary, Community and Social Enterprise Sector (VCSE) and stakeholders in the local care partnerships (LCPs). This view has been echoed from HWBs, with one drawing specific attention to the positive support the ICB has provided to the working groups set up to lead on delivery of the four priorities in its HWB Strategy.
As the transition beds down we look forward to working with the ICB as its focus switches increasingly to the implementation of the Integrated Care Strategy and the Joint Forward Plan.
Improving population health and healthcare
In the period following becoming established on a statutory footing, the ICB has put in place effective governance structures to support oversight and assurance of quality and safety and to provide a focus on improvement. The ICB has established two new quality forums:
The ICB Quality team complements this framework with more informal meetings with providers to look for themes and emerging issues, in order to develop a more proactive system of identifying risks.
These arrangements are based on the National Quality Board best practice guidance.
The ICB has also set up a Clinical Effectiveness South East London (CESEL) forum, to support primary care through developing resources, training and learning opportunities. We note that this has already attracted funding from Wellcome.
Whilst it is early in the ICB’s existence to expect significant evidence of how the ICB has improved the quality of local services, including outcomes, we do see evidence of progress in this area. The ICB is developing systems and approaches to support improved quality across services. There is a commitment within the ICB to giving equal focus to delivering incremental improvements in access, performance and quality standards and to deliver required efficiency improvements. This is supported by discussion of risks including physical and workforce capacity, the pandemic backlog, increased demand and a material underlying deficit within the system. A further specific example of activity to support improvement is an “After Action Review” relating to the Guys and St Thomas’ IT outage which shows a commitment to learning and applying change to improve system wide responses to similar incidents in the future.
In terms of the operational performance of services during 2022/23, the ICB has had to address, in common with all ICBs, the ongoing impact of the pandemic and the increase in waiting lists, and performance has remained challenged.
For Urgent and Emergency Care (UEC), the ICB’s current 4-hour performance is worse than it was at the start of the year. However, following deterioration between March and December 2022, whilst performance has remained below the 95% standard it has improved to 73.8% in April 2023. 12-hour breaches also increased during the year, peaking in December; they have since decreased but are still above the level at the beginning of the year. The mean for ambulance hand-over delays remained relatively flat, despite some fluctuation throughout the year.
The Referral to Treatment (RTT) waitlist has increased by 9.2% from the start of the year, driven by increases across all three acute trusts. Improvements have been seen in very long waits (78 weeks and 104 weeks), although 52 week waits have increased.
For cancer, there has been a general deterioration in 62-day performance and the trend is getting further from the target. Performance against the Faster Diagnosis standard has improved, however, and exceeded the standard at the end of the year and the Decision to Treat performance has also improved.
In maternity, we note that provider leadership and engagement in improvement and innovation activities are at a good level and there is good support from the Local Maternity and Neonatal System. The ICB has taken a very proactive interest in supporting providers in difficulty and working collaboratively, and there are several excellent provider-led programmes to improve service user engagement when redesigning services and tackling health and staff inequalities.
We note the excellent progress in Children and Young Peoples’ Eating Disorder (urgent) waiting times, with the ICB achieving above the 22/23 target by the end of the year. For people accessing NHS Talking Therapies, the ICB has consistently exceeded the 22/23 targets for 6-week and 18-week waiting times, as well as the recovery rates. We note also the improvements in Dementia diagnosis rates leading to the ICB delivering slightly above target by the end of the year. The ICB continues to make good progress in expanding and transforming community mental health services, linking closely with primary care and VCSE services.
The system faces challenges with access across Talking Therapies, Perinatal, and Children and Young Peoples’ mental health services, driven by workforce barriers and low referrals.
Across mental health and Learning Disabilities & Autism (LDA), there has been good performance on inpatient numbers, a good start to work on keyworker development and a genuine focus on co-production. Work is happening across the ICB to meet the Special Educational Needs and Disabilities (SEND) statutory requirements. We would suggest that ppossible areas for the ICB to consider in the future include, in respect of inpatients, further focus on Children and Young People (CYP) and readmissions; support to maintain the positive start to the keyworker development, including investment into Autism diagnostic support; and upskilling to support Autistic people and people with a learning disability in mainstream services.
Safeguarding oversight and reporting is delivered via the monthly Quality and Performance Committee. There is considerable work in progress and a Safeguarding Development Plan is in place to ensure robust and efficient systems, and we note that the ICB is Developing an ICB Safeguarding Governance Framework and establishing a safeguarding sub-committee.
Notable specific achievements include an Asylum Seeker and Refugee programme which has delivered tailored safeguarding training for clinicians and implementation of a local incentive scheme for GPs to contribute to assessing risk and safety plans. The ICB has contributed to Safeguarding Statutory Reviews, and there has also been a good piece of work on Learning from Safeguarding Statutory Reviews, detailing priorities and key areas. Moving forward we would like to better understand the work underway to address these priorities and the actions being undertaken in response the thematic review of health assessments.
We welcome the work the ICB has undertaken to develop effective engagement and consultation with patients and the public. There is a robust governance structure with the further development of the Engagement Assurance Committee (EAC) which is made up predominantly of citizens, and with membership from very senior managers to ensure a direct link to the Governing Body. We welcome the funding allocated to two senior posts, Director of South East London Healthwatch and Director of Voluntary Sector Collaboration and Partnerships, to ensure that citizens’ voices are represented throughout ICB structures. We note examples of targeted engagement with communities experiencing significant inequalities to develop the ICB’s Working with People and Communities Framework in 22-23. Place-based engagement work across a range of services has used a variety of methods including digital, targeted outreach through VCSE partners and service re-design working groups.
Specific examples of good practice include a Muskulo-Skeletal pathway redesign which focuses on increased personalisation and self-care options for residents; and the development of Me, My Health, My Choice digital resources to promote choice and involvement in decisions people make about their own health and well-being, including personalised care.
Tackling unequal outcomes, access and experience.
We note that the ICB has established an Equalities Sub-Committee which is chaired by the Chief of Staff and Equalities SRO, with a responsibility to address inequalities as they apply to service users, local communities and staff. The Sub-Committee reports to the Board. We welcome the decision by the ICB, following a review, to extend its membership to include representation from Local Care Partnerships, Quality and Safety forums, and staff networks. The work of this group is driven from the ICB’s Equality Delivery Plan, which has identified key priorities.
We welcome how the ICB has expanded its use of equalities analysis throughout 2022/23 and that Equalities Assessments have been undertaken to inform decisions across a number of programmes, including the development of best practice guidance for assessing mental health capacity and conducting best interest meetings in General Practice.
A major strand of the health inequalities work is engagement with local communities, to build on the existing understanding and analysis of health inequalities across the system and ensure that services are co-designed to most effectively meet the specific needs of local populations and groups. We note a range of activities where the ICB has sought to develop inclusive practice in engaging with communities that have not been heard historically. These include making resources available to local VCSE organisations to work directly with identified communities who have not traditionally engaged with services. The work is fed into the Engagement Assurance Committee which is part of the ICB governance structure.
Lewisham HWB has referenced how the ICB has worked through the Lewisham LCP and used the HWB strategy to identify key priorities that are specific to the needs of the Lewisham population. These include, for example, a focus on cancer screening uptake, and delaying and reducing the need for long term care and support through the Lewisham LCP Older People Group and the Home First Programme. The CESEL initiative, referenced above, has helped to secure funding to support primary care activity to reduce inequalities.
We note that addressing Health Inequalities is a focus for all of the system’s Local Care Partnerships, with evidence of a range of localised initiatives being supported to address local challenges across all six boroughs and to meet the specific needs of different demographic groups within local populations. Examples include the Bromley Winter Homeless Healthcare Clinics, which won a national innovation award for its work in helping manage a range of health issues that can particularly affect the homeless community; work in Greenwich, including pop-up vaccination and wellbeing events, to improve the take up of vaccinations across under-represented demographics; and activity in Lambeth to address health inequalities among black people experiencing mental distress.
The ICB’s Public Health Management programme of work complements and supports the health inequalities agenda. This work identified 5 leading causes of ill-health across the system, and we welcome that, based on this analysis, funding has been allocated to support the development of initiatives by the ICB’s Prevention and Equalities working group, to address the challenges in these five areas. We note that one HWB would welcome extending information sharing and access to data. This is particularly important for development of the population management approach at the local level.
We note that the ICB continues to commission work from local trusted voices – across local voluntary, community and social enterprises. These commissions support specific programmes of work, for example Mabadiliko who worked with SEL to support prevention and education programmes across Diabetes and Cardio Vascular Disease (CVD) pathways in SEL.
As set out above, the ICB’s key mechanism for Equality, Diversity and Inclusion (EDI) oversight and assurance is the Equalities Sub-Committee (ESC), which now includes representatives from all of the ICB’s staff networks. Amongst initiatives to address equalities and diversity challenges in its workforce, the ICB has established a dedicated Equalities in Recruitment Working Group. One if its initiatives includes contracting with an organisation to provide accessible careers support for disabled candidates. Following the transition from the Clinical Commissioning Group (CCG) to the ICB, we note that the ICB is further developing and implementing its approach in respect of the Workforce Disability Equality Standard and the Workforce Race Equality Standard; and will be producing it first Gender Pay Gap report in 2023/24.
Enhancing productivity and value for money
The ICB reported a £16k surplus on its £3.121bn allocation; and the SEL system overall reported a £251k surplus; this included a £20m deficit at Kings offset by surpluses reported by three other providers. The ICB also balanced its capital finances, reporting a £2.2m underspend of its £231.3m provider capital allocation, and a £454k underspend against its £7,336k ICB capital allocation.
The ICB met the requirements of the Mental Health Investment Standard, reporting £405.5m spend against a target of £404.7m for 2022/23 (an increase in spend over 2021/22 of 7.14% compared to the target increase of 6.94%).
SEL providers overspent their £95.6m agency spend threshold by £25.1m (26%).
The required NHS minimum investment of £149.0m into the Better Care Fund (BCF) has been made with an additional £32.3m discretionary NHS contribution.
SEL ICB delivered £17.7m of its planned recurring £22m efficiencies (81%), and a further £2.6m of unplanned non-recurrent efficiencies, and its providers delivered £81m of their £106m of planned recurrent efficiencies (78%) and £76m of their £79m planned nonrecurrent efficiencies (96%). The system overall reported a total £177m of efficiencies (85% of the total £207m plan). The £30m shortfall to plan in the system’s total recurrent efficiency delivery, combined with new recurrent cost increases incurred at providers during the year, resulted in the system relying on significant non-recurrent benefits to achieve breakeven in 22/23. This will add considerably to the challenge of balancing the system’s finances in 23/24.
We welcome the work that the ICB has started with academic and other partners to better understand and identify how it can embed, and exploit the potential of, research and innovation. We note that the ICB has already established, through the SEL Clinical Effectiveness Group, a more systematic approach to translating research evidence into clinical practice in primary care. We note also the progress of work to research resilient health systems, focusing on lessons from the pandemic.
Helping the NHS support broader social and economic development
We have noted the arrangements that the ICB is putting in place, through its Anchor System and the Anchors Alliance, to build its capacity and capability to make a contribution to the development and support of communities across the wider range of social and economic dimensions. Some of the work in this space has been reflected elsewhere in this assessment.
The ICB’s emerging and developing engagement with, and support, for this work has been recognised by the ICP, which has spoken positively of the contribution the ICB is making by working with local authorities and other partners to support a shared agenda to improve the economic and social resilience of communities in the system. The ICP has also referenced positively the ICB’s work to support the development of a stronger Voluntary, Community and Social Enterprise ecosystem across South East London.
As the Anchor arrangements become more embedded, we look forward to seeing developments and outcomes as the ICB shapes and implements its co-developed specific programmes of work.
We ask that you share our assessment with your leadership team and consider publishing this assessment letter. NHS England will publish a summary of the outcomes of all ICB performance assessments as part of its 2022/23 Annual Report and Accounts.
Finally, I would like to take again this opportunity to thank you and your teams for the hard work and effort in your first nine months of operation. We will continue to work with you in our shared ambition to improve healthcare for the local population and across the system.
Caroline Clarke (Regional Director – NHS England, London Region)