Systems

A changed system

The architecture for the way our health and care services are delivered in England was changed in 2022. New integrated care systems (ICSs) were formalised along with their respective integrated care boards (ICBs). Challenges for systems include improving outcomes in population health and healthcare, and reducing inequalities in people’s access to care, their experiences and outcomes from care.

In line with these changes, we are changing the way we do things at CQC. Assessing local systems is one of our core strategic ambitions to enable us to provide independent assurance to the public of the quality of care in their area.

We have a new responsibility to provide a meaningful and independent assessment of care in a local area. We want to know if different parts of a system are working together and meeting the needs of their local populations. Our new work involves a review of local authorities in some aspects of their duties, as well as a review of the provision of health care and adult social care within an ICB’s area – and to assess how well the ICS functions.

As a result, we will be able to present a more in-depth and holistic view of health and adult social care services by assessing how well local systems perform against the important things that matter to the people in that community.

Moving forward, we will be looking at how services are working together within an integrated care system, as well as how systems are performing overall against the 4 key aims of: improving outcomes, tackling inequalities, enhancing productivity and value for money, and helping the NHS to support broader social and economic development. CQC also has a new role in looking at how local authorities meet their duties under the Care Act (2014).

This will be informed by data and insight and include more about the experiences of people who use services. Our new way of working is not fully operational, but for this report, we have begun to examine some aspects of care at a system level.

Our approach will use a subset of quality statements from our new assessment framework. In 2023/24, we began pilot assessments of how systems are working together to meet their aims following government approval of interim guidance and the quality statements for ICSs. This process began with a focus on themes in the equity in access quality statement.

We are currently running 2 pilot assessments, testing how we will assess leadership, integration, and quality and safety across ICSs. The full programme of ICS assessments will begin in 2024.

In last year’s State of Care report, we reported on the challenges and opportunities for ICSs. Systems that understand their local populations and their needs have an opportunity to plan across all services for greater equity in people’s access to the care they need.

In this section, we present some snapshots of aspects of the new local systems in their early stages, considering how they are shaped to act on opportunities and tackle the challenges ahead.

Local authority assessments

As we prepare for our new formal assessments of care across local systems, we begin to understand the starting point from which services are operating.

Since April, we have been reviewing data and publicly available evidence from across all 153 local authorities, focusing on themes in 2 of our new quality statements: care provision, integration and continuity; and assessing needs.

At a national level, we have seen evidence that local authorities are aware of increasing demand for care and support and complexity of need across all population groups. Workforce capacity and capability pressures, and concern about financial pressures, are forcing some care providers out of the market or increasing the reliance on people who pay for their own care (self-funded care).

Nationally, local authorities have reported:

• under-provision in some types of specialist care, such as services for autistic people, specialist dementia care, and in the availability of beds in care homes with nursing
• traditional forms of support remain dominant, but some examples of new and innovative models of support are emerging, including highly personalised and bespoke support
• more flexible use of beds in residential care homes to respond to local needs
• prevention and reablement models and home first policies, including using technology to help people to remain independent
• a strategic focus on unpaid carers, including identifying carers more proactively using co-production to understand their needs, working with employers to support carers to stay in employment, and a focus on young carers
• an intention to promote direct payments as a way of providing more flexible and personalised care. We have not seen evidence of how local authorities will achieve this.

Regional and national variation

There are similar areas of focus for future service provision across regions, with a clear shift from long-term care to community-based services that promote independent living, prevention and enablement.

Local authorities are planning for increased demand for services for people whose needs are more complex to meet. This includes specialist dementia care, managing multiple long-term conditions or services for people with a learning disability. There is a focus on moving away from traditional provision of residential care for these groups of people, in favour of services to meet people’s needs in the community.

However, significant market investment will be needed to provide extra care housing, supported living and suitable community housing, as well as homecare services.

There is a need for respite, reablement and step-down/discharge-to-assess services to help support the speedy discharge of people from hospital to the most appropriate place for their needs – preferably into the community.

We found that few local authorities had published workforce plans – and even fewer had joint workforce plans with the wider system. Across local authorities, the adult social care workforce is identified as a clear risk to sustainability and reform, with all highlighting the challenges of staff recruitment and retention. There is also recognition of a skills gap for more experienced or specialist staff that will be needed to care for people whose needs are more complex to meet.

Unpaid carers

Support for unpaid carers is a crucial area of local authority responsibility. We reviewed this against our quality statement on assessing needs. Carers are not being identified enough, which affects their ability to access care and support. The unpaid carer ‘workforce’ is a key lynchpin in adult social care provision, worth about £162 billion a year. In April 2023, The Health Foundation pointed to the small percentage of unpaid carers who approach their local authority for help.

In October 2022, the government announced new laws entitling unpaid carers to one week of unpaid leave a year to ‘support those most in need’ – the Carer’s Leave Act 2023 came into being in May 2023.

Analysis shows clear variations across authorities – and across all metrics – on the number of carers accessing timely support and levels of satisfaction with the support received. Also, not all local authorities had a published carers strategy, but where plans were available, most acknowledged there was work to do to identify and support unpaid carers.

In detail, we wanted to find out what local authorities know and share publicly about:

• the needs of unpaid carers
• demographics and people’s needs
• gaps in care
• forecasting the care needs of the population
• partnership working
• workforce risks and challenges
• system-wide workforce planning.

We found that most local authorities have not published a recent carers strategy and there is little up-to-date data on local carers that they have shared publicly. They are also often using 2011 census data. Some census data from 2021 was only recently available and there is more to come.

There were some common themes across local authorities:

• although the number of carers is increasing, sometimes they do not identify themselves as carers and so they are not identified by local authorities
• carers are caring for longer in both the number of hours each week, and the length of time (months or years) they provide care
• carers are caring for people with increasingly complex conditions; this is affecting their physical and mental health, as well as financial and employment opportunities
• for young carers, there is a negative impact on their education
• some councils report that carers from ethnic minority groups are less likely to seek help than their counterparts from White groups.

Some local authorities share more strategic information and there is evidence of joint working with targets and evaluation criteria. However, evidence of their actions to meet the needs of carers is not easily available.

Most publish advice and guidance for carers on their websites, with information about assessments, access to support, including financial support, support for young carers, health and wellbeing support, training, and [how to access] respite care. They don’t all have good information on how to get emergency support in a crisis.

Where there was evidence of a strategic approach, some common themes included:

• raising awareness to enable people identified as a carer to find information about assessment and support
• identifying the need for a more ‘culturally sensitive’ approach, to encourage more people in ethnic minority groups to identify and seek support
• including unpaid carers in some market position statements as part of an approach to shaping the care market, including in relation to hospital discharge and enabling people to go home.

A recent survey from the Carers Trust suggests there is some way to go before carers feel they are adequately supported in their role. Many of those surveyed said their local authority, health services or other organisations didn’t advise them where to get support and instead had to find out about available help themselves. The experience was worse for people from ethnic minority communities, where 16% said their local authority had told them where to get support, compared with 31% of White carers, and only 6% had received support.

In the 2023/24 financial year, the Department of Health and Social Care earmarked £327 million from the Better Care Fund to provide short breaks and respite services for carers. This also funds additional advice and support to carers and a small number of additional local authority duties.

Demographics

Most local authorities publish information about their local population. Some also had up-to-date market position statements, which describe the changing needs and services they want to develop in future to meet people’s needs. Almost all are predicting growth in their older populations and an increase in demand related to complex health needs, dementia care and long-term conditions. Some of this need is predicted to be early onset of chronic conditions.

Many local authorities also tend to provide information about working age populations in relation to learning disabilities, autism, physical disabilities and mental health needs. They also record information about workforce pressures, and market sustainability in relation to quality and cost of living/inflationary pressures. Some also share information about health inequalities, and some note a strong correlation with deprived areas and places where people lived in poor health for longer.

Gaps in care

Local authorities have identified gaps in care. These are often around care for people with needs that are more complex to meet and for specialist dementia care, as well as services for people with a learning disability or mental health needs and autistic people.

There appears to be a trend towards a more flexible approach to care, with an outcomes-based focus, as well as preventative and reablement services, and a community or care at home first approach. Local authorities anticipate the need for more high-quality community care provision.

There is an increased demand for care in people’s homes – this is often identified where there are workforce challenges, and sometimes where transport links are an issue.

Although there is plenty of residential care, there are not enough nursing beds for people whose needs are more complex to meet. Most councils recognised this nationally.

They also recognise that services can be unevenly distributed and not always where there is demand – they reference the impact of people who pay for their own care in the market, a lack of provision in areas of deprivation, and fewer options for people in rural areas.

There is evidence of some local authorities focusing on preventing unnecessary hospital admissions and promoting reablement with local system pressures in mind. For example, converting beds in residential adult social care into beds for more complex care or nursing, or short-term reablement to help people get discharged from hospital. Some authorities are planning to support better system working by helping people get care in the right place, relieving pressure on hospitals and improving patient flow. There is also evidence of prevention-based approaches to reduce hospital admissions – for example, safety at home and falls prevention interventions.

Other gaps identified include culturally appropriate care provision, which some local authorities are looking to address. Workforce development is a recognised factor to help shape the markets.

Forecasting care needs of the local population

Not all local authorities have shared information about longer-term plans to support people’s changing needs in the years ahead. Where we have seen plans, they tend to be short-term – they are focused on important areas including early intervention, caring for people at home where possible, prevention and reablement. Independent living and community-based solutions are also evident.

There are investment plans as councils look to ‘Extra care’ and supported living (for older people and people with specialist needs), community housing, reducing isolation and supporting people with dementia or more complex needs, while preventing the need for residential care or hospital admissions. Plans also cover support for people with a learning disability, autistic people and people with physical disabilities to enable them to stay in communities and get support to lead more independent lives and find employment.

Partnership working

So far, there is a lack of detail from most local authorities about potential joint commissioning strategies. For example, some London boroughs refer to their ‘whole system’ approach, but with little detail. Others have reported on work with neighbouring boroughs to shape provision in the market – especially where people are placed out of their local authority area.

In Greater Manchester, there is evidence of health and social care teams working closely at neighbourhood level and in developing the workforce. The area has been working to a people and culture strategy since 2022 and was described in Parliament in 2023 as the ‘most mature’ of the ICSs. Other authorities in the North West are planning to partner with neighbouring authorities or ICSs.

Workforce risks

Local authorities are concerned about risks to their care workforces, but they recognise that workforce development is important for their strategies – especially recruitment and retention of staff. Aspects affecting the wider system include a lack of nursing staff and the importance and growth of the homecare workforce to enable appropriate hospital discharges and the move to more care in the community where it can meet people’s needs.

There are challenges with the adult social care workforce that require effective collaboration. However, in our survey of adult social care services, when asked whether their local authority consulted or engaged with them, only 18% of responding providers said ‘completely’, with a further 44% responding as ‘somewhat’ consulted.

The most common reason care providers gave for unused capacity was a lack of commissioning opportunities. Providers told us that poor access to, or a lack of transparency in the bidding process, affected their ability to increase capacity and to recruit accordingly. 

Despite the recognised challenges for staffing, very few authorities have published workforce strategies. They report working with service providers in different aspects of workforce development and recruitment, such as setting up academies to train and develop staff, training to upskill people to care for people with more complex medical needs, and working with primary care on nursing associate roles where there is less need for registered nurses.

System-wide workforce planning

There are some examples of a system-wide workforce approach. One local authority described ‘blended roles’ in a homecare service, where staff worked alongside a district nurse and were trained to provide low-risk services. The aim is to improve joined-up care, workforce retention and to offer staff progression through development.

In the North East, we saw that some councils and health partners worked together to explore practical solutions for a nursing care problem. Where there was a shortage of nurses in residential care, this involved a pilot homecare service to help with people’s emerging needs overnight after being discharged from hospital.

Support for carers

Across England and Wales, there are an estimated 5 million unpaid carers, according to Carers UK.

At this early stage in our new role with local authorities in England, we are interested in the experiences of carers and their contribution to people’s needs locally. NHS England publishes a biennial survey – the Personal Social Services Survey of Adult Carers in England (SACE). This reports on the opinions of unpaid carers aged 18 or over, who are caring for a person aged 18 or over, on topics considered to be indicative of a balanced life alongside their caring role.

Results for the 2021/22 period show variation in experience across England.

About a fifth of carers (22%) say that they feel in control of their daily lives, with carers living in the South West less likely to report this. Even fewer carers are able to spend their time doing things that they value or enjoy (16%), again carers in the South West are less likely to report this.

On average, less than a third (32%) of carers are accessing support groups or have someone to talk to, with only 22% of carers in the North East able to access support.

When excluding carers who had not received support or services, 36% reported being ‘very’ or ‘extremely satisfied’ with their support from social services. There were differences geographically, as 6 of the 10 local authorities with the lowest satisfaction score were in London. There was also variation in terms of receiving support, with 35% of carers in Yorkshire and the Humber not receiving any support or services.

Across England, there is significant variation in the numbers of carers who access support that allows them to take a break from caring. For carers accessing support for a rest from caring (for between 1 and 24 hours) it ranges from 7% to 61% across the local authorities. On average, only 20% of carers access this kind of support.

There was also significant variation in carers accessing support for a break from caring for more than 24 hours. Nationally, 13% of carers accessed this support but there is huge variation for carers in different local authorities, with this ranging from 4.7% to 40%.

Sometimes, carers need to access support services so they can take a break from caring at short notice or in an emergency. Accessing this type of support varied between different local authorities, ranging from 2.7% to 27%, with the national average of 11%.

Carers are also experiencing financial difficulties because of their caring responsibilities – 43% of carers reported this. The highest proportion of carers reporting this was in the London region, where 52% had experienced financial difficulties because of their caring responsibilities.

The Joseph Rowntree Foundation published research that found carers lose on average £8,000 a year after 6 years of caring. It found carers are forced to reduce their working hours, don’t follow career opportunities or give up work altogether to provide unpaid care, pushing some people into poverty. The Survey of Adult Carers in England (SACE) shows the percentage of carers accessing support to keep them in employment was low across the country (2.8%) but higher in London (4%) than in other regions. Also, over a fifth (21%) of carers reported not being in paid employment because of caring responsibilities – this was higher in London, where 28% of carers reported this.

This highlights why local authorities must be proactive in identifying unpaid carers in their area and ensure they are aware of the information, advice and support available to them. We found some examples of authorities that have considered the importance of carers and have published plans, including South Gloucestershire and Bournemouth, Christchurch and Poole.

Urgent and emergency care

In 2022, our State of Care report described a “health and care system in gridlock” that was having a negative impact on people’s experience of care. We reported how many people had to wait too long for the health and social care support and treatment they needed – and the effect on people needing urgent and emergency care.

The effectiveness of urgent and emergency care services can indicate how effectively health and care services are co-ordinated across a local system.

Variation across emergency departments

Local health systems can work better when patients flow through services in an effective way – making sure people are seen in the right place and at the right time. But with many factors affecting patient flow, sometimes people get stranded where they don’t need to be – for example, people remaining in hospital if there is no onward social care provision. Hospital emergency departments are a critical part of this system, and often the centre of attention because of the urgent nature of their work.

Across England, the performance of NHS emergency departments varies. For example, at a regional level, there are different outcomes in terms of converting people’s attendances into hospital admissions. And there are differences in the numbers of patients waiting more than 12 hours for a hospital bed after a decision to admit.

Attendance and admission

At a regional (NHS England) level at June 2023, the percentage of emergency department attendances that were admitted (known as a conversion rate) ranged from 13% (53,243 people) in the London region to 19% in both the North East and Yorkshire (66,488 people) and the South West regions (34,970 people). The England average was 17%.

Regionally, there was a large variation in the percentage of ambulance handovers that took longer than 60 minutes – from 1% in the South East to 17% in the South West. The England average was 7%.

Waiting 12 hours or more after decision to admit

Once a decision is made to admit someone to hospital, there is sometimes a wait to be admitted. Across all NHS England regions as at June 2023, 7% of patients waited more than 12 hours from a decision to admit to being admitted. At a regional level, this varied from 3% in the North East and Yorkshire to 11% in the North West. There is variation in waiting times within regions too, with people in some ICB areas likely to have much longer waits than others (figure 20).

Figure 20: Emergency admissions through A&E waiting more than 12 hours from decision to admit to admission, by region (June 2023)

Region	Total waiting more than 12 hrs from decision to admit to admission	Total emergency admissions through A&E	Percentage waiting over 12 hours
East of England	2,054	41,376	5%
London	5,196	53,243	10%
Midlands	6,217	72,809	9%
North East and Yorkshire	1,831	66,488	3%
North West	6,323	56,114	11%
South East	2,517	62,972	4%
South West	2,393	34,970	7%
England	26,531	387,972	7%

Source: A&E attendances and emergency admissions (NHS England)

Responding to the crisis in urgent and emergency care and the recognised systemic problems, we published the PEOPLE FIRST resource in 2022. It is the product of work by a group of senior clinical leaders in CQC’s National Emergency Medicine Specialist Advisor Forum.

This resource recognised the need for solutions ‘across the artificial divides between primary, secondary, community and social care’. It aims to support the design of person-centred urgent and emergency care services and encourage innovation across integrated care systems.

In 2023, we surveyed providers to find out if PEOPLE FIRST was influencing their work. Although we learned about the level of understanding of the resource, the majority of those who responded took the opportunity to tell us about the significant pressures and problems they were facing. They told us about fatigue and stress, while some mentioned the immediate problems faced by providers over the last year, such as industrial action.

From the 384 responses, 96 were from NHS emergency care providers or representatives from integrated care boards. Respondents told us about barriers to change including time, costs and staffing – these were the overwhelming factors among responses to the survey.

Some providers told us they were aware of plans to mitigate against the winter pressures ahead. These varied in focus from system leadership programmes and crisis contingency plans to specific practical measures such as embedding paramedics in community response hubs.

Asked about innovative ongoing work, one respondent told us about using ambulance clinical audit data. For example, using data on falls and for the ambulance sector to see if work to avoid admissions has been safe and effective.

Other responses to emerge from the survey included leadership, culture and change fatigue. One person told us there was “complete apathy” and “a lack of understanding from management”. They said that “clinical decisions [were] being shaped by non-clinicians” and there was “disagreement about permissible level of risk”.

People’s experience in urgent and emergency care

We specifically highlighted last year how urgent and emergency care services were in crisis – people could not get the care they needed, and when they needed it most urgently. Looking ahead to winter 2023/24, we wanted to consider the factors that are some hallmarks of better urgent and emergency care systems, and people’s experiences that might point to systemic issues.

More effective urgent and emergency care services can be a sign of better co-ordinated health and care services across a local system.

In our own 2022 survey of people who used urgent and emergency care services, we analysed type 1 (major accident and emergency department) services to understand how people experienced this care. It covered 122 NHS trusts and gives insight into some aspects of care – how long people waited for care, how their pain was managed and how they felt their dignity was affected. These findings are based on responses from 29,357 people who used an emergency department (A&E) in September 2022 and an analysis of what people freely chose to tell us in the survey.

We know that waiting times increased significantly as 32% of respondents waited more than an hour to first speak to a doctor or a nurse, compared with 15% in 2020, 19% in 2018 and 18% in 2016. And 17% said they waited more than 4 hours to be examined – the equivalent was 4% in 2020.

People told us these waits were made more challenging by the environment, which could be overcrowded, uncomfortable and lack the basic facilities needed when waiting for extended periods – often 8 hours or more. Not knowing how long they would have to wait made the situation difficult. We heard that: “No-one spoke to us about what was happening”, it was described as feeling like they had been “forgotten”. Three-quarters (76%) of people were not told how long they would be waiting, and the majority (82%) did not get updates on this.

People’s pain was not managed as well as in previous years. They said dealing with pain in public and in an uncomfortable environment could be traumatic. Fewer people in the 2022 survey (51%) said staff ‘definitely’ did everything they could to control their pain, compared with 60% in 2020.

Busy, crowded environments meant people’s privacy and dignity was not supported well. We were told about how waits on trolleys, and treatment in corridors and waiting rooms, and a lack of personal care had compromised people’s dignity. One person described the experience as “embarrassing and humiliating”.&

Analysis showed fewer people (78%) felt they had enough privacy while being examined and treated, compared with 84% in 2020, 83% in 2018, and 82% in 2016. The percentage of respondents feeling they were treated with respect and dignity had also dropped to 72% in 2022 compared with 81% in 2020.

Similarly, when asked about privacy and communication, people were less likely to feel they had enough privacy at reception. In 2022, fewer patients (45%) felt they ‘definitely’ had enough privacy when discussing their condition with the receptionist, compared with 55% in 2020.

Despite the waiting times and the associated impacts, there remained some strong praise for the staff. People reported being satisfied with their care and treatment. Even when describing a negative experience, respondents usually attributed this to the ‘system’. People described staff in positive terms, using words such as:

Caring, kind, helpful, fantastic, professional, reassuring, brilliant, excellent, polite, efficient, fabulous, friendly, understanding, exceptional, attentive, amazing, wonderful

The survey provided evidence to suggest that poor system-working had an impact on urgent and emergency care. For example, some people said they attended the emergency department because of difficulty accessing their GP, or they attributed poor experiences to a lack of good joined-up care and follow-up care.

There were concerns about a failure to share existing information about a patient’s past medical history or medication. One patient said the hospital she attended had informed her it could not correspond with a previous hospital she attended because they “did not communicate with hospitals outside their area”. Another patient said: “Every time I go into hospital my medication is recorded incorrectly… time, dose and type”.

These experiences suggest that at least part of the problem is due to a lack (or perceived lack) of communication between different service providers, either by area or type of service, or the inability to share electronic records effectively.

Similar issues were raised around discharge from hospital. Patients’ notes or results were not always shared with a GP and promised referrals for further care did not happen soon enough. People were dissatisfied where they felt they were offered either no advice or ‘very inconsistent advice’.

People also said they felt ‘rushed or dismissed’. Only 40% of respondents who were prescribed medicines were ‘completely’ told about side-effects. Less than half (46%) were ‘completely’ told about what symptoms to watch for when they were at home or their place of residence (compared with 53% in 2020 and 51% in 2018). And 51% of respondents were ‘definitely’ given enough information to care for their condition at home, compared with 60% in 2020 and 59% in 2018.

For some people, the issue was about being discharged without sufficient onward care organised, rather than poor medical treatment.

One patient told us: “…I felt I had no other option but to sign myself out… I felt like no one had the time to care. I left the hospital alone and stood alone in the dark outside waiting for a taxi.”

A failure to provide suitable follow-up care, or a failure to show effective joined-up care, can lead to a poor overall view of the emergency care experience. Sometimes the failures might not be due to failings in the emergency departments but instead represent a miscommunication or a failing in other systems, which may not connect effectively. For emergency departments and the wider system, an impact could be people returning to their GP or being re-admitted to hospital. A few people told us how they went on to seek a second opinion or get private healthcare.

Equity in access across systems

We have started to look at the way ICSs are approaching their role of ensuring everyone has equal access to care.

Our formal assessments of integrated care systems will begin in 2024. Our initial work has a focus on publicly available information that systems have published in relation to our Equity in access quality statement.

This quality statement is part of the ‘quality and safety’ theme of our assessment framework for integrated care systems, which uses a subset of the quality statements from the new overall assessment framework. This is the commitment for providers to make sure that everyone can access the care, support and treatment they need when they need it.

Based on NHS England guidance and recognising that most integrated care systems are relatively new, we considered these focus areas

• Creating an enabling system context
• Building a clear and shared understanding
• Maintaining a sense of urgency and commitment to act
• Focus on implementation, impact and evaluation.:

Reviewing publicly available information related to this quality statement for all integrated care systems in England, we can see there are continuing challenges for many people who want to access health and social care. This is regardless of people’s socio-economic background, geographical location, protected equality characteristic status or their inclusion in other groups more vulnerable to health inequalities.

These challenges are sometimes exacerbated for people living in the most deprived areas, for people with protected equality characteristics, or people who are otherwise vulnerable to inequalities in accessing, experiencing or outcomes from health care.

There are themes of unequal access for people across ICSs in mental health services, particularly for children and young people. We can also see these themes in access to oral health care, when people are contacting GPs (by telephone and online), in digital exclusion, and in delayed access to adult mental health services.

We also saw themes around inclusivity and a lack of cultural understanding acting as a barrier to accessing care.

Creating an enabling system context

Across England, most integrated care systems demonstrated a commitment to engaging with people living in their area. We found that most systems publicly recognised the importance of equality, diversity, and inclusion, and addressing health inequalities and equity in access to care services.

Protected equality characteristics had been considered in various strategies that we saw, but we did not find evidence that they had all considered under-served and marginalised groups that may be affected by inequalities.

We could not find clear plans for all integrated care systems to reflect how they would address unwarranted variations in population health, disparities in access, outcomes, and experience of health and social care.

NHS England points out the importance of ‘creating an enabling system context’. It says system leaders in ICBs, integrated care partnerships, provider collaboratives and within individual NHS bodies need to consider whether they are creating the necessary conditions for improvement.

Building clear and shared understanding

While integrated care systems show an understanding of the value of engaging with residents, their approach to engagement and co-production varied across the country. Some systems did recognise the need to reach people whose voices are seldom heard, and under-represented groups.

Most integrated care systems ran engagement events leading to bespoke engagement strategies – some strategies had more focus on equity in access than others. We saw that where NHS England best practice guidance had been used to produce engagement strategies, these were innovative and focused on engagement principles, use of community assets, anchor organisations, community influencers, faith leaders and the community they served. An example where this worked well was when Healthwatch supported women from the Bangladeshi community, autistic people and people with a learning disability to be involved in work linked to the menopause, to ensure they had the appropriate information to access services. Teaming up with national public health teams, breast screening recall letters were also available in an easy to read format for people who needed them.

It is evident that where ICSs have made efforts to engage directly with residents and through the voluntary, community and social enterprise sector, Healthwatch and other bodies, there was a stronger focus on reaching and engaging people who are less likely to engage. Engagement strategies aimed to enhance collaborative working, improve people’s experiences and health outcomes, and reduce health inequalities.

We also saw that all ICSs were engaged with Healthwatch to some extent. Evidence of wider engagement with the adult social care sector was less evident. In July 2023, we carried out a survey of adult social care services to find out more about the challenges they face. Only 8% felt that their ICS ‘completely’ consulted with them and 45% reported having never been consulted or engaged with.

Urgency and commitment to act

We have identified a strong intention and commitment to address inequalities and act on issues, including equity in access. However, few integrated care systems have demonstrated an urgency to act on this area.

Engaged leadership can support effective, well-performing health and care systems, but we found a mixed level of urgency to act on equity in access. In systems where there was apparent urgency, this was reflected across their work with clear plans in strategies, policies and other documentation. These considered the impact on equity in access when making decisions and taking action on relevant issues.

Focus on implementation and assessment

The ICSs in England are in various stages of maturity. We know that systems have been working together at different levels and in different forms before the new ICBs assumed legal status in July 2022, so there is variation in implementation and assessment.

We have seen that all ICSs have some equality and health inequalities objectives, but they did not all include timeframes and measures. A lack of clear and realistic goals and key performance indicators could be detrimental to meeting shared objectives. Research shows that to support effective and well-performing health and care systems, it is important to have:

• a shared strategy and vision that includes realistic and attainable goals
• a structured plan
• the use of key performance indicators and continuous improvement supports.

The Equality and Human Rights Commission required integrated care boards to publish their staff equality information and equality, diversity, and inclusion objectives by 30 March 2023. However, we have not found this documented for all boards. Equity in access has been discussed at some board meetings in relation to other matters, but we have not seen evidence of equity in access on board agendas – either as a set agenda item or a strategic key performance indicator.

Looking ahead

Going into 2024, the development of our focus on health and social care across systems takes another step forward – we have begun our new pilot assessments of integrated care systems in Birmingham and Solihull and in Dorset.

We are collecting the evidence that we need to review and, as part of our assessment, we are speaking directly with people using health and care services and with staff working in these systems about their experiences.

We will also carry out on-site interviews for each ICS in the pilot. Specialist advisors and executive reviewers, who are experts in different health and care sectors, will be part of the team carrying out the assessments. During the pilots, we will be testing our assessment methods, including how we:

• work with partners and stakeholders, including NHS England
• use feedback from providers and people using services
• involve Experts by Experience effectively in our assessments
• use our tools and methods, including the information return
• enable efficient ways of working.

For each of the pilots, we want to look at:

• how leadership works
• whether systems are integrated
• progress towards reducing inequalities
• how quality and safety is managed across local services.

We will also be acting on our responsibilities to assess how well local authorities are meeting their duties under Part 1 of the Care Act (2014) for people accessing care and support.

These assessments will use a subset of quality statements from our new assessment framework. They will be structured specifically around the context, aims and roles of a local authority and focus on 4 themes:

• Working with people
• Providing support
• Ensuring safety within the system
• Leadership.

The intention of CQC’s assessment of local authorities is to increase transparency and local accountability and make good practice, positive outcomes and outstanding quality easier to spot locally and share nationally. The government hopes this will identify where improvement and additional support is needed.

The pilot phase for our assessments is underway at 5 local authority sites: Nottinghamshire, Lincolnshire, Birmingham, North Lincolnshire and Suffolk.

The Secretary of State for Health and Social Care will approve the final approach to assessments, as required by the Health and Care Act 2022.

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