Integrated Care Systems: autonomy and accountability – Report Summary

This is a House of Commons Committee report, with recommendations to government. The Government has two months to respond.

Author: Health and Social Care Committee

Related inquiry: Integrated Care Systems: autonomy and accountability

Date Published: 30 March 2023

Download and Share


There is a lot of optimism about the 42 new statutory Integrated Care Systems (ICS). These systems are partnerships of organisations that are intended to offer a refreshed way of working across health, social care, wider local authority functions and voluntary, community and social enterprise organisations, to facilitate integration and to offer the flexibility to focus on the priorities that matter to local people. We have been encouraged by the commitment to, and positivity about, the potential of ICSs. However, alongside the optimism are concerns that this potential will not be realised, and that, in a number of areas, there is a serious lack of clarity. We share these concerns, particularly when it comes to the balance between accountability and autonomy that was the focus of our inquiry.

Collaborating well with partners will be the make-or-break factor in determining the success of ICSs. It is vital that social care is not forgotten, and that ICSs do not become too NHS centric. To support this, NHS England and the Department of Health and Social Care (DHSC) need to adapt their approach, with NHS England in particular needing to move away from its centralised “command and control” approach. There also needs to be a recognition that accountability in the NHS is different to that in local authorities, and an effort made to ensure they work well together. While it is well established how ICSs will be held to account for NHS services, it is currently unclear how they will be held to account for partnership working. We recommend that DHSC and NHS England provide more clarity about this and what action could be taken to resolve poor partnership working. Partnership working needs to be about more than just collaboration if there is to be true integration within ICSs.

In a national, taxpayer-funded service, it is right that the Government and NHS England set out the outcomes that ICSs should be working towards. However, to protect the intended flexibility of ICSs, it is vital that the Government and NHS England do not dictate how ICSs should deliver the outcomes. We recommend that any targets are outcomes-based and that any greater prescription is done sparingly.

ICSs have been designed to support a focus on longer-term issues, like population health and tackling health inequalities. In reality, they will need to balance this with the often intense short-term, operational challenges. The nature of such challenges means there is a risk that they will dominate ICS capacity and resources. This tension needs to be recognised by DHSC and NHS England, and they must make active efforts to ensure ICSs have the capacity they need to focus on public health and prevention. It needs to be clear to ICSs, at this early stage of their development but also as they evolve, that they will get the necessary national support to pursue longer-term work. A refreshed version of the NHS Long Term Plan would be a good opportunity to provide that confidence. We recommend that any update to the Long-Term Plan, and the pending Major Conditions Strategy, put prevention and long-term transformation at its heart. We also believe that all Integrated Care Boards must include a public health professional or public health director.

Given the enthusiasm for ICSs, and the challenges currently facing the health and care sector, it would be disappointing if the opportunities for real change were missed. ICSs are still in their early stages and so, if the opportunity is to be taken, it is important that the issues we have identified are addressed promptly. We share the enthusiasm for ICSs, and we do not want the opportunities they present to be wasted. We are aware that, after our ministerial evidence session, NHS England told ICBs that their Baseline Running Cost Allowance will be “subject to a 30% real terms reduction” by 2025/261 and we are conscious of the impact this will have on ICSs’ ability to meet their aims and objectives.


1 NHS England, Correspondence to ICB chief executives, 2 March 2023