The NHS in England is about to be reorganised. In April 2022, government passed the Health and Care Act 2022 – the biggest legislative overhaul of the NHS in a decade. The Act is based on the idea that collaboration – between hospitals, GPs, social care, and others – is needed to improve local services and make the best use of public money. The legislation undoes many of the changes made by the Coalition government in the last round of major NHS reforms in 2012.

The centrepiece of the legislation are integrated care systems (ICSs) – area-based agencies responsible for planning local services to improve health and reduce inequalities (Box 1). From July 2022, England will be formally divided into 42 ICSs, covering populations of around 500,000 to 3 million people. ICSs have existed informally since 2016, but – until now – lacked formal powers.

ICSs face a mammoth task. Staffing shortages in the NHS are chronic,¹ record numbers of people are waiting for routine hospital treatment,² and health inequalities in England are wide and growing.³ But these challenges are not evenly distributed between ICSs – and some systems are better equipped to deal with them than others. Policymakers have allowed some flexibility in how local systems have been developed and organised, which means they vary widely in size, structure, and other characteristics.

In this long read we analyse publicly available data on some of the characteristics of ICSs and context in each area – including the organisational and policy context, health challenges, and capacity within the health care system to address them. We compare areas and discuss implications for policy.

We use publicly available data to describe the basic characteristics of ICSs and key health challenges in each area. We describe data in five domains: ICS organisational and policy context, population health and inequalities, integrating services, elective care, and workforce. The objectives of ICSs are broad and we only cover a small number of indicators related to the new systems. As a result, we do not provide a comprehensive picture of the context for ICSs in England and the challenges they face.

We selected relevant indicators in each domain and used the most recent data available to illustrate how the context for ICSs vary as close as possible to their time of launch. Our analysis is based on the ICS boundaries that will take effect from July 2022. The indicators we chose were limited to those available at the ICS-level or that could be aggregated to ICS level (for instance, through aggregating data from clinical commissioning groups or lower layer super output areas (LSOAs) – small areas covering around 1,500 people). This meant we could not include some indicators, such as healthy life expectancy or workforce vacancies. See appendix 2 for more detail on these data and rationale for indicator selection.

ICSs vary widely in structure and complexity

The average population covered by an ICS is around 1.5 million people. But the range is large: the smallest covers a population of just over 500,000, while the largest covers more than 3 million people (Figure 1). New ICBs will be responsible for managing most health care resources in each area. But many other organisations – local authorities, NHS trusts, general practices, and others – often with powerful interests, will be involved in local planning and decision making.

Bigger ICSs tend to involve more health and care organisations. For example, some systems cover more than 10 upper-tier local authorities – responsible for social care, public health, and other services – while others cover just one. Bigger ICSs are also likely to involve more ‘places’, which will involve additional governance and infrastructure (such as more local committees).

The complexity of the organisational landscape within each ICS is likely to affect how the system functions – for example, by making it easier or harder to make decisions and implement service changes. Differences in governance and decision making between organisations – for instance, between the NHS and local government – can hold back partnership working.⁹ And evidence from past integrated care initiatives in England suggests that having fewer participating organisations – ideally with similar geographical boundaries – can help facilitate faster progress.¹⁰

The historical context in each ICS will also have a strong influence on how local agencies work together.⁹ For example, the existing relationships between hospitals, GPs, and other agencies – good or bad – will shape how ICSs develop. Some parts of the country may have a head start through their involvement in previous policy initiatives on integrated care (see appendix 1). West Yorkshire and Harrogate, for example, has a relatively high concentration of areas involved in recent policy initiatives on integrated care – including new care model ‘vanguards’ and integrated care ‘pioneers’. The experience of working together in previous versions of ICSs will also make a difference – and national NHS bodies established ICSs in waves depending on their perceived ‘maturity’.

The latest reorganisation of the NHS in England comes at a time of intense pressure on the system. The backlog of unmet need is growing and NHS staffing gaps currently stand at more than 100,000.⁴¹ Public satisfaction with the NHS has fallen to a 25-year low.⁴² Ongoing underinvestment in adult social care means that many people are going without the care they need. These challenges are compounded by a gloomy economic outlook and rising inflation that will eat up a share of planned health and care budgets.³⁸ ICSs face a daunting task when they inherit responsibility for managing NHS services in July 2022.

But the task facing ICSs is not equal. Pressures on services and the health of the population vary widely between ICSs – as do the resources available to address them. ICSs also look very different in their size, complexity, and other characteristics. Variations within the NHS are nothing new. But these differences will shape how ICSs function and their ability to collaborate to improve services. For instance, more complex systems with little history of working together may find it harder to make decisions and agree service changes. Less complex ICSs in more affluent areas may face an easier task.

What does this mean for policy on ICSs? First, national policymakers must acknowledge the wide variation between local systems and be realistic about what different areas can achieve. ICSs have already been set a long list of objectives and national priorities – including improving the responsiveness of urgent and emergency care services, increasing access to primary care, returning the NHS to pre-pandemic levels of productivity, and more.¹¹ NHS England is in the process of updating the NHS’s guiding strategy, the NHS Long Term Plan. This presents an opportunity to define realistic expectations for the performance of ICSs. But it should also acknowledge that progress will differ between systems, given their varied contexts and starting points.

Second, these differences should be reflected in how ICS performance is assessed and reported. The approach to doing this is currently unclear. A mix of policies are under development: a revised system oversight framework from NHS England,⁵ a new approach to assessing ICSs from the Care Quality Commission,⁴³ and an outcomes framework for the ‘place’ level of the system²² have all been promised by national policymakers. Measures to assess previous versions of ICSs were narrowly focused and imbalanced towards hospitals – and used to construct overall ratings for local areas.⁴⁴

The right approach to measuring local health system performance depends on policy objectives – for example, whether policymakers want to judge ICS performance or support local systems to improve services.⁴⁵ Any future approach to measuring ICS performance should reflect the broad range of objectives for local systems and avoid overly simplistic comparisons between areas. Publicly reported data should also link ICS performance to the underlying resources and context in each area – for example, to allow comparisons on relevant indicators between ICSs with similar levels of deprivation.

Finally, policymakers must provide targeted support and resources for ICSs with different needs. For example, national NHS bodies are seeking to reduce health inequalities by targeting interventions at people living in the 20% most deprived areas of the country. But the most deprived areas are not evenly distributed between ICSs (Figure 2). Cuts to local government spending have also been greater in more deprived areas.⁴⁶ As a result, ICSs in some areas will likely require additional resources to help deliver national policy objectives. The same is true within ICSs, where variations in health and use of services exist between ‘places’ and neighbourhoods within them – for example, in the provision of high-quality GP services between richer and poorer neighbourhoods in England.^33,47 National NHS bodies must also focus their support for ICSs on the broader range of factors needed for local partnerships to operate effectively – including culture, management, use of data, and more.⁹

Please note, on 6 July 2022 we updated this analysis (and appendices) with 2020/21 data for the following three indicators:

1. Unplanned admissions for chronic ambulatory care sensitive conditions (ACSC).
2. Emergency readmissions within 30 days of discharge.
3. Emergency admissions for conditions that do not usually require hospital.

On 14 July 2022 we corrected an error and updated the indicator ‘The number on the waiting list per 1,000 population’ as it was previously a duplicate of the indicator ‘The number of complete pathways per 1,000 population’. We also removed a column from appendix 1 (the data table) – 'The number on the waiting list per 100,000 population’ – as the data were incorrect.