Priority setting for Integrated Care Systems: Why a combination of top down and bottom up is now possible and desirable, especially if we are to tackle health inequalities

One of the most crucial tasks for Integrated Care Systems (ICS) in the new system architecture is setting the priorities from which the allocation of resources will flow. Operating within a tax-funded service, such as the NHS, means that national government will always have a say. But in the new, reformed health and care system, there is also an opportunity, through the statutory Health and Care Partnership Boards, to bring local views to the table.

Considering priorities from two directions could create some tension. But, equally, it could also create the conditions for purposeful resolution, with priorities being set according to commitments that are consistently applied to the whole population (e.g. constitutional standards on waiting times). These will, however, vary based on local conditions and circumstances (e.g. reflecting the different age profiles of communities, such as comparing student cities with seaside retirement towns).

Tackling health inequalities

Even more importantly, this new, stronger local influence on priorities and resource allocation also creates the basis for tackling health inequalities. There’s been a lot of discussion about this for a number of years, but it’s yet to turn into positive action. Tackling health inequalities effectively requires a braver approach: we need to direct more health and care resources to people and places in greatest need (e.g. reflecting the inverse care law more directly, or taking into account the inequalities of access experienced by people of ethnic minority backgrounds). A challenge to taking such bold decisions has, in the past, been hampered by the dominating national voice guaranteeing consistency, while the local voice, defending variable allocation of resource, is harder to hear.

In the recently published Planning and Priorities Guidance, health inequality features as one of the key priorities. But in truth, many NHS leaders will see this alongside the commitment to secure elective planned care recovery, and therefore be inclined to see it as a second order priority. However, the ICS and Integrated Care Partnerships (ICP) level, now with the presence of the Health and Care Partnership Board, may reinforce the need to see both elective care and health inequalities as equal priorities - or to address elective care through the lens of health inequalities.

Balancing national and local priorities

There is so much to play for in this new system, but one design principle that could make a huge difference is the new opportunity to balance the national and the local setting of priorities.

Whilst the NHS is accountable nationally and for patient care, local authorities have a statutory duty for the health and wellbeing of their populations. If the health and care system is to meet the challenge of rising demand outstripping available resource, then it has to focus its energy upstream and try to prevent ill health or tackle it much earlier. It can only do this by focusing on ‘the population’ rather than simply ‘the patient’.