Population Health Management

Population Health Management (PHM) is a new approach which helps us understand
people’s health and care needs and how they are likely to change in the future. It aims to
improve physical and mental health outcomes, reduce health inequalities and help us live our extra years in better health. This case study looks at how integrated care systems are using population health management to improve health and wellbeing.

Full document: Population Health Management: Understanding how integrated care systems are using population health management to improve health and wellbeing

Integrated Care Systems: workforce, people and skills

This manifesto outlines the workforce powers, freedoms and responsibilities ICSs and STPs are increasingly asking for and the local commitments and relationships necessary to deliver change.

Key points

  • There is a clear desire for integrated care systems (ICSs) to become the default level for future workforce decision making in health and care. This would enable increased autonomy over the development of local system architecture, responsibility for managing strategic external relationships and critically, control of dedicated funding streams.
  • Sustainability and transformation partnership (STP) and ICS leaders have repeatedly argued that their success is dependent on much greater capacity to influence the development and deployment of the local health and care workforce and an improved ability to affect local labour markets.
  • For an ICS to realise its potential, it should have increased accountability across three key areas of workforce development: strategy and planning, supply and retention, and system deployment.
  • To complement a more involved strategic role, ICSs should pilot and prioritise local approaches to supply and retention, such as ‘Grow Your Own’, and develop and deploy new measures to better understand and use their existing health and care workforce.
  • While the role of the national arm’s-length bodies will remain important, there is a need for greater clarity about the roles and functions of the various national workforce organisations and how they encourage longer-term, more strategic local planning.
  • This manifesto also focuses on the role of the NHS in the wider local labour market. As the largest employer in any given area, the NHS and local authorities could exercise significant power and influence on local skills development and employment. However, there remains the question of how best to use it.

Full document: Growing our own future: a manifesto for defining the role of integrated care systems in workforce, people and skills | The NHS Confederation

See also: NHS Confederation blog: A national people plan is fine but local labour markets require local responses

Royal College of Psychiatrists: Integrated care and mental health

Royal College of Psychiatrists | December  2019 | Integrated care and mental health  

A new guide from the Royal College of Psychiatrists, this guide aims to understand the priorities and lessons for improving mental health services in established and emerging ICSs and makes recommendations that reflect the opportunities and challenges for areas in doing so.  

Full details from the Royal College of Psychiatrists

Improving mental health services in systems of integrated and accountable care:
emerging lessons and priorities Executive summary

Leading For Integrated Care

This report explores the progress, challenges and opportunities the move towards greater integration presents, through interviews with 16 people leading or chairing an integrated care system or sustainability and transformation partnership | The Kings Fund


The report underlines that these local systems are still evolving. But it is important
to note that the interviewees did believe that it was evolving: progress is being
made towards a more integrated way of working. This has meant major changes
for leaders, many of whom have spent their careers within a world where
organisational autonomy was key and success was based on your organisation’s
own performance.

Full report: Leading For Integrated Care: ‘If You Think Competition Is Hard, You Should Try Collaboration’ | The Kings Fund

Health and wellbeing boards and integrated care systems

This long read examines the part Health and Wellbeing Boards, and local government more broadly, have played in the emergence of Integrated Care Systems so far and options for their future.


Health and wellbeing boards (HWBs) were established under the Health and Social Care Act 2012 to act as a forum in which key leaders from the local health and care system could work together to improve the health and wellbeing of their local population.

In this article, The Kings Fund explores questions in three main areas:

  • What has been the overall role and contribution of local government to ICSs so far? How involved have councils been? How far has this influenced the development of ICSs and how they work? How helpful or otherwise has this contribution been?
  • To what extent does the HWB feature in the overall governance arrangements for ICSs, both now and in the future? How does this work in practice, for example, where there is more than one HWB in the ICS footprint?
  • What part has the HWB played in the development of ICSs so far and how far might this change in the future, taking account of proposed national changes in NHS legislation? What is the future of HWBs in a world of ICSs?

Full article: Health and wellbeing boards and integrated care systems

Integration: what physicians need to know about implementing the NHS Long Term Plan

Royal College of Physicians | October 2019 | Integration: what physicians need to know about implementing the NHS Long Term Plan

The NHS Long Term Plan (LTP) published in 2019 set out significant structural changes in England with the aim of delivering more integrated care.  The Royal College of Physicians have produced a  practical guide which explains the changes and what physicians can do locally to support and influence the development of integrated care.

Image source: rcplondon.ac.uk


Key recommendations

  • Integrated care is seamless, coordinated and locally designed care that puts patients at the centre of service organisation. It considers their needs in a holistic way, and develops high-quality services that meet those needs in settings that are accessible and convenient for patients.
  • There is rightly a renewed political focus on integration. In an ageing society where multiple health conditions are becoming the norm, more joined-up healthcare is essential. This should lead to better outcomes and an improved experience for patients.
  • The NHS Long Term Plan outlines the government’s commitment to prioritising more integrated care. Chiefly this will be through the rollout of ICSs – where organisations such as local councils, acute trusts and CCGs will take collective responsibility for resources such as funding and workforce – which will cover all of England by 2021.
  • It is important that physicians influence the development of ICSs in their local area, as there will be no national blueprint. Each ICS will define its own priorities and how it operates, so it is vital physicians are involved from the start.
  • Physicians can benefit from learning the lessons of ‘good integration’ and top tips from those at the forefront of integrating services. For example, the importance of properly involving patients, commissioners, public health and primary care to develop intelligent KPIs (key performance indicators) (Source: RCP)

The report is available to download from the RCP

WHO: Integrated care for older people

World Health Organization | October 2019 | Integrated care for older people

The WHO Integrated Care for Older People (ICOPE) offers evidence-based tools and guidance for every level of care o understand, design, and implement a person-centred and coordinated model of care. ICOPE helps health systems support Healthy Ageing and maximise older people’s intrinsic capacity and functional ability (Source: WHO).

Integrated Care for Older People  


What is Healthy Ageing?

We want your feedback on the development of a health information website for pregnant women, parents with children, young people and families across South Yorkshire and Bassetlaw

South Yorkshire and Bassetlaw Integrated Care System | September 2019 | We want your feedback on the development of a health information website for pregnant women, parents with children, young people and families across South Yorkshire and Bassetlaw

call out

The NHS in South Yorkshire and Bassetlaw would like to hear your views about a health information website they are thinking of developing for pregnant women, parents with children, young people and their families.  They understand how difficult it can be to get simple and trusted health and wellbeing information to support access to the right services; and recognise that health and wellbeing information is vast which can lead to inconsistent messages about health in pregnancy your child’s health. This sometimes leads to being directed to services (like A&E) when they are not necessarily the best place to be seen and treated.

They want pregnant women, young people and parents to feel empowered when making decisions about their own or child’s health and wellbeing, including when and where to seek help and the various choices available to them.

To support this, South Yorkshire and Bassetlaw Integrated Care are considering developing across South Yorkshire and Bassetlaw a website similar to one developed in Hampshire called Healthier Together; which is available using the following link: https://what0-18.nhs.uk/parentscarers

Further information about the consultation is available from South Yorkshire and Bassetlaw Integrated Care System

LGA: Achieving Integrated Care the 15 best practice actions

Local Government Association & Social Care Institute for Excellence | September 2019 | Achieving Integrated Care: 15 best practice actions

The Local Government Association (LGA) & Social Care Institute for Excellence (SCIE) have collaborated to produce an accessible and practical resource that supports local systems in fulfilling their ambition of integration.

They envisage a “whole system” approach in taking these actions forward, involving system leaders, health and social care commissioners and providers, front-line professionals, local communities and local people. By applying these actions, local partners will be able to focus on three key elements:

  • the delivery of person-centred coordinated care – i.e., the core objective of integrated care
  • the building of local “place-based” care and support systems
  • system leadership for integration. (Source: LGA)

The fifteen actions prioritised in this resource draw on international research, emerging best practices and engagement with their own  stakeholders and partners. The actions are aligned with national policy, legal frameworks and regulatory guidance, but most important, they allow for local variety in system design and service delivery to flourish.

Access them here

Understanding primary care networks

Understanding primary care networks: context, benefits and risks |  The Health Foundation


This briefing places Primary Care Networks (PCNs)  in the context of previous changes to general practice funding and contracting. It examines the rationale for networks, explores relevant evidence and draws out intended benefits and possible risks for the future of PCNs.

Key points
  • From 1 July 2019, all patients in England will be covered by a primary care network (PCN) – the most significant reform to general practice in England in a generation.
  • PCNs should help to integrate primary care with secondary and community services, and bridge a gap between general practice and emerging Integrated Care Systems.
  • Since January 2019, practices have been organising themselves into local networks to provide care at greater scale by sharing staff and some of their funding.
  • While PCNs offer huge potential to integrate care and improve services, there is a risk that the speed of implementation will undermine the best intentions of the policy.

Full briefing: Understanding primary care networks . Context, benefits and risks

Additional link: NHS England press release | NHS England blog