What does local government reorganisation mean for Integrated Care Systems? Three opportunities, three risks and three actions

Since our analysis on the relationship between councils and Integrated Care Systems (ICSs) three years ago, we have been asked repeatedly for views and insights on this developing relationship. This relationship is now about to change significantly.

There is a ‘devolution revolution’ happening in local government – with 40 council areas scrabbling to submit proposals on fundamental restructure by 21 March. This has the potential to fundamentally change how the interface between councils and health work in practice.

So, to what extent is this a risk or an opportunity for Integrated Care Systems?

Firstly, what is happening? The Government is moving at pace to fundamentally restructure local government. The English Devolution white paper in December 2024 laid this out and the timelines that have followed are rapid. In summary, the Government has indicated moving towards a model where there are just two levels of local government – Combined Authorities (to be called Strategic Authorities – areas of at least 1.5m people, governed by a mayor) and Principal Authorities (unitary councils covering areas of at least 500k people). The first two moves in this are 1) setting up new Combined Authorities in six regions and 2) replacing all two-tier district and county councils by creating new unitary councils in 21 areas. Following that, there would need to be further changes at council and Combined Authority level to give a consistent map across the country.

With this complex picture, it can be hard to work out the opportunities and risks.

What are the opportunities?

• A new or strengthened Mayor as a primary point of contact (in some ICSs). Although the details are uncertain and will vary, the direction of travel is for Mayors to have increasing power and influence over local areas, including care and health.

• An alignment in focus on ‘neighbourhood’ level. With unitary councils there could be both a clearer single point of connection at ‘place’ level plus a refreshed focus on keeping close to local communities – giving an opportunity for shared agendas in neighbourhoods.

• Prevention, early intervention and collaboration will be an important part of deliberations. There is the chance that reorganisation could lead to a deeper understanding (and business case) for increasing the focus on what councils and partners could do to impact health demand.

What are the risks?

• Multiple complicated governance changes. ICB membership, provider relationships, and contracts may all have to be recast. In many areas, both the new Combined Authorities and the new footprint unitary councils will drive health governance changes. Some Combined Authorities will not match ICS boundaries, some new councils may even cross ICS boundaries.

• Cross-boundary reticence. In many areas there are strongly held differing views on the right footprint. As different footprints are considered, there will be more awareness of boundaries. Regardless of who ‘wins’, there could be increased reticence to work together across boundaries

• Distraction. Perhaps the biggest risk is that this agenda is going to be a huge distraction for Council Chief Executives, Leaders and management teams. It will take up much of their analysis capacity and thinking time. The amount they are therefore able to focus on working jointly with health partners will inevitably decrease.

So, what should ICSs and health partners do?

1.  Understand what is going on. Spend time finding out the likely local implications, the likely timelines, and who is driving the discussions.

2.  Be wary of being seen to pick sides. When there are different options portrayed, it may be natural for ICSs and other health partners to have a preferred option. This could make working with partners down the line very challenging. Instead ensure all parties are sighted on the big health and care issues, including health inequalities and wider determinants.

3.  Help frame the business case. The extent to which the proposed model helps deliver better health and social care can and should be a significant factor. Councils analytical functions will be overwhelmed. Helping by providing demographic and demand analysis in a format that can feed the business case will be well appreciated.

If you would like to understand more about what this might mean for your system and how you should respond, please get in touch.