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Amid a health and care system in deepening crisis, one of the first tasks for new integrated care systems (ICSs) was to establish governance arrangements. This included decisions about who sits on the two constituent parts of each ICS: the integrated care board (ICB) and integrated care partnership (ICP). ICBs hold considerable power in the new NHS structure, controlling over £100bn of resources every year to provide health and care services in their area. So their membership matters.

How have the new ICBs been set up?

We analysed the 42 ICB constitutions – legal documents that set out an ICB’s governance and board membership. We looked at how the various ICS partners are represented on these boards and whether this varies between areas.

Each board must fulfil requirements set by the Health and Care Act 2022 and NHS England guidance. Membership should include at least 10 people:

  • a chair and chief executive
  • a director of finance, medical director and director of nursing
  • at least two non-executive members
  • at least three ‘partner’ members to bring ‘knowledge and a perspective from their sectors’, nominated by NHS trusts, primary medical services and local authorities in each ICB area respectively
  • one member should bring knowledge of mental health services
  • no board member should be appointed if their involvement in the private health care sector would impact on their role.

Non-voting ‘regular participants’ and observers can also be invited to attend meetings to try to enable more transparency and wider contributions. Beyond this, the guidance on membership is permissive and ICBs have taken advantage of this flexibility. Some examples of additional roles include a member of a trust provider collaborative in the North Central London ICB, a Healthwatch member sitting on the West Yorkshire board, a public health expert in Somerset ICB and a member of the ICP as part of Norfolk and Waveney ICB.

Many ICBs have sought specific experience and knowledge through their partner members – such as those representing rural or urban areas, people with experience of children’s and adult social care or public health, or representatives from different parts of the health care system such as community and acute services.

Too many members or not enough?

Our previous analysis showed that ICSs vary considerably in size and structure – for example, in the number of upper tier local authorities within their footprint (from 1 to 13), and population size (from around 520,000 to over 3 million). It’s perhaps no surprise that board size ranges too from 11 to 24 members, with an average of 16 members across all ICBs.

Existing evidence illustrates the importance of adapting board governance to different contexts: there is no one size fits all. In forming boards, ICSs will have encountered a trade-off between size and the need to ensure broad representation of relevant stakeholders.

Smaller boards may enable agile working and efficient decision making. While a larger membership may ensure more diverse partners have a seat at the table and may (in theory) improve collaboration. But past attempts at collaboration through sustainability and transformation partnerships (STPs) showed that too many people in meetings could make it difficult to make decisions fast, and broad membership may limit the chance of consensus.

Striking the right balance has been challenging. One ICB chair stated in June that there were ‘many, many people frustrated’ that they were not on the board, despite a large membership. More complex systems – such as North East and North Cumbria ICB with its 10 NHS trusts and 13 upper tier local authorities – may have found this even more difficult.

ICPs will have faced a similar if not greater challenge, given they are forums involving a broader range of partners than their ICB counterparts. Some appear to have substantial memberships, such as Mid and South Essex ICP which is made up of 50 members. Agreeing an integrated care strategy among this many will not be a straightforward process. Similar concerns were voiced when health and wellbeing boards were set up a decade ago, with many fearing that they would become ‘talking shops’ if too large.

Local government – an equal partner?

Local government is at the heart of the new ICSs, and adult social care and public health are primarily represented on the ICB through mandated local government partner members. But each system operates within a different landscape, with variation in organisational complexity and political affiliation. Some, such as Lincolnshire ICB, only have one local authority in their area and are able to appoint one member to represent it.

Various approaches have been used in areas with more than one local authority. In South East London ICB, the six local authorities nominated one partner member and six ‘place executive directors’ were chosen from each borough’s local care partnership. Other ICBs are relying on one to four partner members to bring local authority perspectives to the table. For example, Greater Manchester ICB covers 10 local authorities but only has one nominated partner member from local government.

The ICB isn’t the only show in town for local authorities: local government are joint conveners of the ICP and partnerships between the NHS and local government are developing at the ‘place’ level of the system (which usually follow local government boundaries). Other mechanisms, such as sub-committees, ensure a broader set of voices across local government are heard. But engagement of local government varied widely in previous versions of ICSs, and early accounts of ICS partnership working suggest some of these tensions may be ongoing.

Regardless of how ICBs have been set up, the question now is how the different partners in ICSs work together to meet their goals. The future looks daunting, with a system struggling to deliver good care and constrained by long-term structural issues, such as staffing gaps and weak capital investment. Making progress will depend on a mix of factors well beyond the composition of their boards – including the culture, relationships and trust between partners, and the broader investment and support they receive from national policymakers.

Skeena Williamson (@skeenareb) is a Policy Intern in the Policy team at the Health Foundation.

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