Birmingham and Solihull Integrated Care System: pilot assessment report

Direction of travel

There is positive progression with development of effective and coherent system leadership to achieve the aims of the ICS. We found leaders who were capable and compassionate, with a focus on a shared vision, inclusion, sustainability, improvement and tackling inequalities. We found:

• early stages of implementation of new initiatives
• continual focus on identifying population needs through data collection and knowledge of partners
• a lack of evidence to demonstrate that the system is listening to the many voices of people who are seldom heard
• feedback that not all partners felt involved and consulted by the ICS, which may risk progression in this area.

Summary of strengths

• System leaders and partners are committed to a clear vision to develop Birmingham and Solihull ICS partnerships strategies. There is a focus on addressing health inequalities underpinned by a constructive and inclusive culture, where trusting partner relationships and integrated ways of working are developing.
• There are clear ‘road maps’ for the system to achieve the aims and objectives of the ICS and good structures around risk, oversight and assurance. Governance arrangements support holding the system to account.
• The engagement strategy focused on hearing people’s voices and we saw pockets of meaningful engagement, particularly in areas of high deprivation.
• Equality, diversity, inclusion, and health inequalities are linked across the ICS work, including in the workforce. This supported a commitment to the anti-racist pledge and demonstrated innovative approaches to recruitment and retention.

Areas for development and next steps

• There is scope to improve the responsibilities, governance and forward view around ‘localities’.
• There are further opportunities to align strategies and plans into clear priorities and deliverables to ensure all activity is scalable and aligned with system objectives.
• There is scope to improve the culture and staff experiences within the ICS and other organisations by continuing to develop the Freedom to Speak Up structures and sharing learning.
• The engagement strategy needs to continue to progress by including listening to  the voice of children, young people, and their families.
• There is scope to improve how data is used to identify system priorities for high impact interventions.

Summary findings for quality statements under the Leadership theme

This theme includes these quality statements:

• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation
• Environmental sustainability – sustainable development
• Workforce equality, diversity and inclusion

Quality statement: Shared direction and culture

ICS leaders and partners strive for a shared vision to understand and meet the needs of the population in a person-centred way.

Prioritising the direction of the system

The system’s overall vision was developed in conjunction with all system partners before establishing the ICB, including extensive engagement activity that was supported by an NHS England-funded external facilitator. The process was open and transparent. Not all senior leaders within the system were in post at the time of the development of the vision and the priorities.

Most system partners felt involved in setting the shared vision and priorities for the system.

A small number did not feel their professional knowledge was being used to best support population needs. This included dentists, the ambulance trust and health and overview committee members (HOSC).

Good progress has been made with the Inception Framework 2022, the ICS Integrated Care Strategy 2023, and its 5-year Joint Forward Plan. The strategy sets out the vision for the future and the specific improvements intended over the next 10 years. There is a clear aim to improve life expectancy for the people of Birmingham and Solihull, and an ambition to focus on 5 key clinical areas. This demonstrates an understanding of the population’s needs, system challenges and a collaborative approach to create strong platforms to enable people to live well for longer in good health.

While the ICS’s vision and the 10-Year Strategy are clear, there are multiple strategies in the ICS and partner organisations that are not aligned, which blurs their interpretation. This makes it difficult for some partners and frontline staff to understand their role in the ICS. System and provider strategies should be aligned to clarify the system vision and enhance successful partnership working.

The ICS’s strategic plan and transitional operating framework supports the ICS Integrated Care Strategy and puts transformation at the heart of improving outcomes for people. Part of the reform is setting out integrated neighbourhood teams at the heart of the community.

Equality, diversity, and inclusion (EDI) is threaded throughout the ICS strategies, with some emphasis on disparities of health inequalities and on reaching those whose voices are seldom heard. The 10-Year Strategy is strong on health inequalities, but its mapping to the practicalities of health services and social care service delivery is less so. 

The ICS Health Inequalities Strategy (HI) for 2022-27 includes key areas of concern and sets out building blocks and ways of working for what the system wants to achieve in relation to health inequalities, people with protected equality characteristics and those living in deprived areas. Some good work has taken place with community representatives to support this area of work.

Quality statement: Capable, compassionate and inclusive leaders

There is an inclusive and positive culture of continuous learning and improvement as system leaders had undertaken self-reflection to review their progress since the inception of the ICB. They have made considerable effort and progress to set a culture for the development of leadership expectations. These set the foundations for integrated working to support improved, professionally engaged partnerships that reduce health inequalities and improve the lives of people who use services and wider communities.

The system is trying to progress a culture of high expectations around capable, compassionate and inclusive leadership. We observed senior leaders maintaining good relationships, being collaborative, accessible, and engaging during their system quality group meetings. We saw empathy and compassion and there is recognition of system and performance challenges, but also praise where improvements had been made.

Senior leaders emphasise the importance of creating a compassionate culture and executives across health and social care worked to develop the Compassionate Charter to support collaborative working and behaviours.

A set of values (TEAM - transformative, equality, accountable, mindful) were created in collaboration with NHS partners and care parties in the statutory sector aiming to align organisational values. In working relationships, there is a desire to speed up resolutions and enhance inclusivity of strategic service development. A minority of system partners raised concerns about inclusivity and perceptions of top-down leadership and decision-making, but progress has been made and most partners spoke optimistically about future ways of working. There is evidence of successful and emerging relationships across the system that benefit people who use services.

Senior system leaders intend to deepen community involvement and overcome recognised challenges to engaging with some of their community due to cultural, linguistic, and ethnic barriers. The ICP Board attendees included 6 community representatives to support this work.

Fit and proper person regulation

Leaders understand the current and new requirements for the Fit and proper person regulations (FPPR). The ICB has updated its policy to reflect the new requirements for FPPR, and new recruits were being taken through this process at the time of our assessment. A sample of records showed that most requirements were met, however not all records had evidence of interview process or proof of stated qualifications.

Quality statement: Freedom to speak up

The ICB has fostered a positive culture and has clear escalation routes for raising concerns. The Freedom to Speak Up Guardian (FTSUG) is experienced and passionate about their role with protected time for this work. Executive leaders engaged with the Freedom to Speak Up Guardian and are committed to seeing improvements.

Roles and processes

A compassionate leadership approach has been adopted to focus on improving relationships with staff and supporting the growth of a positive culture, trusting relationships and a platform to speak up safely.

There is a good sense of direction and The ICB’s Freedom To Speak Up policy will be developed once the National Guardian’s Office (NGO) provides guidance and has engaged with the system Freedom To Speak Up Guardian.

The ICB follows the National Guardian’s processes and submits data to support transparency in freedom to speak up events. Analysis of data demonstrates themes and trends, and protected equality characteristics are collected to understand where developments and future actions are needed.

Both leaders and staff within the ICB and ICS have a shared understanding of speaking up. They are able to describe what speaking up is and the methods within their own organisations. However, a minority of leaders and staff felt they would be uncomfortable raising concerns in their own organisations.  

Freedom to speak up training

The ICB intends to roll out mandatory training once the new Freedom to Speak Up policy and framework has been finalised and the Freedom to Speak Up Guardian has consulted with staff to consider how to do this.

Quality statement: Governance, management and sustainability

System leaders have established clear responsibilities, systems of accountability and governance arrangements. Leaders are committed in delivering good quality, sustainable care, treatment, and support. The maturity of these arrangements is evolving and in development.

Governance systems

The Chief Executives group across Birmingham and Solihull, including representation from all NHS, local authority and primary care organisations, meets every week. The group was created following several system leadership changes to help the new group to recognise the system perspective and work together constructively.

Recognising the level of challenge to delivery within the system, the ICB led the establishment of a System Oversight Group (SOG) chaired by the Chief Delivery Officer. The SOG’s role is to drive improvement and delivery through performance and transformation to achieve the ICS’s commitments. It also shares insight and intelligence and identifies opportunities for improvement. This forum is credited with the co-ordination that has delivered improvements in long waits for elective treatment.

We saw evidence of place-based structures in both Birmingham and Solihull. The system has implemented a governance structure to pilot integrators at a Place level, reflecting its ambitions for services to be delivered in the community as close to patients’ homes as possible. Although governance structures at place level still required further development, they had some success in rolling out the Fairer Futures Fund – an initiative designed to fund activities that will contribute to improving outcomes and tackling inequality.

There is an emerging good culture of risk-sharing within the system. This can be seen among senior leaders, particularly when addressing challenges of performance and quality, finance and workforce. For example, the system and Birmingham City Council have supportive and mature discussions about implications of a recent Section 114 declaration, to try to limit the impact on patients.

Performance delivery and recovery

The ICS outcomes framework tracks progress against the 10-Year Strategy, in alignment with the national ICS outcomes framework and health and wellbeing strategy metrics.

The SOG has 2 areas of focus: part A (performance, system pressure and actions) and part B (transformation, initiatives, and overall delivery). The System Quality Group is the strategic multi-stakeholder forum where emerging and current insight, risk, intelligence and improvement is managed with an oversight of quality concerns.

Urgent and emergency care has been a national challenge. Birmingham and Solihull ICS has recognised this and developed recovery plans in line with national guidance. For example, there have been significant improvements in urgent and emergency care, moving from tier 1 support (the highest level) to tier 3 at the time of our assessment.

The ICS is not always made aware of health inequalities in maternity safety incidents (SIs). System leaders acknowledged that other than monitoring of maternity SIs, they are not made aware of health inequalities in other patient safety incidents and further review of this is required. In the interim, an outcomes framework is in place, which identified ethnicity, gender, deprivation, and other available characteristics.

The system has processes with both overview and scrutiny and health and wellbeing boards, and met regularly with the HOSC to provide updates and attend scrutiny committees. However, HOSC felt its role and position in the system was not well understood by the ICS and partners. Health and wellbeing boards focus on reduction of health inequalities through commissioning decisions, delivering the Joint Strategic Needs Assessment for Birmingham, promoting greater service integration, participating in the annual assessment process to support Integrated Care Boards authorisation and identifying opportunities for effective joint commissioning arrangements and pooled budget arrangements.

Quality statement: Partnerships and communities

System leaders and partners understand their duties to collaborate and work in partnerships to enable services to work seamlessly for people. They are working towards implementing and delivering system-wide objectives at local levels, including reducing health inequalities, with some positive examples of collaborative working. System partners see the benefits of bringing people together to identify and resolve issues and perform more effectively.

System-wide objectives and processes

There is leadership commitment to work in partnership with the population, providers, the voluntary community and social enterprise, and a clear strategy for it. Transition to working as a system had not been easy for everyone. System partners spoke positively of the shift in approach to integration and collaborative working as a community.

The ICS strategic plan and transitional operating framework supports the ICS strategy and puts transformation at the heart of improving outcomes for people. The ICB set out a clear strategy around devolution of the tactical commissioning and contracting of services to 3 provider collaboratives. This will create single operating models in mental health, community (currently in pilot) and acute (due to begin 2024) sectors in Birmingham and Solihull. Some of the aims of the collaboratives are to provide systemwide focus on delivery, quality and safety of services, health prevention, and improvement in people’s access and experience in outcomes. 

These collaboratives are intended to help the system to improve how it manages demand and supply across sectors, but they still faced challenges and only one was operational at the time of our assessment.  Partners talked positively of the shift in approach to integration and collaborative working as a community. We heard of ‘green shoots’ and being at a ‘happy point of joined-up working’, with recognition of the need to translate this into operational working for all system partners.

A small number of concerns were raised regarding methods of sharing primary care information. An operating model to address the fragmentation of primary care services is being considered to ensure one voice, address access challenges and improve services through a GP Provider Support Unit. A senior leader told us there is a primary care risk and quality group, and that primary care also fed into the System Quality Group and then the Quality Committee as needed.

Working collaboratively

The Integrated Care Partnership Board connects the local authority, adult social care, wider partners and voluntary services. Relationships are maturing and system leaders felt they are on course for delivery with a shared culture and collaborative working. Most system partners felt confident to make decisions and felt supported by ICB leaders.

System partners felt there is increased collaboration through the Integrated Care Partnership Board between health services, the local authority, police, and particularly voluntary services, who included the voice of the population, which had led to better oversight of challenges across the system. We saw evidence that system partners understand risks across services, and we heard examples where the ICB has facilitated and funded integrated working. For example, we heard how it funded collaborative working between the ambulance service and an NHS trust to expand acute emergency services.

There is good integration, improvement and collaboration between the ICS and its partners for some pathways of care through the mental health collaborative. As a result, people are receiving the mental health support they needed and there is a significant reduction in the length of time people are staying in hospital.

There are still significant challenges regarding transitions of care, for instance for children transitioning to adult care particularly when they still need hospice services.

There are good examples of partnerships and communities working together, building relationships, more engagement and less silo working. We were told about examples of successful work through the West Birmingham Community Health Collaborative, Flourish, and work to help unemployed and young people from Birmingham and Solihull into entry-level jobs in health and social care through the iCan programme.

Commissioners felt they worked well with system partners, and better engagement meant that information and available data could be shared at the relevant governing boards, sub-groups and working groups to improve outcomes for the population. Public health leaders have built good relationships with good quality information being shared. This enabled them to lead on the work for the ICP’s 10-year strategy, which has resulted in forming a 10-year strategy with a clear focus on prevention at locality and neighbourhood level.

The ICS is working towards meeting the NICE (National Institute of Health and Care Excellence) Quality Standard on Community Engagement: improving health and wellbeing (QS148). It had carried out work against all 4 quality statements of the standard.

Quality statement: Learning, improvement and innovation

System leaders and partners are committed to a culture that brings continuous learning, innovation, and improvement across the organisation.  An alliance has been created with Birmingham Health Partners, to bring together industry, charities and patients to co-design and deliver innovative solutions to urgent healthcare challenges at scale and pace. However, some system partners reported confusing and inconsistent learning and improvement structures.

Systemwide learning culture and process

The ICS Strategy, Inception Framework and Health and Wellbeing Strategy are considered as part of the Birmingham Health Partners Strategy to agree strategic direction and priorities. The ICS works with local universities to create alliances and innovation.

The ICS Inception Framework sets out expectations of enabling and fast-tracking improvements as a matter of routine, not exception. Although an important and related strategy, the 10-year Strategy does not focus on learning and improvement in the system.

The ICS introduced a system-wide escalation pathway for people with a learning disability and/or autistic people following learning from The Birmingham and Solihull Annual LeDeR report 2022/23.

System leaders and partners recognise the challenges they face in sharing learning across the system. There are early indications of a system-wide learning culture and shared efforts to innovate and improve services. Various events had taken place to reflect and learn from experiences and there is a quality improvement structure across parts of the system. We heard that sharing learning on quality is a key role for the System Quality Group jointly chaired by the ICB’s Chief Nursing and Medical Officers.

Some staff told us the Quality Improvement structure is confusing to understand and navigate, which led to people relying on existing relationships to escalate learning needs. Other partners and staff told us in many areas learning is not consistently shared, which left room for incidents recurring. A small number of system partners raised concerns about the effectiveness of system learning from Healthwatch reports that highlighted concerns regarding how access to GPs and NHS dentistry were affecting preventative care. It is felt these issues had not been resolved.

Partners in primary care feel they hold good local knowledge regarding health inequalities and would like to see this knowledge used more, with opportunities to lead on work to benefit localities and place planning.

Quality statement: Environmental sustainability – sustainable development

The ICS Green Board is responsible for monitoring the ICS Green agenda and the ICS has committed to a reduction trajectory. It recognises further governance around the Green Plan is required to outline specific targets and deliverables to partners and providers within localities.

Understanding of environmental sustainability and action being taken

The ICS Green Plan 2021-2026 has a heavy focus on carbon reduction. There is mention of health inequalities and the link with air pollution and health, although a lack of consideration about the need to prevent ill health more systematically through working with system partners such as the local authority. There is some reference to making Birmingham a healthier place to live, but action and the link to environmental sustainability are unclear.

The Green Board focuses significantly on estates and runs the risk of not being embedded in the wider healthcare provision, for example by not addressing health inequalities, partnership working or improving systemic social determinants of health.

The ICS sustainability lead told us the Green Plan needs refreshing to align with system plans, brining partners together and broader conversations. They also told us there is good representation from providers and they are going to individual provider boards to learn more, for example about primary care, so this could inform the green plan further.

The ICB recognises further work is required during 2023/24 to deliver Net Zero (carbon reduction), with greater engagement with local authorities and NHS England expected. 

Quality statement: Workforce equality, diversity and inclusion

The ICS values diversity in its workforce and is committed to an inclusive and fair culture. Senior leaders across the system recognise that workforce culture requires focus, demonstrated by the high-profile culture concerns raised during late 2022 and throughout 2023. A series of planned ‘big conversation’ events with staff have been arranged to gain an insight into staff views including inclusion and diversity.

Policies, procedures and practices

The ICS wants to promote a fair and open culture. It has some clear pledges, such as ‘We support making Birmingham the first Anti-Racist city in the UK’. This work continues to be supported by the Birmingham Race Impact Group, which focuses on resourcing the next generation of activists by pulling together Birmingham's best practice on fighting racism. However, it is unclear how this initiative would be rolled out to the rest of the system and include Solihull.

Birmingham and Solihull ICB’s Interim Equality Strategy 2022-2023 outlines its approach to equality, diversity and inclusion, focusing on addressing inequalities within the workforce. It is developed through analysing staff demographics, experiences, and staff feedback sessions, including the 2022 staff survey results. It includes a quality improvement approach, with ongoing analysis of data, to identify under-representation within the workforce of people with protected equality characteristics.

Accountability frameworks and Feedback from staff

The ICS uses data from the workforce oversight framework and the workforce dashboard to monitor staffing, report on risk and inform the actions needed. This includes a variety of measures such as staff survey results, sickness absence, people in leadership roles who are from ethnic minority groups, gender and protected equality characteristics. The ICS is planning to develop more metrics, including some Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) information, to be clearer and provide better triangulation, oversight and assurance.

There is some variation in the views of staff regarding discrimination in practice and meeting national targets for workforce disability, but leaders and partners are aiming to improve an inclusive and fair culture by improving equality and equity for people who work for the organisation.

ICS data on senior leaders who have a disability showed that 2 out of 7 NHS trusts are meeting national targets for having senior managers who are disabled. Three trusts are not meeting the national target and there is no data for 2 trusts.

There is some variation in whether staff in the area believed they are discriminated against, with 2 of the large partners within the ICS being in the lowest quartile in the NHS Staff Survey for this measure. The survey also shows that the ICS is ranked among the lowest in the country in relation to staff who feel their organisation acts fairly regarding career progression, promotion regardless of their ethnic background, gender, religion, sexual orientation, disability, or age.

Providers within the area are mostly meeting the national target of having 12% of senior managers from an ethnic minority background, but as an area with a high level of diversity, this alone may not meet the test of whether the workforce reflected the population.