If Integrated Care Boards (ICBs) and Integrated Care Partnerships (ICPs) have seven ages then they are still at the mewling infant stage, having become statutory in July.

Are the 42 Integrated Care Systems (ICSs), nursed into being to improve local health outcomes and efficiency by joining up health and care services, starting to thrive  - or are the significant pressures they face hindering progress?

Moving from partnerships to successful integration and delivery locally is the prize on offer, but one that is increasingly hard to achieve. Last week the Care Quality Commission's (CQC) annual report has highlighted a care system in crisis, with ‘alarmingly high' vacancy rates and staff living with the risk their patients will come to harm.

The CQC's picture of a ‘gridlocked system' comes after a National Audit Office (NAO) report earlier this month that concludes there is a substantial risk that ICSs will find it hard to live up to the high hopes many stakeholders have for them. It says this is because of the inherent tension between ‘meeting national targets and addressing local needs, the challenging financial savings targets, the longstanding workforce issues and wider pressures on the system, particularly social care'.

The NAO notes that NHS England has asked ICSs to take a long-term approach focused on preventing ill-health, ‘but the targets it has so far set for ICSs are about short-term improvements, particularly elective care recovery' post-pandemic. The report also uncovers widespread variation in access to services.

Last week, the Health Devolution Commission held the third in its series of thought leadership roundtables this year on developing ICS best practice, looking at workforce development, partnerships in place and system regulation. Health Education England (HEE) is responsible for planning the future workforce. Speaking at the event, HEE's director of strategy Jo Lenaghan sees the biggest benefit of the new bodies as the ability to have integrated planning – ‘by that I mean what we tend to do in the NHS in particular is to have service planning'.

She adds: ‘We work out what services we need to provide, with separate planning processes for the finances -  and then workforce particularly comes as an afterthought. Given that in the NHS it accounts for 70% of our spend and the workforce plan is the delivery plan - because it's people who deliver care and wellbeing -  that is remarkable.'

ICSs, she believes, offer instead the opportunity ‘just to bring those three different processes and conversations together – service planning, workforce planning, and finance planning aligned.'

There needs to be ‘a relentless focus on managing demand' she adds. And she warns that  ‘our biggest risk is that another period of austerity will make it hard….to focus on prevention and invest in the workforce'.

Cllr Tim Oliver is chair of the Surrey Heartlands Integrated Care Partnership and leader of Surrey CC. Asked if the early days of his ICP are going ‘as well as he would have hoped', he says the key focus has to be on prevention and early intervention, as ‘that is the only the only way in which the systems are going to survive actually, financially or otherwise, and more importantly to improve our health outcomes'.

He adds: ‘I think the starting point has to be understanding your local landscape, not just the geography, but the areas of deprivation.'

What is crucial, he emphasises, is to use the Joint Strategic Needs Assessment ‘as the document that sets out what is going on in communities and where that deprivation is'. He continues: ‘I think that is a really important document and that [it] should then drop into the health and wellbeing strategy for that geographical area. That is for me about the practical delivery.

‘We split that into three areas looking at the physical health, mental health and then looking at opportunity – particularly addressing the inequality of life expectancy, That's where the prevention and early intervention agenda is crucial. We need to stop people falling into chronic conditions.'

He says the culture of the NHS is different from that of local government, starting with budgets. ‘Local government has seen a significant cut in funding over the years but it has continued to deliver services as best it can. The NHS hasn't actually seen so much of a cut, but equally they don't have the same discipline in working within a budget, and I think that is something that is going to potentially cause some challenges where the two systems come together.'

There are already ‘arguments or conversations across the country about who funds the discharge to assess facilities and so on', he points out. He says that if he was the Government he would use  something like the Better Care Fund as a way of forcing the two systems to sit down and have that conversation.

He stresses that ICBs need to have clear arrangements to ensure there is joint oversight of major decisions around budget allocations for significant service reconfiguration, and he says it's disappointing to see that the latest operating model produced by the NHS ‘has virtually no mention of ICPs - and ICPs are going to be the oversight body for the delivery in the communities, for how budgets are spent and for how services are delivered'.

Overall he says his experience of the new system has been ‘pretty good I think because I've been within the ICS in shadow form for the last three years', but he does not think that this positive experience is necessarily reflected across all of the country.

There is a ‘massive' workforce shortage in Surrey, and addressing that crisis successfully across both the NHS and social care will need an even-handed approach, he concludes. ‘Social care staff quite often are not treated or recognised in the same way that those in the NHS are. They both do extremely important and difficult jobs.

‘So we need to make sure there is a level playing field, there is equal recognition and there is true partnership.'