1. System leadership. ICS leaders, including but not limited to chief pharmacists, should ensure that medicines optimisation teams are mainstream in projects and service redesigns from the start, so downstream effects and preventative impact of medicinal interventions, alongside social prescribing, can be considered and ensure best value.
2. Establish the right governance. ICS should consider establishing a clear board-level medicines lead, supported by appropriate system-wide committees and sub-committees, which help to provide multi-disciplinary expertise to drive transformation across each system. Governance arrangements should ensure a better balance with medicines optimisation teams between time spent on operational and transformational activity.
3. Build one medicines optimisation team. Alongside developing pharmacy workforce plans that develop innovative and rotational roles, ICBs should consider how they can build awareness of medicines optimisation right across the system including into social care, providing training where necessary.
4. Harness digital and data. Use shared care records to enable access to medicines information for relevant healthcare professionals across care pathways. Meanwhile, use system-wide data to assess incidence of avoidable harm, specifically inappropriate sodium valproate prescribing, as well as medicines expenditure, to establish an initial baseline in each system to measure success and improvement going forward.
5. Shared learning and self-improvement. ICSs should be supported to share learning about their respective progress transforming medicines optimisation to drive a process of peer learning and self-improvement. This could include learning on how different systems are delivering improvement in risk assurance; data analytics; digital interoperability; pharmacy workforce planning; development of rotational and cross-sector roles; and integrating medicinal and social prescribing.

1.  Collaboration within and between systems and national bodies.
2. A limited number of shared priorities.
3. Allowing local leaders the space and time to lead.
4. The right support.
5. Balancing freedom with accountability.
6. Enabling access to timely, transparent and high-quality data.

 The report states that:

•  Delivering on these principles will require a genuine change in how the health and care system operates and a shift of resources, with the share total NHS budgets at ICS level going towards prevention needing to be increased by at least 1% over the next 5 years.
• National and regional organisations should support ICSs in becoming ‘self improving systems’, given the time and space to lead - with national government and NHS England significantly reducing the number of national targets, with no more than 10 national priorities.
• For every ICS, increased transparency is vital to enabling local autonomy. The availability of timely, transparent and high-quality data must be a priority, and NHS England and the Department of Health and Social Care (DHSC) should incentivise the flow and quality of data between providers and systems.
• To support ICSs work the government should produce a complementary strategy for the social care workforce. It also states that more should also be done to enable flexibility for health and care staff, both in moving between roles and in the delegation of some healthcare tasks
• It recommends that work should be undertaken to design a new framework for General Practice (GP) primary care contracts, as well as a review into other primary care contracts.

1. Embedded culture and behaviours and inter-organisational power dynamics
2. Organisational complexity, duplication, and overlapping focus
3. Resource constraints
4. Difficulties in defining, measuring and evaluating integration
5. Integration fatigue.

In response, this report offers some suggested approaches to mitigating those risks, which should be the focus of system leaders as partnerships take hold. These include:

1. Ways of building integration into the day job
2. Bringing clarity to the complexity of governance structures
3. Better use of performance management, metrics and data
4. Fostering culture change through greater mutual understanding
5. Rebalancing capacity, including management capacity.

• A strong and effective ICS will have a deep understanding of all the people and communities it serves.
• The insights and diverse thinking of people and communities are essential to enabling ICSs to tackle health inequalities and the other challenges faced by health and care systems.
• The creation of statutory ICS arrangements brings fresh opportunities to strengthen work with people and communities, building on existing relationships, networks and activities.

1. How are provider collaboratives being set up and resourced?
2. What are provider collaboratives aiming to achieve?
3. What are the opportunities of collaboration for different trust types?
4. What are the key enablers for provider collaboratives?
5. What are the emerging risks for boards to manage?

The presence of an intermediate tier in the NHS is nothing new, and ICSs have existed in some form since 2016. But they have lacked any formal powers – until now.

ICSs will assume their new role in the health system at a precarious moment: the NHS faces a growing backlog of unmet need, staffing gaps of more than 100,000, and declining public and political satisfaction. An added challenge is that money is in short supply, with rising inflation eating up a share of planned budgets and no new funding on the horizon.