Moving towards an Integrated Community Care System (ICCS) for Wales

Background:  Wales is seeking solutions to help make health and social care community services more accessible, coordinated, and home-focused, aiming to prevent unnecessary hospital admissions and support timely, safe discharges. In 2024/25, the Care Action Committee and the 50-Day Integrated Care Winter Challenge shifted the focus from reactive hospital care to a proactive, enhanced community-based model. This intervention successfully tested new approached for building community capacity, integrated planning and system delivery, and provided proof-of-concept, which is now being adopted through the Integrated Community Care System (ICCS) to enhance person-centred community care, further improve outcomes, and build resilience through collaboration and shared system responsibility.

 

Approach: The 50-Day Challenge targeted ten high-impact actions, including optimising hospital flow, implementing proportionate 7-day working across health and social care, building community capacity, establishing integrated navigation hubs, and providing proactive support for high-risk groups. £19 million was invested in boosting community capacity, creating transition beds, and enhancing reablement and domiciliary care services.

 

Welsh Ministers led the CAC, brought together leaders from health, social care, and government to create joint solutions and shared accountability. Regional Partnership Boards and Senior Accountable Officers provided both strategic and operational oversight. Data-driven delivery was ensured with combined health and social care dashboards, regional reporting, and an ‘adapt, adopt or justify’ approach, driving responsive learning and continuous adaptation. Stakeholder workshops and feedback informed improvements. The ICCS blueprint was co-designed through cross-sector engagement, aligning national programmes and integrating digital and population health initiatives.

 

Results: The 50-Day Challenge and CAC achieved a 17% reduction in people delayed in hospital by March 2025 (target ↓15%), while delays to assessments dropped by 22% (target ↓20%). 92% of those experiencing the longest waits at the start (395 people) were discharged by March 2025. Over 2024/25, reablement support access increased by 31%, and domiciliary care waiting lists fell by 33%.

Proactive care and anticipatory planning for high-risk groups saw 5,343 people reviewed in the community and 2,670 Future Care Plans created to prevent escalation and hospitalisation. Emergency admissions for those aged 70+ dropped by 3–5% (the lowest in four years), and care home hospital transfers reduced by 12% compared to the previous year. This progress resulted from a collaborative culture at national/regional levels, enhancing integration, prevention, and continuous improvement.

 

Implications: Sustaining improvements relies on embedding integration and strengthening regional accountability. Wales has introduced new ICCS governance structures, replacing CAC, with a National Leadership Group (Ministerial), an Integrated Care Delivery Group (Operational leads), and regional Building Community Capacity meetings (Delivery partners). The focus is on preventive interventions, enhanced community care, and proactive support to further reduce admissions and improve outcomes.

 

Standardised datasets enable consistent evaluation and evidence-based decisions. Sharing case studies and impact summaries supports peer learning and ongoing development. Aligning funding and priorities across programmes ensures sustainable integrated care, with continued emphasis on joint winter planning, regional integration, and strategic change. Wales’ experience demonstrates the value of cross-sector leadership, agile governance, and community care, providing useful lessons for other systems aspiring to integrated, preventative, person-centred care.