The NHS in England has been changing for some time. National policymakers and local service leaders are seeking to promote and embed collaborative ways of working across health and care services. This shift to system working has been driven by the need to provide better joined up care to the growing numbers of people who rely on multiple health and care services.
Since 2021, all parts of England have been working as 42 ICSs, which bring together NHS organisations with key partners including local authorities and the voluntary sector, to coordinate and plan health and care services to meet the needs of the local population. ICSs cover populations ranging between 600,000 and three million. National policy identifies four key purposes for ICSs:
- improving population health and healthcare outcomes
- tackling inequalities in outcomes, experience and access to health care
- boosting productivity and value of health care
- supporting broader economic and social development in local communities.
The Health and Care Act came into effect in July 2022 making wide-ranging changes to the legislative framework underpinning the NHS, aimed at facilitating greater collaboration and integration. Under the new legislation, ICSs will become statutory bodies with a two-part structure comprised of an integrated care board (ICB) and an integrated care partnership (ICP).
ICBs will manage NHS funding and performance. They will include members from trusts, local government and primary care. ICPs will be formed in each ICS as joint committees of ICBs and the relevant local authorities in the system, bringing together a range of local stakeholders to create an integrated care strategy that meets the health, care and wellbeing needs of local populations.
While this two-part ICS structure aims to bring NHS organisations, local authorities and wider partners together to plan and deliver services differently, it has not altered the fundamentally different accountability structures between the NHS and local government. Navigating this complexity when developing local priorities will remain a key challenge for systems and place-based partnerships, particularly in systems which have several local authorities of differing political complexions or potentially divergent priorities.
National policy developments relevant to place
Recognising that place is a key footprint for implementing integration, national policy has aimed to support partners to work together effectively at place level (alongside guidance focused on supporting collaboration between trusts at ICS and multi-ICS level).
In 2021, NHS England published an ICS design framework which made clear that place partnerships would be characterised by collaboration across the NHS, local government, voluntary sector and wider partners. The Thriving Places guidance, also published in 2021, positioned place-based partnerships as the building blocks of ICSs, and identified a number of functions which may be well suited to being led at place, including strategic planning, leading service change, population health management, connecting with local community insight and facilitating action on wider determinants. Places will need to establish shared objectives and vision, built on a mutual understanding of the population and their health aspirations.
In February 2022, the government published an Integration white paper which sought to help accelerate the integration of health and social care services at place level. It articulated some expectations for places, including:
- places are asked to clarify leadership arrangements by spring 2023 via identifying a single person accountable for delivering shared health and care outcomes
- places will develop joint outcomes for health and care services, informed by a national outcomes framework (both are expected in spring 2023)
- places are asked to explore growing the proportion of health and care budgets that they manage using pooled or aligned arrangements (such as section 75 agreements).
The Department of Health and Social Care (DHSC) led an engagement process on the white paper in Spring 2022, and we submitted a response summarising trust leaders’ views. The outcomes of that consultation and next steps on implementation of the white paper’s proposals are expected to be made clearer in the coming months.
Places within integrated care systems
Trusts have been working with each other and wider partners in a range of formal and informal collaborative arrangements for many years. Their experiences of implementing service change, including during the pandemic, have demonstrated that, in many systems (though not all), much of the work to join up care happens naturally at smaller footprints than ICSs.
Systems have defined place footprints locally, often based on local government boundaries and/or hospital patient flows. ICSs vary in how many places they cover, depending on a number of factors such as population size, geography and organisational configurations. Similarly, the relative roles and responsibilities held at system and place levels within ICSs is subject to local variation.
In many cases, partners have developed collaborative arrangements – of varying degrees of formality – at place to support their shared purpose. Different terminology has been used to refer to these place-focused collaborations, or programmes of work, including integrated care partnerships, alliances, localities etc. As system working has evolved, trusts have supported system-wide aims by working in more collaborative and integrated ways, as explored in the following section.
Key themes of trusts' work at place
Trusts of all sectors have a role at place – but those roles will rightly differ depending on the local context, geography, and population size, as well as the nature of the services they provide. Looking across the sites we spoke to, the roles that trusts are adopting at place fall into broad themes:
- planning, delivering, integrating and transforming services
- improving population health and wellbeing and tackling health inequalities
- workforce planning and development
- leading and directing their organisations to facilitate partnership
- supporting a collaborative culture.
A number of trusts providing services at scale, including ambulance trusts and colleagues across community services, mental health and acute care, will be balancing the need to work collaboratively at scale with a smaller population focus. This will prove a challenge for those trusts whose services are predominately at scale, as each place will have its own distinct culture and priorities.
Planning, delivering, integrating and transforming services
People access the majority of health services in the places they live. In many systems, it will make sense to plan and deliver some of these services at place level, such as non-complex acute care, surgery and diagnostics, and community services for physical and mental health. Urgent care services are also likely to be an important collaborative endeavour at place. Many of these services are being transformed and integrated with wider health, care and public services, as trusts work with partners to join up care and redesign end to end care pathways. Many trusts have the capacity and capability to add significant value to this service transformation and improvement agenda at place level.
Improving population health and wellbeing, and tackling health inequalities
Trusts are establishing themselves as anchor institutions in their places and communities in several ways. As large employers within and across places, trusts have scope to positively influence the socio-economic development of their local areas, and in turn the health and wellbeing of their local populations, through the choices they make around employment and purchasing decisions. They also have opportunities to positively impact local communities, tackle health inequalities and shape the wider determinants of health through their collaboration with local government. Some trusts are also building partnerships with wider public services in their places, e.g. working with education institutions to encourage participation and broaden career paths.
Workforce planning and development
Trusts are supporting and developing integrated workforce arrangements at place level including across health and social care services. As trusts employ 1.2 million NHS staff, they have helpful insights into how hyper-local joint working across health and care can make a tangible difference to patients and service users, and allow staff to maximise their skills. Increasingly, trusts are supporting local approaches which enable places to understand their collective workforce resource and capabilities, harness the potential of integrated multidisciplinary teams and career paths, and look for opportunities to deploy staff differently.
Leading and directing their organisations to facilitate partnership
Our case studies show how trusts are playing varied roles at place level depending on their organisational size, configuration and local context. Some trusts are taking a leadership role, leading programmes of work, acting as a host for collaborative arrangements, and delivering key capabilities on behalf of the partnership. In some cases, this includes trust senior executives leading the place partnership alongside their substantive roles, with support from local partners. In other places, trusts are taking more of a supportive role; for instance, deploying their resources and infrastructure to support the partnership’s aims, supporting other organisations to lead the partnership following local agreement, and ensuring their trust’s operational model dovetails effectively with the place-based partnership(s) to which they contribute. In all cases, trust boards remain responsible for the services their organisation delivers, so they continue to manage organisational priorities and oversee care quality, alongside partnership-focused work.
Supporting a collaborative culture
A recurring theme throughout our discussions with trust leaders was the importance they placed on a culture of collaboration, as an enabler of service change and improvement. They also noted that decisions about leadership and partnership arrangements, though important, are in practice dependent on leaders and operational teams fostering a sense of shared endeavour based around serving the local population. Whatever leadership and partnership management arrangements are chosen, it is essential that they have been designed to fit local circumstances with input from participating organisations and therefore enjoy the genuine support from partners within a place. As our case studies show, there is no ‘one size fits all’ model at place level.
Alongside collaboration at place, trusts are working together to support the delivery of ICSs’ four key purposes. Provider collaboratives, partnerships of two or more trusts, will play a leading role progressing a number of key agendas such as driving standardisation in clinical services, reducing inequalities in access to care and making health services more resilient through sharing staff and other resources between sites and organisations.
From July 2022, NHS England expects all acute and mental health trusts to be part of at least one collaborative, with other trusts, such as community and ambulance trusts, forming or joining collaboratives where it can support improvements in care. Although not the main focus of this piece, provider collaboratives will interface with place-based collaborations and many trusts will contribute to place-based partnerships alongside working as part of a collaborative(s).
To find out more, please see NHS Providers’ successful programme of influencing and support for provider collaboration.