Background and context
Integrated care system (ICS): South West London ICS
Number of places in the ICS: Six borough-based places: Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth
Key partners in the Croydon place:
- Croydon Health Services NHS Trust delivering acute and community health services
- South London and Maudsley NHS Foundation Trust (SLaM) provides mental health and learning disability services across a number of London boroughs, including Croydon (as well as a range of specialist services across a larger footprint).
- London Borough of Croydon, which is a unitary council with a directly elected mayor (as of May 2022)
- South West London ICB (formerly commissioning functions were led by South West London CCG)
- Croydon GP Collaborative
- Age UK Croydon
Key features of the Croydon population:
- 380,000 people
- One of London’s fastest growing and most diverse boroughs, with a large community of people from ethnic minority backgrounds (estimated at around half of the population) and a large number of people in the Core20Plus5 cohort (which includes: those living with deprivation; poorer than average access to, experience of, or outcomes of care; and health inclusion groups such as people experiencing homelessness, traveller communities, and people in contact with the justice system).
- Significant health inequalities: life expectancy for men, for instance, varies by up to 10 years between different parts of the borough.
Role of the trusts at place
Croydon Health Services NHS Trust has helped lead the development of the place partnership within the borough, providing leadership and organisational capacity to the programme. The chief executive of the trust is also the place-based leader, which has enabled the development of more integrated services between primary, secondary, community and social care, and supported greater emphasis on population health. In the future, there is scope for it to develop its role further, working more closely with other partner organisations, providing a broader spectrum of services, contributing to a population health agenda, and supporting greater coordination across organisational boundaries.
Reflecting Croydon’s comparatively simple organisational context – a single trust delivering both acute and community services, and a co-terminous local authority (and previously co-terminous CCG) – partners in Croydon have sought to work through a relatively streamlined model for leading and delivering place-based working.
Initially, this took place under the auspices of the One Croydon Alliance, a partnership between a group of health and care organisations with a focus on services for older people (aged 65 and over). In time, the agenda developed to include services for the whole population. Additionally, in 2019, Croydon CCG and Croydon Health Services NHS Trust developed proposals to align their functions and ways of working to create an approach to health care planning and delivery that would support their aspiration to develop a truly ‘place-based’ model of care.
Prior to the introduction of the Health and Care Act in which CCGs were abolished, Croydon Health Services NHS Trust and Croydon CCG worked collaboratively over several years and effectively operate as a single organisation with a single financial control total. All key decisions relating to strategy, transformation and finance were taken at ‘committees in common’ made up of executives, NEDs and lay members of both organisations. The committee in common was underpinned by an MOU between the key provider organisations, which formed the main vehicle for delivering change in how services are delivered.
A health and care board oversees transformation work in Croydon, where partners come together to make decisions and discuss operational priorities and assess delivery progress. As in other places, the health and wellbeing board (HWB) for the borough articulates the broad aspirations for the local population through its health and wellbeing strategy. The One Croydon Alliance then uses this strategy to inform its collective programme of change.
The alliance arrangement provides a single forum where partners can collectively articulate strategy and set shared priorities, for instance the alliance developed a shared health and care plan for Croydon. However, in line with the legal framework, these arrangements do not affect the legal status of the trust: the trust board remains in place and responsible for their respective statutory duties.
Working through an alliance creates scope to introduce service developments drawing in a broad range of local partners’ capabilities and informed by an understanding of local communities’ strengths and needs. For instance, SLaM works with VCSE partners in Croydon to deliver support and recovery services – in community settings – which are designed around local people’s needs and with a strategic focus on promoting cultural inclusion, responding to the diversity of the borough’s population.
For Croydon Health Services NHS Trust, their role supporting collaboration at borough level sits alongside active involvement in the south west London acute provider collaborative, which brings together the four acute trusts in the system: Croydon Health Services NHS Trust, St George’s University Hospitals NHS Foundation Trust, Epsom and St Helier University Hospitals NHS Trust and Kingston Hospital NHS Foundation Trust.
Croydon has moved to a shared leadership team for their place-based partnership. Since October 2020, Matthew Kershaw has been chief executive of Croydon Health Services NHS Trust and managing director for Croydon CCG with a shared leadership team including a joint chief nurse, joint chief finance officer, and joint director of strategy and transformation working across both organisations. This model has been a key enabler of breaking down organisational boundaries between partner organisations with a view to deploying local management capabilities – finance, clinical leadership, strategy and transformation – more effectively.
Approach to managing collective resources
Over time, leaders in Croydon have been nurturing a shared approach to financial resources and increasingly looking for opportunities to deploy resources for the long-term benefit to the health of local populations. In operational terms, there are a couple of key aspects to this.
Firstly, in line with national expectations around the Better Care Fund, the CCG and council entered into a section 75 agreement to pool a proportion of their budgets to support more joined up working across health and care services. This work programme has focused on funding community-oriented services and improving reablement and rehabilitation care. The pooled arrangement is overseen by the Croydon HWB.
Secondly, Croydon Health Services NHS Trust and Croydon CCG developed a risk share arrangement whereby the two organisations’ resources were effectively pooled and operated a joint control total. Both organisations committed to a 50/50 allocation of risk for deviating from financial plans. The aforementioned joint governance and leadership model supported this way of working. This arrangement was suspended when NHS England introduced special financial planning arrangements to support the NHS response to COVID-19.
Looking ahead, partners in Croydon want to develop this model further now that the new legislation has come into effect. A place-based lead for health, as outlined by the integration white paper, will be a continuation of the approach previously in operation across Croydon Health Services NHS Trust and the CCG. Discussions are ongoing about the details, but South West London ICB is supportive of delegating substantial resources to place level. The alliance arrangement will provide a platform with capabilities to further develop integrated planning and delivery in Croydon.
Benefits and learning
For Croydon, having a trust chief executive as the place-based leader has been beneficial and facilitated a different lens on traditionally health-based issues. For example, when looking at urgent and emergency care as both a trust leader and a place-based leader, it is easier to see how pressures in this pathway are partly influenced by the health needs, inequalities and unmet needs of the local population. Having this consideration of the wider determinants of health can generate a set of place-based priorities and objectives that partner organisations can support, to the benefit of patients and communities.
The alliance approach also provides a framework to bring together key players at place level – acute, community, mental health and primary care services – to collectively address those priorities over time. Croydon Health Services NHS Trust is also carrying out a piece of work to take forward NHS England’s Core20Plus5 model of tackling health inequalities and is considering what this means for the trust’s work. This population health focus is a result of the place lens and demonstrates the importance of senior leadership buy in.