The pendulum of NHS reform seems to be swinging between an ambition to empower local decision-making and plans to centralise power in Whitehall. The health and care bill, for example, aims to enable local leaders to create system arrangements that meet local population needs, but also contains provisions to increase the secretary of state's role in local service reconfigurations which the House of Lords recently voted to remove after debating this very dichotomy.
A similar tension – between working at scale and prioritising local responsiveness – could also be seen to play out in the design of integrated care systems (ICSs) themselves. While the health and care bill, and national guidance produced over the past year, prioritised the strategic role and larger footprint of ICSs, the recently published integration white paper focuses in detail on smaller, operational planning and delivery footprints known as 'places'.
Trust leaders are emphatic about the importance of collaboration and integration with local authorities, primary care, the voluntary sector and wider partners at place level. However, they also see potential in collaborating at scale with one or more trusts across their ICS (or indeed several ICSs) as provider collaboratives. In short, trusts are embracing both.
The size of the prize
The opportunities of working at place and at scale are often aligned. In its broadest sense, this collaborative approach enables trusts to work in new and different ways, for example, to improve the quality of care along entire patient pathways. Collaboration in this new context should be easier than in the previously fragmented, competitive system.
Secondly, trusts are increasingly seeing their role through a population health management lens. They better understand their impact as "anchor" institutions – large public sector organisations that make a significant contribution to their local area – and are working differently with staff and local communities to tackle inequalities in outcomes, access and experience.
Finally, trusts see the potential of using collective resources in the most efficient way to improve population health. The ability for integrated care boards (ICBs) to delegate budgets and functions to provider collaboratives and/or place-based partnerships signals the important role both could play in delivering these ambitions.
But how will their roles in each ICS be defined clearly and interface coherently?
Flexibility is key
The functions of place-based partnerships and provider collaboratives must be determined locally, informed by an understanding of local population needs and service configurations.
Place footprints within ICSs vary significantly across the country. Some places in the larger ICSs cover the same population size as a small ICS. In other systems, the ICS and place effectively cover the same geographic footprint, so sub-system arrangements will look very different. Indeed there is still some nuance in what makes sense locally as a 'place'. So, inevitably, the functions of places will vary.
Similarly, provider collaborative arrangements have developed organically, and therefore differ between systems. Some build on pre-existing models such as clinical networks, others evolved from 'gold command' structures during the pandemic. While some are developing sector specific collaboratives for acute trusts or community/primary care, others are developing 'all in' provider collaboratives. Many of the more established mental health provider collaboratives have a wider membership involving commissioners and non-statutory providers. A trust can be, and surely should be, part of several collaborative arrangements simultaneously.
This necessary variation requires us to move away from linear, hierarchical concepts with strict tiers at system, collaborative and place level, and focus on locally agreed interfaces instead. But it will only work if the Department of Health and Social Care (DHSC) and NHS England and NHS Improvement enable places and provider collaboratives to decide locally which activities and decisions take place where in the system.
Managing potentially conflicting pulls
Trust leaders often see place as the locus of integration between NHS, social care and wider services. They see potential to tackle health inequalities and influence the wider determinants of health through place partnerships.
Meanwhile, there's also potential for service transformation of a different kind to be led by providers working together across larger footprints. Trust leaders see these provider collaboratives developing clinical strategies, standardising pathways, reducing unwarranted variation in care quality and sharing common electronic patient records.
Trust leaders could be seen as being pulled in different directions by these different partnership arrangements. For example, how will trusts focus on changing funding flows at place level to address inequalities and prevention, when the performance management regime will likely focus on provider collaboratives' work to recover care backlogs?
Trusts and their system partners will need to resolve these pulls between uniformity at scale and responsiveness to local needs. This tension could, for example, be managed by at scale provider collaboratives defining the 'what' in terms of clinical standards and pathways, and place-based partnerships deciding 'how' they will deliver them.
This will of course require place-based partnerships and provider collaboratives (and their constituent organisations) to align their strategies and priorities within the wider ICB's approach. But trust leaders are looking beyond this work on the ICS' internal infrastructure and are channelling their energies into how collaboration can deliver real improvements for their local populations.
We know that developing provider collaboration and place-based partnerships, including considering the delegation of resources and decision-making from an ICB to different collaborative arrangements, will be a key priority for 2022/23.
Systems and their component parts need a national policy framework with clear and consistent aims and priorities, which is nonetheless permissive about how those goals will be delivered, allowing local leaders – who are closest to the services they deliver – to determine the functions of places and provider collaboratives. National policy and local action need to reconcile these different, and potentially complementary, approaches to transformation within a landscape which is becoming more complex.
Provider collaboratives and place-based partnerships will need the right resources and capabilities to establish positive working cultures in support of their system, staff and patients, and to deliver change. This could be supported by distributed leadership models in trusts to enable sufficient bandwidth.
It's therefore important that trusts and their partners are supported to grasp this opportunity. If it passes by, the pendulum may swing back to centralisation and prescriptiveness, and we may see competition re-emerge between parts of the new system. Trust leaders tell us that staying focused on realising benefits for local communities will help them navigate this complexity.