Place: The real testing ground for system reforms

The Thriving Places guidance is out and follows national documents on provider collaboration, integrated care systems (ICSs) and working with communities and professionals. But that sequence illustrates the nuance and complexity of getting the steer right, not the relative importance of these vital collaborations.

The place guidance truly emphasises the need to agree locally about function before finalising form. Jointly produced by Department of Health and Social Care, NHS England and the Local Government Association, it suggests some roles that could be delegated from the integrated care board (ICB) to a place. It makes clear an accountability for multi-organisational integrated care partnerships (ICPs) in agreeing how place will thrive. The list of possible place functions outlined, such as improving population health and wellbeing, are managerial in shape, akin to roles previously led in many areas by clinical commissioning groups (CCGs). But it is understood that place is the footprint where local authorities, trusts, clinicians including primary care, local communities and the third sector, will agree priorities for health improvement.

We know that delivering national priorities and reflecting local voices, will demand changes to how care is organised. COVID-19 has shown the adaptability of local partnerships to do more and to work differently. Community-based approaches have a clear evidence base in tackling inequalities. Levelling up necessitates neighbourhood action. Changing demand in A&E departments requires upstream investment. Improving population health requires working ever more closely with the third sector and local government. The scope of action is huge and it is important that plans are framed to see early wins and create momentum and inclusion.

The principle of subsidiarity is at the heart of the guidance. This is a 'push-pull' principle. Local actors at place need to assess their bandwidth and appetite to lead. They need to understand which forms of care and transformation require these local partnerships. ICSs will face significant financial and performance pressures this winter and into 2022/23. The twin temptation to either hold finances and decision making centrally, or to pass responsibilities and therefore pressures to local partners will be a delicate balance. Across the country many places have operated on existing footprints for some time, and it will be an important maturity test for ICSs as to how they nurture the current and develop the future, with more than 80% of authority held at place not system level.

It remains important to recognise that providers will offer much of the innovation capability, financial risk management, and pace to drive place based working. But it is also vital to acknowledge that organisations of very different scales and traditions will need to come together to succeed at place. Providers will need to reflect on how to operate with that agility. Provider collaborations are often established in the pursuit of reducing variation. Some trusts voice concern that the diversity of offer implied by place based working may be in conflict with that view. The guidance is clear that a matrix is the expectation. Eliminating variations and gaps in outcome and access, but supporting variation in form, function and approach: What counts is what works.

Reflecting on the guidance, which outlines the technical steps needed to establish place level governance by April 2022, there are some important considerations to focus conversations and attention upon:

  1. The trusting relationship signalled in this guidance must be met with delivery: Providers are united in a view that one form will not work everywhere. Meeting national expectations to have the structures and purposes in place in five months' time is crucially important to collective confidence in this permissive policy framework.

  2. A focus on purpose is essential at local level: It is clear from the vaccination response that a shared mission facilitates otherwise dry discussions about role and form. Imagining how a place will be different in 2024 will unlock the right governance choices from 2022.

  3. Delivery at place will be enabled by all partners having locally delegated decision-making responsibility: The guidance encourages delegation arrangements from the ICB, with support provided by the ICP. All forms of trusts are expected to be represented at place, with different arrangements for ambulance providers. Those in the room must have delegated authority to act, from their own organisation, if place collaboration is to have the impact and pace that is needed to meet the challenges we face.

  4. The role of place should be seen as an evolution in healthcare leadership arrangements: Partnerships at place level will differ in their depth and breadth at the current time. Support arrangements may need to be more extensive now than in the future. Different places within an ICS may work in different ways or achieve the same delegation at different speeds.

The renewed focus on Thriving Places creates opportunities to work differently to tackle health inequalities and improve community satisfaction and employee engagement with the NHS. Trust leaders and their partners see place as the real testing ground where ICS reforms will make a difference to improve population health – the ultimate purpose of moving to system working.

This blog was first published by the National Health Executive.