Changing places: the NHS and Total Place

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What happens when we look at public money in terms of where it's spent instead of which organisations spend it? In one area, 23,000 falls (out of 41,000) could have been avoided; a 1 per cent reduction in smoking could save the local economy £17m; and two families – local criminal dynasties – cost the public purse £250,000 a year.

These were just some of the findings reported at a conference held at The King's Fund this week on the Total Place initiative, which looks at how a 'whole area' approach to public services can lead to better services at less cost. The event also highlighted the work of the 13 pilot programmes across England where local public service organisations are collaborating to see how public resources could be used more effectively.

So what would a place-based approach to spending mean for the NHS?

Thirty-four primary care trusts (PCTs) have been directly involved in the Total Place pilot programmes and the conference heard from participants in three sites – Coventry and Warwickshire, Birmingham and Bournemouth, and Dorset and Poole. The overall message is upbeat and while it is still a work in progress there is good reason to believe this approach could reach the parts that previous initiatives have not.

First, it could help to redistribute resources around the needs of places and people rather than organisations and their complex funding streams. By putting citizens at the centre of services and embracing the philosophies of personalisation and choice, Total Place is an integral element of public service reform.

Second, it can help to eliminate waste and duplication; local public bodies are often spending money on the same things. The Treasury has estimated that if these local bodies achieved 2 per cent savings in 2013-14 this would release more than £1.2 billion in England.

Third, it offers a different model for collaboration between the NHS and its local partners that could help rejuvenate tired partnerships and inject new life into efforts to join up health and social care. In the words of one contributor, it's about culture as well as counting.

Finally, it's an opportunity to recast a historically tense and ambiguous relationship between local public service organisations and central government. It could herald a new relationship based on freedom from central performance and financial controls, incentives for local collaboration, and investment in prevention. Allied with the new government's commitment to localism this opens up the opportunities for stronger local leadership.

Yet it remains unclear how Total Place fits with the policy priorities of the coalition government. Their programme for government is peppered with references to efficiency savings, reducing waste and better collaboration between different parts of the public sector. If the new government is true to its localist word, it's reasonable to expect that this approach will have a place in its programme. However, why would PCTs choose not to participate in place-based approaches? Even now there is nothing to stop them; it could offer a powerful boost to long-standing aspirations for care closer to home.

But it won't be easy. Redesigning the use of public money around people and places instead of organisations will demand radical change. Delegates underlined that engagement of the workforce will be crucial, and it's far from clear what role GPs, with strengthened commissioning powers, would play in a place-based approach. It seems clear however that whatever we choose to call it, Total Place is part of the solution for the NHS and not part of the problem.


Mike Leaf

Director of Health Improvement,
Lancashire County Council
Comment date
30 January 2014
An additional benefit of a place-based approach is that the public sector can collaborate on the engagement with the (same) local community on the pressures facing the sector, and the potential solutions to the challenges. We need to collectively make use of the assets within the local community

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