Place-based partnerships: challenges and opportunities

Overview 

• Place-based partnerships are non-statutory collaborative arrangements within integrated care systems (ICSs) in England. They bring together NHS, local government and other organisations responsible for arranging and delivering health and care services, and others with a role in improving health and wellbeing. Recent policy has encouraged the delegation of functions and budgets to place level to support these local partnerships. 

• We surveyed leaders of place-based partnerships and undertook three case studies of partnerships that were at different stages of delegation – ie, fully delegated, partially delegated, and no delegated budgets. 

• Partners at place level have a strong appetite for tackling health inequalities by focusing on their root causes, and this runs alongside other critical issues, such as reducing waiting times and improving access to care. In our case studies, the delegation of budgets was welcome, and the lack of any delegation in one site presented significant challenges. Overall, however, place-based partnerships were not able to accelerate in their roles due to practical and relational factors. 

• Based on our findings, there are three key areas that will support place-based partnerships to work effectively: accountability, collaborative leadership and resources. 

Why we did this research

There is little information available nationally about place-based partnerships – how they are set up, what they do, what resources they have, and what factors facilitate or impede their progress. In 2023, the Department of Health and Social Care (DHSC) approached The King’s Fund wanting to know what progress has been made by systems in arrangements for place-based partnerships, and what impact those arrangements have had, to inform its future planning and support to place‑based partnerships.

What we did

Our research comprised two key elements, as follows.

A survey of leaders of place-based partnerships, covering leadership, governance and accountability arrangements, working relationships, progress, and delegated responsibilities and budgets. In May 2024, the survey was sent to 121 place‑based partnership leaders (or their proxies such as integrated care board (ICB) communications or research and development (R&D) departments) across England. There were 78 survey responses, of which 48 could be fully analysed, providing broad descriptive information.

From these responses, we selected three case study sites for further research based on the current state of delegated budgets (whether fully or partially delegated, or not delegated). These case study sites reflected a broad range of demographic characteristics. During the case study research (September to October 2024), we conducted 28 interviews across the three sites with various stakeholders in the place-based partnership, including the lead, chair, ICB and local authority representatives, local NHS providers, GPs, Healthwatch, and voluntary, community and social enterprise (VCSE) sector representatives, to gain a holistic perspective of partners’ views. Topics included their role in the place-based partnership, governance and accountability mechanisms, finances, and partnership working.

What we found

The progress of place-based partnerships was often hampered by the governance models, and decision-making was not always clear to all members of the partnership. Health and care partners described themselves as being accountable to their own organisations, and there were no mechanisms for them to hold each other to account for work that would benefit places as opposed to individual organisations.

Our case study sites were facing extremely challenging financial circumstances and there was wide variation in how much ICBs had delegated budgets, with one even taking back delegated funds due to being in significant financial deficit. In addition, the approach to pooling budgets in some places was still under development and had not become embedded as a default way of working.

Partners acknowledged the importance of strong relationships. However, there were differences in ways of working, and perceived power imbalances within place‑based partnerships that frustrated efforts to work collaboratively. In some places, there appeared to be misalignment in the aims and approaches taken by ICBs and by place-based partnerships.

Despite the enthusiasm and motivation shown by partners working at place level, place-based partnerships still have some way to go before they can fulfil the policy aims and ambitions set out for them. Developing health and care as integrated systems within systems is renowned as complex and challenging.

What next?

Our findings suggest there are four key areas that national bodies (ie, DHSC and NHS England until it is succeeded) and place-based partnerships should focus on, including making the most of policies currently being developed (ie, the introduction of neighbourhood health services, separating strategic commissioning from performance management, and reforming local government). We set out recommendations for each area, as follows.

1. A clear focus with protected space for reform

Recommendations for national bodies

• Some of the key goals for systems are best tackled at place level, particularly when it comes to prevention, tackling health inequalities, and redesigning out‑of-hospital care. Future guidance and the forthcoming strategic commissioning framework should reinforce the purpose and role of place‑based partnerships in planning and priority-setting; it should send a clear signal about the value of place-based partnerships.

• Future guidance and the strategic commissioning framework should be as clear as possible on how place-based partnerships fit into a changing landscape in which ICBs are strategic commissioners.

• The guidance and framework should ensure that through clear delineation of competing responsibilities, urgent issues do not unduly prevent progress on long-term ones, and it should clarify both the authority that place-based partnerships have to lead reform and expectations for the rest of the health and care system to support them.

2. Accountability

Recommendations for national bodies

• There is a need to engage with place-based partnerships to develop resources and guidance on stronger governance and accountability at place level that also supports the development of new ways of working. This should particularly include:

• mutual accountability (for behaviours and outcomes), as well as the support needed for transitioning to this way of working (eg, case studies)

• accountability to communities (including certain mandatory basics, such as publishing names of partnership leaders and plans or strategies, as well as developing responsive capability to different communities).

• The separation of performance management and strategic commissioning roles is an opportunity to ensure that accountability above place level reflects the right balance of focus on both shorter-term and longer-term priorities, and on NHS organisations’ performance and whole-system performance.

Recommendations for place-based partnerships

• As there are limited resources on mutual accountability, place-based partnerships will need to develop ‘test and learn’ approaches (which could also help inform any future guidance).

• Even though they are not statutory bodies, place-based partnerships should consider how they are accountable to their local communities and compare themselves to others.

• Partnerships should review whether they make most progress through broad, ambitious plans or whether initially focusing on just a small number of priorities would enable greater opportunities to follow through transformation plans in practice and learn new ways of working together.

3. Collaborative leadership

Recommendation for national bodies

• It would be useful to consider place-based integration as a process of cultural change, as well as a process of developing services. National bodies should reflect this approach in their leadership frameworks and in how national leaders ‘set the tone’. In addition, national guidance should say more about expected behaviours and ways of working across levels of the NHS hierarchy.

Recommendation for place-based partnerships

• Although there can be a natural desire to focus on delivering results, it is also essential to invest time and effort in developing collaborative leadership within the partnership and, especially as they become strategic commissioners, with ICBs.

4. Resources

Recommendations for national bodies

• Though simply mandating delegation of functions and budgets may not be appropriate, it may still be possible to go further by creating a scale of place‑based partnership maturity, with an increasing expectation of delegated budgets and responsibilities as a partnership progresses and matures.

• Sharing examples of good practice and practical toolkits should help develop confidence in navigating the challenges involved in pooling more resources.