Developing place-based partnerships: The foundation of effective integrated care systems

Major changes are taking place in the way health and care is organised in England as the emphasis of national policy continues to shift towards promoting collaboration within local health and care systems. Integrated care systems (ICSs) are being established in all areas of the country to drive changes that are intended to lead to better, more joined-up care for patients and improvements in population health.

A key premise of ICS policy is that much of the work to integrate care and improve population health will be driven by commissioners and providers collaborating over smaller geographies within ICSs (often referred to as ‘places’). 

While the importance of working at place has been emphasised in key policy documents, there has been a stronger focus nationally on structures at ICS level, including clinical commissioning groups (CCGs) merging onto ICS footprints, the creation of provider collaboratives to work at scale, and the prospect of legislation to put ICSs on a clearer statutory footing.

While working together across the wider geographies covered by ICSs will be helpful for issues that benefit from being tackled at scale, there is a danger that focusing too much on activities and structures at this level risks detracting from or even undermining the local collaboration described above. To make a reality of ambitions to deliver more joined-up care and bring about meaningful improvements in population health there will need to be a major focus on strengthening partnerships at the level of place (alongside the development of ICS structures and capabilities).

We wanted to understand how partnerships at place (described here as place-based partnerships) are forming in practice, and draw on existing evidence and experience to provide local health and care leaders with a set of principles to support their approach to working at place. Our goals were to:

• explore the potential role and contribution of place-based partnerships by drawing on evidence and insights within the existing literature
• understand the approach being taken by some local systems that have prioritised the development of place-based partnerships within their ICSs
• draw out learning for other areas as they work to evolve their approach
• consider the national policy implications of this way of working and what national NHS bodies can do to support its development. 

Our research consisted of the following components:

• a review of published literature exploring place-based working in health care and wider public services
• scoping conversations with stakeholders (national policy-makers and system leaders) to understand key issues and areas of interest
• exploring the approach to place-based working in three example systems that have developed a clear vision for how their place-based partnerships will operate (Nottingham and Nottinghamshire; Suffolk and North East Essex; West Yorkshire and Harrogate)
• two engagement sessions with executive leads and independent chairs from ICSs in England (supported by NHS England and NHS Improvement, and the NHS Confederation) to discuss the implications of our findings
• three roundtable discussions (in partnership with National Voices and the Local Government Association) with participants drawn from local government, voluntary and community sector (VCS) organisations and social enterprises to explore the perspectives of non-NHS partners working at place. 

Places vary widely in their scale and nature, reflecting differences in local geographies, populations, organisational contexts and historical relationships. The ability to reflect and respond to local characteristics is critical and a one-size-fits-all model specifying the size, boundaries or ways of working for place-based partnerships would not be appropriate. Our report therefore seeks to support local implementation by exploring key functions of these partnerships and identifying principles to guide their development.

Key functions of place-based partnerships

Through this work, we identified a number of ways in which place-based partnerships can contribute to the improvement of health, wellbeing and inequalities reduction, and in particular where they have the greatest potential to add value over and above the contributions of individual organisations or entire systems (see Figure 1). As systems and places establish their purpose and priorities, we would invite them to consider these functions and how they can best be delivered locally.

Some of the most promising opportunities to make progress in these areas come from building broad multi-agency partnerships involving local government, NHS organisations, VCS organisations and communities themselves. Partnerships involving a broad range of agencies and sectors are able to draw on a wider range of levers to influence health outcomes. 

Principles to guide the development of place-based partnerships

The success or otherwise of place-based partnerships will come down to how they are implemented locally. The report sets out a series of principles for local health and care leaders to help guide them in these efforts.

Start from purpose, with a shared local vision

• Setting a local vision starts with an understanding of the population and the place, underpinned by local data and insights.
• Developing a shared sense of purpose requires a process of collaborative development across a wide range of partners, including with local communities.
• Place-based working stands the best chance of success when place footprints make sense to local people and partner organisations.

Build a new relationship with communities

• Working more closely with local communities creates opportunities for health and care organisations to improve the services they provide and increase their impact on population health and wellbeing.
• Efforts to connect with, support and mobilise communities are likely to have greater impact if pursued by multiple organisations in tandem, and place-based partnerships can play an important role in this by agreeing a shared approach and co-ordinating action.
• Partnerships need to know whether place-based working is leading to improvements for local people and will not be able to do this without hearing directly from people using services and other community members.

Invest in building multi-agency partnerships

• Local government and VCS organisations need to be able to drive the agenda at place level alongside their NHS partners. 
• It is crucial to ensure that putting ICSs on a statutory footing does not make it harder to create joint ownership of partnership working.

Build up from what already exists locally

• Wherever possible, partnerships should build on pre-existing agendas, relationships and structures and embed them into a coherent place-based way of working.
• Health and Wellbeing Boards are important local partners in place – and can also play a role in ICSs.
• Differences in local government and NHS organisational configurations mean there will not be a universally applicable model for how HWBs engage in a place agenda, but it is important that their roles are clarified locally.

Focus on relationships between systems, places and neighbourhoods

• Place-based partnerships need to establish how they relate to surrounding places and to partnerships at other geographical levels (including ICSs and local neighbourhoods) to ensure that their activities are complementary.
• The exact division of responsibilities will need to be determined locally given the significant variation in the scale of places and systems and the inevitable interdependencies between them. Central to these decisions should be the idea of subsidiarity: that decisions should be made as close as possible to local communities, and that activities should only be led at scale where there is good reason to do so.
• ICSs are made up of their constituent places. They should operate as a mechanism for working across places to bring benefits of scale rather than as distinct entities in a hierarchy.

Nurture joined-up resource management 

• There are significant advantages to having some NHS budgets controlled at place. In the context of CCG mergers and proposals for them to be subsumed by statutory ICSs, there is a risk these benefits are lost.
• ICSs will need to develop arrangements for delegating some budgets to place level and ensure appropriate skills and expertise in planning and resource management exist at place. National bodies will need to support ICSs to develop processes to robustly and transparently allocate financial resources to place.
• Place-based partnerships can help create a more joined-up approach to resource management underpinned by shared priorities and an ethos of ‘one place, one budget’, even if they do not become budget-holding entities in their own right.

Strengthen the role of providers at place

• Much of the work to deliver more integrated services needs to happen at  place level through collaboration between providers of all kinds.

• Larger providers such as hospital trusts need to be able to engage in place-based collaboration at the same time as pursuing closer integration with neighbouring trusts through collaboratives covering larger geographies.
  It is likely that a range of overlapping collaborative arrangements will be needed involving different providers working together in different ways.

Embed effective place-based leadership

• Effective leadership is critical to achieving the opportunities described in this report.
• Multi-agency leadership teams can help co-ordinate change at place level and work across different levels of activity within an ICS.
• Effective place-based leadership requires a leadership mindset supportive of collaboration. 

While the development of place-based partnerships will largely rest on local implementation, larger systems and national bodies will also have an important role to play in enabling and supporting these efforts. The report concludes by considering the implications of our findings for ICSs as they establish themselves and clarify their roles and structures, and for national bodies and regional teams as they approach the next stages of policy development and support for integrated care. The issues highlighted include:

• ICSs are set to be established as statutory bodies from 2022 with significant responsibilities for NHS planning and funding and developing broader partnerships to improve population health. This process will require careful implementation to avoid detracting from or even undermining the efforts of local place-based partnerships.
• As ICSs move onto a more formal footing, they should continue to focus on the priorities of their local places. Some mature systems have successfully nurtured an approach where the ICS is built up from its constituent places. ICSs should now embed this model by prioritising and supporting the development of their local places, ensuring they are adequately represented in formal ICS structures and strengthening connections between priorities, governance and leaders at system and place level.
• ICSs and place-based partnerships will need to prioritise the relational aspects of their development, with a sustained commitment from leaders to develop collaborative ways of working. Formal changes to structures and contractual mechanisms should be seen as supporting tools rather than an end in themselves. The expectations and behaviours of national bodies and regional teams will be important in supporting this focus.
• As place-based working develops, there is a risk that variation in local arrangements could create a lack of clarity around accountability and decision making. While continuing to support locally led change, national policy makers will need to set clear minimum expectations for governance and transparency. In turn, ICSs and place-based partnerships will need to communicate about their work and decision-making arrangements with their local populations.
• As CCGs merge and (if proposed legislative changes are passed) their functions are subsumed by ICSs, there is a danger that advantages of place-based planning and resource management could be lost. It will be important to develop arrangements for ICSs to delegate budgets to place level and for national NHS bodies to provide guidance and support to enable this. Over time, local partnerships should use these flexibilities to develop a more joined-up approach to resource management that makes best use of the total collective resources available.
• Finally, evidence and experience indicates that the changes discussed here will take time to deliver results. This means that local and national leaders need to make a long-term commitment to the development of place-based partnerships and ICSs, avoiding the past mistake of moving swiftly to the next reorganisation if desired outcomes are not rapidly achieved. There should be a focus on incremental change, progressively strengthening partnerships and delivering tangible improvements in health and wellbeing.