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From safe landing to real impact: the next phase for Place-based Partnerships

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Over the last 6-12 months, Place-based Partnerships (Places) have worked at speed to develop their structures and working practices from loose collaborations to more formal structures in readiness for the establishment of Integrated Care Boards (ICBs) on 1 July 2022.

With many ICBs only recently having appointed designate leaders, and a plethora of guidance to work through, many ICBs and Places are focused on the ‘must dos’ for the system to operate as effectively and efficiently as possible on ICB establishment day. It is clear however that this will be day one of a new journey for both ICBs and Places as they navigate a new operating model against a backdrop of significant financial and operational challenges. 

We have been working with Places nationally for several years. This work has intensified in the run up to ICB establishment as we have helped design workable operating models both for day one and beyond. Reflecting on this work, we have set out below five areas of focus for Places in their first ‘transition’ year to April 2023.

To hear more of our reflections on our Place work and future priorities for Places, you can sign up to attend our webinar on 14 June 2022 here.

1. Making subsidiarity a reality – the ‘function’ of Place

For the majority of Places we are working with, defining which functions will and will not be delegated by ICBs to each Place on day one is a significant challenge. The principle of subsidiarity of decision-making to Places was helpfully reaffirmed in the White Paper Joining up care for people, places and populations (the Integration White Paper). Putting the principle into practice has however been more challenging. After all, Places are not intended to be simply operational units of their ICB; to achieve their fundamental aim of improving outcomes for their populations they must have a broader role and involve, and encompass functions from, wider Place partners. This requires a different approach to decision-making, a collective risk appetite and acceptance that conflicts will exist and need to be managed. 

It is probably too early in all but the most mature ICB areas with established leadership to expect a ‘full delegation’ model from ICB to Places, however this should be the longer-term aim. The Integration White Paper gives April 2023 as a key date for the development of shared outcomes by Places together with a shared resource plan. 2022/23 will therefore be a key period for Places to further develop their approach to support the delegation of more functions from ICBs to Places, and from other key partners (see paragraph 2 below). There will need to be a particular emphasis on developing shared local outcomes, aligned to the Place Joint Health & Wellbeing Strategy, Integrated Care Partnership Strategy and the ICB’s plans.

To support further delegation from the ICB, Places will need to demonstrate strong governance that is capable of managing the significant spend the Integration White Paper anticipates being funded through resource held at Place. A clear approach to allocation of resource, as well as dealing with deficits, will be critical if Places are to be ready to discharge this function for the next financial year. In some Places this has been described as a ‘stewardship’ basis for the Place resources, ensuring they are deployed to organisations where they have the maximum impact on population outcomes. Doing so will be a key challenge for Places as NHS funding returns to the pre-pandemic regime. 

2. Strengthening the foundation for health and social care integration

Focus has been placed to date, by necessity, on delegation from ICBs to Places as CCGs face dissolution. As noted above, however, the success of Places in improving health outcomes will depend on a broader partnership approach, not least with local authorities. This is not easy given the different statutory and governance frameworks for local authorities, not to mention funding streams and challenges. Despite expectations that it might do so the Health & Care Act 2022 does not in fact provide new tools for local authorities to delegate their functions to Places. 

The key statutory tool to enable health and social care integration, which long precedes the integration agenda, therefore remains section 75 of the NHS Act 2006. The Integration White Paper confirms section 75 as the key tool for Place outcome-based approaches. NHS and local authority commissioners are familiar with section 75 arrangements enabling integrated and lead commissioning, as well as aligned and pooled funding arrangements., The Better Care Fund makes use of the tool forming the bedrock of integrated health and care approaches in many Places. In some Places, NHS Trust providers also have integrated provision arrangements in place with their local authority partners under section 75. 

Many Places have commissioner section 75 arrangements which only pool the minimum funding required under the Better Care Fund guidance (and some do not even pool that). There are a few however that have gone much further, recognising the opportunity section 75 provides to embed a transparent approach to NHS and local authority resource through ‘aligning’ or bringing ‘into view’ Place resource, underpinned by joint governance and oversight mechanisms as well as integrated teams and leaders. 

Bearing all this in mind, a key task for Places in 2022/23 and beyond will be to review section 75 arrangements and consider how they could be developed to support the approach to shared outcomes and resource at Place, potentially expanding their scope and bringing them within the wider Place lens and governance arrangements. 

3. Deploying the Place people resource 

As CCGs are dissolved and replaced by, in many areas, much bigger ICBs, a key task in the run up to July 2022 has been CCG staff engagement and retention as the operating model is designed. Places should be at the forefront of these discussions since the majority of CCG staff will transition to Place-based positions. 

Understanding the staff resource and expertise available and how the Place can best utilise it to support its operating model is key. Equally, the Place should be supported by collaborative leaders from partner organisations who are capable of generating trust and developing relationships. In most Places, Place ‘leads’ or ‘directors’ will have been appointed ready for July, some of whom will be new to the Place. This role requires a different kind of leadership as a partnership ‘convenor’ to the previous competitive approach which has typically characterised the NHS, but reflects the significant collaboration achieved during Covid-19.

Developing the Place team and leadership during 2022/23 will be key to successful Place operations and this may include (aligned to point 2 above) consideration of more joint appointments between Place partner organisations where this will contribute to the achievement of Place outcomes. 

4. Developing the system operating model: getting the right balance between ICBs, Places and Provider Collaboratives

The Integration White Paper emphasised the need for clarity about what is done at Place level, and what is done at system level.
A consistent theme in our recent Place work has been how provider collaboratives (operating at ICS level) and Places will work together as part of the wider ICS. In some areas there is anxiety about the impact of provider collaborative activity on Place resource. 

The principle of subsidiarity suggests that Places should have a clear focus on the areas where their constituent partners can best influence outcomes for their local populations, with provider collaboratives concentrating on the issues needing a wider focus. Places link in with local authorities and primary care as well as voluntary and community sectors in a way which provider collaboratives (generally as there are exceptions given their permissive nature) do not. 

In many systems provider collaboratives are at an earlier stage in their development than Places. In the short term this points towards Places having a stronger foundation to take on delegated functions from the ICB, with most ICBs looking to future delegation of functions to provider collaboratives over a longer timeframe. Place and provider collaboratives will need to establish a way of operating, with the ICB playing a key role to support them to work effectively and cohesively together. There is overlap in membership between the two, with NHS Trusts and Foundation Trusts playing a key role in both. That role should include acting as the bridge between these groups, to help to ensure integrated working, avoiding disconnect and duplication between them. 

5. Refining the governance – the ‘form’ of Place

A major and necessary focus for Places over the last 6-12 months has been developing and formalising their governance arrangements ready for ICB establishment. In many areas, this has of necessity come in advance of confirmation of the Place function within the wider system – ie exactly what will be delegated from the ICB to the Place from day one – a reversal of the usual form follows function principle. 

As ICB establishment approaches, delegation arrangements are starting to be confirmed by ICBs, enabling initial governance structures to be finalised. Most Places we are working with have taken a ‘safe landing’ approach to their governance structures for day one, with many opting to tweak their existing collaborative forum structures to cater for ICB directors having delegated authority in respect of certain ICB functions. Others are looking to establish ICB committees at Place. 

A key workstream for 2022/23 and beyond will be to strengthen and develop Place governance to support further delegation of functions to Place from the ICB (on the basis that many ICBs will take a more cautious approach to delegation in the first year). 

Places will be familiar with the governance models set out in Thriving Places, with most opting for the ICB director or the ICB committee approach for day one. However, it will be critical to ensure that this is not the end point for the governance approach given the intention that the Place is wider than simply the discharge of ICB functions at a local level. Options should be explored by Places to strengthen partnership working and enable delegation by other statutory partners into the Place arrangements, particularly local authorities. The addition of a new NHS joint committee option in the Health & Care Act 2022 has been of interest to many Places, but regulations underpinning the operation of this new type of joint committee have not yet been published. The further development of section 75 arrangements by Places should also inform the governance structure. 

Most importantly, whatever path is chosen for future governance, Places should ensure that decision-making arrangements are simple and easy to navigate, avoiding duplication of existing structures, especially given capacity constraints amongst senior leaders. Resource constraints mean that difficult decisions are likely in the coming years, such that robust decision-making processes will be key. 

Conclusion

Although Place-based working has been in development for several years now, we are entering a critical phase with the establishment of ICBs anticipated within months. There is much for Places to focus on once they are operating in the new environment, beyond ensuring that critical infrastructure is in place and operational to support the new operating model. 

In the medium to long term, Place-based partnerships should keep at the forefront of their minds the need for the Place to be population, rather than organisation, focused, as there is a clear risk that Places could simply become operational units of ICBs in the short term. 

Strong Place leadership and partner relationships will be key to retaining a clear focus on the end goal of improving population outcomes in shaping the Place approach in the next development phase. 

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