Background and context
Integrated care system (ICS): Greater Manchester (GM) ICS, which evolved in the context of a bespoke devolution deal from central government from April 2016
Number of places in the ICS: Ten localities*
*[Greater Manchester refers to its place-based partnerships as localities, reflecting the ten metropolitan boroughs that sit within the Greater Manchester area]
Key partners in the Bolton locality:
- Bolton NHS Foundation Trust (physical acute, specialist and community health services)
- Greater Manchester Mental Health NHS Foundation Trust (delivers a range of mental health services across several GM boroughs, including Bolton)
- North West Ambulance Service NHS Trust
- Bolton Council, which is a metropolitan borough and unitary authority
- Greater Manchester integrated care board (ICB), which will have a Bolton presence (formerly NHS commissioning functions were led by Bolton CCG)
- Voluntary and community sector
- People and local communities
Key features of the Bolton population:
- 290,000 people
- Over one fifth of the local population are from Black, Asian and minority ethnic backgrounds
- Higher-than-average levels of deprivation and lower-than-average life expectancy for both men and women
Role of the trusts at place
For trusts in Bolton, working through the place partnership represents an opportunity to address health inequalities, transform how care is delivered across organisational boundaries and improve the health and wellbeing of local people. Bolton NHS Foundation Trust envisages a future as an integrated health and care organisation, taking on some planning and oversight functions, and coordinating integration across a spectrum of local services in partnership with other organisations including the voluntary sector and primary care. Greater Manchester Mental Health NHS Foundation Trust is developing its strategic planning role beyond specialist mental health services, supporting a tailored offer at place level and supporting transformation of adult secure mental health services through a provider collaborative arrangement.
Decision-making arrangements
Health and care organisations in Bolton formed a partnership several years ago to support closer collaboration. This has involved changing ways of working for all partners, including trusts. For Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust, the focus has been on developing a provider partnership at place level – known as an integrated care partnership.*
*[In some cases, including Bolton, place-based delivery partners are collectively referred to as integrated care partnerships (ICPs) to reflect their joined-up work. However, this reference to ICPs at place is not to be confused with the statutory integrated care partnerships operating at system level, as required by the Health and Care Act 2022].
The place-level partnership aims to enable clinical and operational teams to work together more closely and deliver care in ways that meet people’s needs at the earliest opportunity and help them to stay well where possible. The partnership was formed as an ‘alliance’, which aims to support operational collaboration without formally affecting partner organisations’ sovereignty.
At the heart of the place approach is the development of integrated neighbourhood teams and primary care networks, which bring together professionals from a range of partner organisations and services – secondary care services, primary care including general practice and community pharmacy, social care and other local government capabilities such as housing advisers – to focus on tailoring local community-oriented services to needs within the nine neighbourhoods in Bolton, each of which serve populations of around 30-50,000.
All aspects of the Bolton partnership programme are overseen by the multi-disciplinary Bolton locality partnership board, which includes the trusts delivering services in the locality. The locality board reports to the Greater Manchester ICB which will hold the locality board to account for functions delegated to place, and the Bolton Health and Wellbeing Board, which holds the locality board to account for delivery against aspirations outlined in the health and wellbeing strategy and the Bolton locality plan.
Leadership model
Prior to the introduction of the Health and Care Act, Bolton opted for a blended model of leadership, with senior leaders in organisations taking on place-focused responsibilities alongside their substantive roles. The Bolton place partnership has a managing director and an independent chair, hosted by Bolton NHS Foundation Trust but accountable to all partners. These roles provide management and leadership capability at the interface between health and care, as the managing director also holds the role of director of adult social services at Bolton council.
Looking to the future, Bolton NHS Foundation Trust’s chief executive will serve as the place-based lead for health and care. As place lead, they will report jointly to the Bolton locality board and the Greater Manchester ICB for the strategy and planning of delegated aspects of health and care in Bolton. Formal accountability for the delivery of NHS services will continue to sit with the foundation trust and with Bolton Council for council-funded services.
Approach to managing collective resources
Traditional boundaries between NHS commissioning and provider functions have been blurring in Bolton for several years, as partner organisations worked together to make best use of local skills and resources for the benefit of the local population. Bolton NHS Foundation Trust moved towards a shared model of financial performance monitoring and oversight with the CCG, including closer working across finance teams to develop a place-based lens on NHS resources. This was supported by the Bolton NHS Foundation Trust chief finance officer also serving as chief finance officer for the Clinical Commissioning Group (CCG). To enable this, Bolton NHS Foundation Trust hosts some shared planning and support functions, such as business intelligence and digital services which deliver for the trust and CCG.
Similarly, NHS and local government planning bodies have sought to unlock new opportunities to plan services more holistically and simplify decision making by working through a single commissioning function. This has seen them bring capabilities together as far as possible, including public health expertise, analytical capabilities, and service improvement expertise. This has been underpinned by a pooled budget arrangement, using a section 75 agreement, focused on jointly planning mental health, learning disability, and some community and adult social care services. This enables resources to be collectively managed as part of a strategic, streamlined approach to planning health and care services.
The intention is that this approach will be extended under the new legislative framework. The integrated business intelligence team will be expanded to include council functions; the NHS and council commissioning functions will continue to bring together their strategy and planning processes; and there will be shared finance and transformation oversight to support joint working through all stages of public service planning and delivery within Bolton.
Benefits and learning
Deepening collaboration at place in Bolton has made it possible to tailor local service offers based on the trusts’ and wider partners’ local intelligence and community connections. For instance, the place partnership’s focus on working in communities has supported improvements to community support for pregnant women in Bolton, including supporting women who experience pregnancy loss, with an emphasis on cultural inclusion and working with communities to develop an understanding of ethnic minority communities.
Additionally, commitment to partnership working is helping the trusts and their system partners manage challenging demand pressures. While challenges remain, patient flow through secondary care settings in Bolton is performing better than some other geographies, which leaders attribute – in part – to good relationships that have been built over the last few years.
Looking to the future, partners in Bolton see their existing collaboration as a platform on which they can build, leaning into the national emphasis on place and developing a more ambitious model of public service collaboration at place. For Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust there is scope to develop the place partnership way of working to bring services together more effectively, working with partners including the local authority, primary care and the voluntary sector, and make different choices about how resources are used based on the needs of Bolton’s residents, including gradually ensuring proportionate investment in mental health care.