April's Hewitt Review of integrated care systems was an important reminder of the advantages of system working, and the need for local health and care leaders to work across organisational boundaries to improve the health of their local populations.
It also identified some key principles that should form the foundations of how systems operate. Chief among these is subsidiarity: the need for decision-making to take place as close as possible to where its impacts are felt – whether across the entire system or devolved to place or neighbourhood level.
We recently hosted workshops, facilitated by Newton Europe, where trust leaders identified barriers – as well as enablers – for this way of working.
Policy Advisor (Primary Care)
At NHS Providers, we have been working to understand trust leaders' initial experiences of working with others at place to set ambitions and deliver better outcomes. We recently hosted workshops, facilitated by Newton Europe, where trust leaders identified barriers – as well as enablers – for this way of working.
The first enabler for successful place outcomes is generating buy-in and ownership of a shared set of priorities for all partners, building on the collaborative approach for place-based partnership members. Often this will require trusts – and their partners in primary care, local authorities or elsewhere – to think beyond their immediate interests and focus on what their populations need.
The second enabler is a focus on specific pathways. Some trust leaders had seen success in focusing on mental health pathways, resourcing primary care networks with mental health practitioners that were jointly funded by primary and secondary care providers. Others had targeted geographic areas of deprivation to improve outcomes linked to circulatory diseases, breast screening and school readiness. By targeting their efforts in this way, they were better able to focus attention on, and, in collaboration with the voluntary sector, reach into the communities they sought to support.
However, focusing on generating buy-in and identifying specific areas of focus will not be enough to realise all the opportunities place-based partnerships potentially offer. Trust leaders agreed there was a third enabler: being able to move money to where it was most needed – whether by targeting deprived areas, providing extra funding for innovation within primary care networks, or pooling funding to drive mental health transformation.
While place-based working offers a range of opportunities, trusts also tell us that there are a number of barriers that they and their partners need to overcome.
Policy Advisor (Primary Care)
Participants in the workshops were clear on the value that funding initiatives at grassroots level could bring but suggested that many places were still working to explore how resources could be combined and sustainable financial models developed to underpin joint work. These challenges sometimes came about because it can be difficult to bring together different funding streams from the NHS and local authority partners, or because shared governance arrangements were hard to implement – both particularly important considerations when integrated care boards are being asked to cut their running costs, with consequences for focus in the short term and capacity in the longer term.
While place-based working offers a range of opportunities, trusts also tell us that there are a number of barriers that they and their partners need to overcome. In some areas, these barriers have been imposed by long-established ways of working that inhibit new approaches by prioritising competition over collaboration or that emphasise the split between commissioners and providers.
For others, especially leaders whose trusts span multiple places or multiple systems, bandwidth remains an issue, exacerbated by the immediate challenges many areas are facing in day-to-day operations. Digital integration to support data sharing and analysis across systems and between partners was also seen as a potential enabler, but attendees highlighted this as an area where national support would be beneficial.
Improving the alignment in priority setting at different levels with each system will help to clarify how work at each level contributes to overall strategic aims.
Policy Advisor (Primary Care)
Progress is, inevitably, varied. So how can place-based partnerships be set up for success? The Hewitt Review rightly highlighted the importance of place leaders being able to take part in system-wide conversations – and the need for system, place and provider priorities to support each other. Improving the alignment in priority setting at different levels with each system will help to clarify how work at each level contributes to overall strategic aims, as well as help to focus minds on the key priorities for each area.
However, these steps can only be taken if all those working at place – both in the NHS and system partners – focus on developing their relationships, thinking beyond organisational interests, and ensuring financial arrangements to support their aims. In turn, national leaders must take data and digital integration as seriously as key infrastructure. With national support and local determination, place-based partnerships will be able to turn their visions into reality.
This opinion piece was first published by HSJ.
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