The final frontier?

Eighty per cent of people’s interactions with the NHS occur in their own homes, their GP practices, community pharmacies, dentists or local health centres, and the vast majority of social care services are delivered at home or in the community.

So it seems obvious to me as a GP that effective partnership working at neighbourhood, community or ‘Place’ level is crucial to the success of integrated care systems.

As we prepare for the proposed introduction of statutory Integrated Care System (ICS) arrangements (subject to the Health and Care Bill being passed), the spotlight is currently on the Parliamentary process and organisational arrangements: recruitment for designate Integrated Care Board (ICB) chairs and chief executives; the make-up of the wider ICB board and the Integrated Care Partnership (ICP).

But within NHS England and NHS Improvement we are just as focussed on the continued development of the partnerships and relationships on which the new arrangements will build.

Last week, NHS chief executive Amanda Pritchard asked Dr Claire Fuller, senior responsible officer of the Surrey Heartlands Integrated Care System, to look closely at how primary care networks can support integrated care systems by bringing partners together at a local or ‘Place’ level to address health inequalities and improve the health of the local population.

We also recently published guidance on four important topics to support system leaders with this: Place-based partnerships, working with people and communities, working with the VCSE sector and promoting clinical and care professional leadership.

Thriving Places: Guidance on the development of place-based partnerships provides a guide to systems as they plan how to get the best out of their place-based partnership arrangements, focussing on what these are really there to achieve – improved access and care co-ordination in the place where you live.

The ICS Design Framework said ICS development should be rooted in underlying principles of subsidiarity and collaboration and that decisions taken closer to, and in consultation with, the communities they affect are likely to lead to better outcomes. The concept being that whilst the system-level ICB will have the statutory responsibility for securing NHS services for their whole population, unless they use the benefits of working at scale to enable collaboration focussed on local populations and communities, the outcomes that are needed simply won’t be achieved.

It also makes clear that ICSs are not just the preserve of the NHS. The Framework describes the need for strong place-based partnerships between the NHS, local councils, voluntary organisations, residents, people who access services, their carers and families. In well-functioning systems these partners will be working together to lead the detailed design and delivery of integrated services within specific localities (in many places, long-established local authority boundaries), incorporating a number of neighbourhoods.

A key principle of ‘place-based working’ is that arrangements should reflect what makes sense locally. Local Government colleagues may well have a wry smile as the NHS catches up with the notion of Place, but it is clear that it requires a relationship of equals, with parity of esteem for all the various components that form a place-based partnership. Putting people (not patients) at the centre and bringing together expertise from those that plan, deliver and use services are necessary ingredients.

In common with a lot of ICS development, this is not a standing start. Many areas in the country have made significant progress in establishing truly integrated ways of working and this good practice is the basis for the recent guidance on place-based partnerships. Taking an asset-based approach, building on what already exists, and defining purpose before structure have been the hallmarks of success.

Other common features include iterating governance over time with a collaborative definition of the footprint and a focus on culture & behaviours. This latter point that should not be shied away from, despite the current operational pressures. Good working relationships are the bedrock of Place-based partnerships – dismiss investment in organisational development at your peril.

Effective joint working at place-level will be essential in addressing both current NHS pressures, including elective backlogs, urgent care pressures and access, and in delivering with the Long Term Plan commitments.

The trick will be putting effort into prevention and wellbeing.  Building strong, enduring partnerships takes time and the full impact of more integrated approaches to care will only be seen over the long term, but the pandemic response has shown how quickly we can change ways of working, and there are scores of examples of where Place based working has achieved incredible results. Here are just a few:

  • In Tower Hamlets, acute asthma admissions in children have been reduced. Whilst the medical model played a role, it was listening and co-designing with children, focussing on prevention and communities and taking a multiagency approach that were the keys to success. The resulting stats, that catch the eye and drive so much of current NHS focus, were in fact the result of genuine Place-based partnership working.
  • A parish council in Wokingham helped flyer drop more than 10,000 leaflets in an area where mental health problems were growing.  Working together the local authority, Citizens Advice and colleagues across the healthcare system had identified an unusually high increase in mental health problems in the Earley region of Wokingham. They promoted a new Citizens Advice service to residents called ‘One Front Door’ where people could ring for advice and be signposted, for example, to their GP, local food banks, mental health services, employment or financial support. Now 400 people have used the service and reported improvements in their mental health status – the model will be rolled out across other areas in the system.
  • In North Tyneside, almost 500 new volunteers joined the ‘Good Neighbours’ scheme helping support vulnerable people by shopping for them and spending time talking to them at their front door or garden gate. During the COVID-19 pandemic they delivered almost 2,000 food boxes and made almost 2,000 shopping trips for people; almost 20,000 check-in phone calls were also made by council staff redeployed to help people who were encouraged to shield.

Mature systems have embedded some excellent practice already but in future, thriving place-based partnerships will need to become the norm everywhere.

A common question as guidance has been developed has been how resources will be managed at Place level – some wishing to start with a delegated budget, others not wishing to go there at all. From the evidence of good practice that currently exists, starting with purpose, defining activities, working through the capacity and capability required to deliver this and then aligning the appropriate budgets and financial mechanisms seems to be the right approach.

There will be variation in the structures and approaches of place-based partnerships. The ICS Design Framework is permissive and flexible and this presents a huge opportunity for Places to use this freedom to take the next step in partnership working. The opportunity this freedom offers is there to be seized by place-based leaders, as they set out their ambitions and plans to deliver better care and improve outcomes.

Taking a population health approach and tackling health inequalities is the natural focus for place-based working. ‘A whole person, whole place’ approach is the final frontier.

Andy Brooks

Andy is a practising primary care doctor and Clinical Chief Officer for the Frimley Clinical Commissioning Group. He is currently on secondment to NHS England and NHS Improvement as a National System Policy Advisor.