In London, place will be the key enabling layer for developing the neighbourhood health service, and the INTs which will sit at its core, supported by our Integrated Care Systems (ICSs) and regional infrastructure.

Existing place partnerships will provide the leadership and local accountability for planning, delivering and evaluating improved population health and reduced inequalities.

Working within each ICS, place partnerships will be responsible for agreeing the footprints of neighbourhoods based on local evidence and data, including existing capacity and demand, and mapping of local assets and needs.

INT boundaries in London will therefore not automatically be defined by existing primary care network (PCN) footprints, except where these boundaries align with recognisable neighbourhoods. Once a consistent set of geographic neighbourhoods is agreed, if PCN boundaries do not align, those PCNs will need to consider either re-aligning to these footprints or developing with the place partnership arrangements capable of operating effectively across more than one INT.

Each place will be responsible for nominating an “Integrator” organisation from within that place to host the identified integration functions required to enable primary, community, mental health, acute specialist, local authority, VCFSE and other partners to work together effectively at neighbourhood level.

In some places, these functions will be hosted within a single organisation with the capacity and capability to support neighbourhood working across all neighbourhoods. In others, integrators may work with one or more local partners to provide the range of required support. In this case, it will remain important that there is a clear line of organisational accountability to the place partnership for ensuring the neighbourhood health service can function effectively, efficiently, and sustainably across the place as a whole.

The integrator will be vital to ensuring the effective delivery of INTs working within place partnerships, operating at a level of scale to allow sufficient organisational resources, capacity and capabilities to be available across all associated neighbourhood teams, whilst drawing on the local knowledge, experience and relationships from local professionals and communities.

This role cannot operate in isolation or remove individual responsibility and accountability from partnering local organisations.

However, it can help in:

1. Bridging fragmentation: Responding to the reality of currently fragmented services by addressing the practicalities of collaboration across sectors, organisational and professional boundaries, building necessary interfaces and relationships, and ensuring cohesive and equitable care for all Londoners at the neighbourhood level.
2. Flexing to local needs: Enabling INTs to adapt to the diverse needs of local communities whilst maintaining alignment with overarching place and system priorities.
3. Promoting consistency: Ensuring that a consistent, core community offer from London’s health and care providers is matched by a core integration offer in each neighbourhood, enabling those services to be effectively coordinated around individual and community needs.
4. Facilitating population health improvements at local and hyper-local level: Providing access to real-time population health data, drawing down on regional and place infrastructure, to enable INTs to target interventions in proactively and preventatively addressing health inequalities and needs.
5. Enabling shared learning: Facilitating cross-borough collaboration, spread and scaling of successful practice, ensuring continuous improvement and increasing alignment to the most efficient and effective models of local care.
6. Mediating challenges and ensuring inclusive decision-making: Including providing support to develop relationships, trust and mediate conflicts; and enabling communities and community leadership to be at the heart of successful INT development and delivery.
7. Providing essential infrastructure: Including aligning people, finance, governance, risk and outcomes management across existing sectoral and organisational boundaries, in a way which is consistent and cost-effective, and ensures integrated neighbourhood delivery is mainstreamed.
8. Improving sustainability: Having the ability to offer additional support options to any part of the partnership, including at individual practice level, experiencing difficulties which threaten the sustainability of the INT and the local neighbourhood health service as a whole.

We believe this role will require an organisational host that is:

• drawn from existing institutions within the place partnership.
• organisationally mature and able to operate at a scale sufficient to manage related budgets and provide required infrastructure, including around data sharing, workforce, estates and digital.
• senior and experienced enough to be credible and influential across the partnership, to build trust amongst partners, navigate and support the partnership as it develops, whilst recognising that this role is about hosting and facilitating, not leading (which will be the responsibility of place partnerships, working with local communities themselves).
• able to operate in alignment with the geographical footprints of the INTs it supports.
• part of the landscape across those INTs – an organisation with “skin in the game” but which is prepared, where appropriate, to ignore short-term self-interest for the interests of the partnership and population as a whole. This will require not just a change in culture but a clear understanding of roles at all levels, including that of organisational boards, in enabling this shift.

It is equally important to understand what this role cannot do.

• This is not about duplication or introducing extra layers of senior leadership, management, or assurance. We cannot afford this, and any resources which can be made available across local partnerships need to be tightly focused on supporting improvement of frontline delivery, working, as appropriate, with existing place and system teams.
• This is about delivery, not planning or decision-making. The integrator will work within system and place leadership structures, including with primary care and local government, and in partnership with all local providers, to ensure that agreed local strategies and priorities for improving health and wellbeing are being translated into day-to-day delivery of services and care.
• This is not about taking away from individual roles and responsibilities within integrated neighbourhood working, including existing contract holders. There is a recognition across our systems that we have not, and are unlikely to, succeed in scaling INTs without some form of core organisational infrastructure and organisational support; but, equally, no set of integrating functions will be viable without the active engagement of professionals and local communities, ownership, and leadership from across all local partners, including the ICB, NHS providers, local authorities and VCFSEs.
• This is not about integration around “just the top of the pyramid”. It is a whole population approach which focuses on improving the lives of all Londoners, including children and young people, working-age adults, and older people, whatever their current assets or needs.

The intention of the Target Operating Model is not to mandate who the integrator should be in each place.

The model is designed to help set out requirements for enabling integrated teams to function effectively at neighbourhood and place level. As part of the next phase of implementation, if agreed, this will facilitate the definition of requirements which all integrators will need to be able to demonstrate to partners that they can meet.

Examples of organisations that could fulfil this role in each place in London include, but are not limited to, community providers, vertically integrated acute trusts, local authorities, or any other existing organisations capable of operating at the scale and with the local connections to support related INTs to succeed.

In some places, this may require the integrator to work formally with other partners to guarantee the full range of supporting capacity and capabilities required within that place.

The determination of this should be made locally, by the place partnership, in consultation with all relevant stakeholders, based on what is required for the partnership to function effectively and sustainably in improving population health and tackling inequalities across related neighbourhoods and communities.