Comment / Everything in its place

The aim of greater integration between health and social care is not new or disputed – achieving it is the challenge. The Health and Care Bill, currently passing through Parliament, sets out the formal system structures that are being created to deliver this integration. However, the government’s recent integration white paper (see HFMA summary) makes it clear that the more local ‘place’ level will play the prominent role ‘as the engine for delivery and reform’.

Systems are due to go live in July. Each integrated care system (ICS) will be made up of an integrated care board (ICB) (the statutory NHS organisation) and an integrated care partnership (ICP) (the statutory joint committee between the ICB and local authorities). But what do we know about the role of place within these systems? And how will this work in practice?

Place-based partnerships are collaborative arrangements between those responsible for arranging and delivering health and care services in a locality or community. They are not statutory bodies.  They vary across the country with system partners able to determine the footprint (commonly aligned with local authority boundaries), leadership arrangements and functions. In some parts of the country the use of place-based partnerships or alliances is already being used to drive service redesign with finance and governance arrangements, including place directors, set up. Other areas are at an early stage of thinking how they might be set up and used.

The idea of ‘place’ is to make decisions as close to the person as possible. In many cases, place is also broken down further into a number of neighbourhood teams (often the size of primary care networks). There are already some examples of where close working between all partners to focus on the patient or local population has made a difference – addressing some of the wider determinants of health, such as housing, or adopting social prescribing initiatives for example.

Governance at place will be complex, with a large number of partners involved from different sectors. It will need a change from traditional structures and ways of thinking to reflect a more network-based model – ensuring it is inclusive, agile and delivery focused. While the government is not being prescriptive about the model systems should adopt, it is setting out criteria for place-level governance and accountability for the delivery of shared outcomes.

It has suggested a place board model – which the ICB delegates functions and budget to – and expects places to adopt this model, or an equivalent, by April 2023 (except for those small ICSs that reflect one place). Alternatives might include a shared executive appointment or delegation to a single NHS trust.

Whatever the model used, clarity will be needed on how decisions will be made about contentious issues and about what is done at place and at system levels.  

There will be a lot to work through to get to this point, particularly for those areas that have not already started to develop these arrangements. In particular, the proposal for a single accountable person in each place (agreed by the relevant local authority or authorities and ICB) will need to be built into existing system and organisational accountability arrangements.

For areas where place straddles ICS boundaries, there will be added complexities to resolve. A place can be a similar footprint to current clinical commissioning groups (CCGs) yet its role is different so we should guard against recreating CCGs within an ICS. Each area will need to work through its scheme of delegation with multiple partners (including provider collaboratives who receive little mention in the white paper) to determine what is best delivered at what level, how this will be measured and how accountability will work.  

In terms of the financial framework, we know that allocations will flow to the system level and it will be for the ICB to determine if and how these are allocated to place. The white paper does tell us it expects the overall use of pooled budgets or aligned resources to increase, ‘eventually covering much of funding for health and social care services at place level.’

Further details are awaited on the legislation covering pooled budgets (section 75 of the 2006 act), which the white paper says will be reviewed and simplified. The better care fund policy framework for 2023 will also be set out later in 2022, including details on how it will support integration at a place level. However, these are the mechanisms for integrating finances; the real heat will come in working out how allocations are divided up and how to avoid a competitive mindset across place and complicated contracting arrangements.

Deciding where to spend the money requires a real shift away from organisational thinking. So where do you start? In some areas the use of CCG allocations seems a logical starting point with a gradual move to levels in the target population tool. In other areas the opportunity to start from a blank piece of paper to collaboratively come up with a bottom-up budget, could provide an exciting, albeit challenging, option.

As always, a shared vision, data and transparency are key to these finance and governance arrangements. But most importantly, it does come down to people and relationships to make this work. In reality, integration will be a success if all partners first focus on the purpose of arrangements and how they will best achieve this, working backwards to ensure the finance and governance arrangements are set up to enable this.  

Current plans for integration, and the prominence of place, are being developed at speed and with a lot of uncertainty. We are seeing a huge shift in the way people are working, with an increase in joint appointments, secondments and co-location. We need to recognise that this is not easy, will take time and cannot be described in one simple diagram.

The flexible and permissive nature of this change, expected to look different in different parts of the country, can be both scary and exciting. Perhaps not having all the answers is the real opportunity to create the local picture of what works best for people, places and populations.

The HFMA’s Integrated care system finance and governance guidance map pulls together key guidance and resources to support the move to new integrated care systems.