The state of integration at place

• Integration at place is crucial to meet the health and care needs of England’s communities. At a time when significant challenges face our public services, most recently detailed in Lord Darzi’s investigation of the NHS in England, a focus on the places that matter to people and communities offers a path forward. Bringing together all the organisations that impact a local population’s health and wellbeing to work more closely and seamlessly is paramount to achieving this.

• Our research is clear that place is often the spatial level where system integration is best delivered and the biggest gains are possible in tackling inequalities, delivering more proactive, preventative care, delivering a ‘community first’ health service, and contributing to social and economic development.

• However, a number of factors are currently holding this back in some areas: the challenging financial and operational environment; pursuing integration without a clear, locally determined purpose; and a lack of system or partnership maturity to accelerate this work.

• The current financial environment in both the NHS and local government is not only restricting place integration in some areas but, in many cases, actively undoing it because: 1) a national emphasis on getting a stronger grip on the financial pressures in the NHS has led to command and control behaviours trickling down into the system; and 2) the running cost allowance reductions asked of integrated care boards (ICBs) have had a restricting effect on affected place-level teams.

• Many models have been copied from one place to another with the aim that the same success can be achieved, but this fails to gain the organic, bottom-up traction required for success. Time and again we heard that locally identified priorities – with integration being the means rather than the priority itself – were necessary ingredients for successful place integration.

• We saw two models for how place partnerships function as part of systems and in relation to neighbourhoods. On the one hand, we heard leaders describe a ‘Russian doll’ model whereby neighbourhoods are the most local levels of scale for planning and delivery, sitting within places, and places in turn sitting within systems. On the other, we heard of a ‘hub and spoke’ model whereby strategy is set at system level, detailed planning and some delivery are progressed at place level, and neighbourhoods are primarily seen as ‘delivery vehicles’ within place-based partnerships. Neither model was deemed better than the other, and indeed, systems should find the right model for their context.

• To continue to accelerate integration at place, leaders are keen to see:

• place given more prominence in national policy across Whitehall, in health policy but also more widely

• a focus on the public pound across a place, rather than what can be siloed, organisational budgets, with aligned, multi-year funding and planning cycles for the NHS and local government, and fewer barriers to pooling budgets and allocating resource according to local need rather than national dictation

• a greater focus on outcomes, not activity

• supporting the system to work towards better data sharing, better representation of different parts of the sector, and richer conversations with the public about these changes

• a move away from a focus on constructs, particularly NHS constructs, and towards community driven and community-focused delivery.

Download the full report.