The progress of place-based partnerships is being hindered by governance models, with decision making not always clear to members, a report by the King’s Fund has found.
The report, called Place-based partnerships: challenges and opportunities, surveyed 48 leaders of partnerships and looked at three case study sites.
It found that health and care partners said there were no mechanisms to hold each other accountable for work they do for places, as opposed to their own organisations, which was hindering progress.
It suggested that despite the ‘enthusiasm and motivation’ by those working at place-level, there was ‘some way to go’ before they can fulfil policy ambitions.
The authors set out recommendations across four key areas, including that place-based partnerships invest time in collaborating with ICBs, even though there can be a ‘natural desire’ to focus on delivering results (see box for full recommendations).
The report said: ‘Partners acknowledged the importance of strong relationships. However, there were differences in ways of working, and perceived power imbalances within place‑based partnerships that frustrated efforts to work collaboratively.
‘In some places, there appeared to be misalignment in the aims and approaches taken by ICBs and by place-based partnerships.’
It added that the case study sites were facing ‘extremely challenging financial circumstances’ and there was ‘wide variation’ in how much ICBs had delegated budgets. The report recommended that examples of good practice should be shared to help navigate the challenge of pooling resources.
It comes as some ICBs have asked for permission from the health secretary to merge and consolidate following the requirement that they would have to cut costs by 50%.
Earlier this month, new chief executive of NHS England Sir James Mackey told ICBs to target areas with duplication when making cuts. He said the 50% reduction to ICBs would ‘be a challenge’ but that it was important to act quickly to ‘seize the opportunities of ICBs acting primarily as strategic commissioners’.
In March, the HSCC was told that the cuts to ICBs could result in as little as 20 ICBs and reduce the need for regional teams.
Recommendations in full
- A clear focus with protected space for reform
Recommendations for national bodies
- Some of the key goals for systems are best tackled at place level, particularly when it comes to prevention, tackling health inequalities, and redesigning out‑of-hospital care. Future guidance and the forthcoming strategic commissioning framework should reinforce the purpose and role of place‑based partnerships in planning and priority-setting; it should send a clear signal about the value of place-based partnerships.
- Future guidance and the strategic commissioning framework should be as clear as possible on how place-based partnerships fit into a changing landscape in which ICBs are strategic commissioners.
- The guidance and framework should ensure that through clear delineation of competing responsibilities, urgent issues do not unduly prevent progress on long-term ones, and it should clarify both the authority that place-based partnerships have to lead reform and expectations for the rest of the health and care system to support them.
- Accountability
Recommendations for national bodies
- There is a need to engage with place-based partnerships to develop resources and guidance on stronger governance and accountability at place level that also supports the development of new ways of working. This should particularly include:
- mutual accountability (for behaviours and outcomes), as well as the support needed for transitioning to this way of working (eg, case studies)
- accountability to communities (including certain mandatory basics, such as publishing names of partnership leaders and plans or strategies, as well as developing responsive capability to different communities).
- The separation of performance management and strategic commissioning roles is an opportunity to ensure that accountability above place level reflects the right balance of focus on both shorter-term and longer-term priorities, and on NHS organisations’ performance and whole-system performance.
Recommendations for place-based partnerships
- As there are limited resources on mutual accountability, place-based partnerships will need to develop ‘test and learn’ approaches (which could also help inform any future guidance).
- Even though they are not statutory bodies, place-based partnerships should consider how they are accountable to their local communities and compare themselves to others.
- Partnerships should review whether they make most progress through broad, ambitious plans or whether initially focusing on just a small number of priorities would enable greater opportunities to follow through transformation plans in practice and learn new ways of working together.
- Collaborative leadership
Recommendation for national bodies
- It would be useful to consider place-based integration as a process of cultural change, as well as a process of developing services. National bodies should reflect this approach in their leadership frameworks and in how national leaders ‘set the tone’. In addition, national guidance should say more about expected behaviours and ways of working across levels of the NHS hierarchy.
Recommendation for place-based partnerships
- Although there can be a natural desire to focus on delivering results, it is also essential to invest time and effort in developing collaborative leadership within the partnership and, especially as they become strategic commissioners, with ICBs.
- Resources
Recommendations for national bodies
- Though simply mandating delegation of functions and budgets may not be appropriate, it may still be possible to go further by creating a scale of place‑based partnership maturity, with an increasing expectation of delegated budgets and responsibilities as a partnership progresses and matures.
- Sharing examples of good practice and practical toolkits should help develop confidence in navigating the challenges involved in pooling more resources.
Source: The King’s Fund
