Developing Place-Based Partnerships in Lancashire and South Cumbria
A place-based partnership is a collaboration of planners and providers across health, local authority and the wider community, who take collective responsibility for improving the health and wellbeing of residents within a place, with a population of up to 500,000. Most people’s day to day care and support needs will be met within a place and delivered in neighbourhoods of 30,000 to 50,000 people.
Place-based partnerships were previously known as Integrated Care Partnerships (ICPs) in Lancashire and South Cumbria.
Within the Lancashire and South Cumbria Health and Care Partnership, there are five place-based partnerships:
- Central Lancashire
- Fylde Coast
- Morecambe Bay
- Pennine Lancashire
- West Lancashire
Our partnerships will create a feeling of belonging to a place, where all partners are valued and respected, and mutual support is offered to all partners. This will be particularly significant in challenging times. It is important to acknowledge that residents are co-partners in the continued evolution of place-based partnerships, and that social movements in communities can increase people’s ownership of their own health and wellbeing and mobilise communities to support each other.
The common purpose of a place-based partnership is to enable collaboration that will address specific place-based challenges and deliver within each place the component parts of the Integrated Care System (ICS) strategy.
The document entitled “Integrating care: Next steps to building strong and effective integrated care systems across England”, published by NHSEI in November 2020 states that:
“Every area is different, but common characteristics of the most successful are the full involvement of all partners who contribute to the place’s health and care; an important role for local councils (often through joint appointments or shared budgets); a leading role for clinical primary care leaders through primary care networks; and a clear, strategic relationship with health and wellbeing boards.”
The core aims of a place-based partnership are to:
- Improve the health and wellbeing of the population and reduce inequalities.
- Provide consistent, high quality services that remove unwarranted variation in outcomes.
- Consistently achieve national standards / targets across the sectors within the partnership.
- Maximise the use of a place-based financial allocation and resources.
As a minimum, each place-based partnership will have the following all age service provision at place level, working together to simplify and modernise care and implement service models which deliver improved outcomes:
Public health and wider community development.
- Community-based wellbeing support, including social prescribing activities, VCFSE provision and local access to green spaces, and leisure facilities.
- GP and wider primary care, delivered through Primary Care Networks.
- Community health care.
- Community mental health care (including for those with learning disabilities).
- Urgent and emergency care, including physical and mental health (noting that some emergency services will be provided in a networked model across Lancashire and South Cumbria, e.g. stroke, trauma).
- Ongoing management of long term conditions, including the use of skills, expertise and resources that have historically been accessed via referral to acute care services.
- Local acute hospital services (noting that some services will be provided in a networked model across Lancashire and South Cumbria, and there will be tertiary services provided in some places for the system-wide population).
- Social care, education, housing, employment and training support.
- The wider care sector within the place
The providers of these services will be partners within the place-based partnerships working alongside place-based commissioning and planning teams.
Several providers will be working collaboratively at more than one level; for example, NHS Trusts who provide acute and community services will be collaborating within neighbourhoods through the provision of
community services, within places through the provision of specialist expertise to support the ongoing management of long term conditions, and across the system in the networked provision of elective care.
In the future, it is expected that the NHS will move towards organisations within each place-based partnership receiving a financial allocation for the place, based on capitation; the principle that money is allocated per person in each place.
This, along with the potential for increased use of pooled budgets, will mean that partners within the place-based partnerships will make collective decisions on how best to invest financial resources in order to deliver neighbourhood-based, place-based, regional and national requirements and ambitions across health, care and wellbeing. Partners will need to be clear on their own role in delivery and will need to hold each other to account
to ensure collective achievement of their place-based objectives.
Place-based leadership and collaboration
Effective, collaborative leadership – with a clear, common purpose, and drawn from all parts of the system including democratic, clinical and professional teams – has been shown to be essential to developing
the partnership culture needed to create and sustain system-wide improvement. Place-based partnerships will:
- Co-create a vision for the place that delivers the system and place strategies through a partnership of equals.
- Provide a ‘system management’ function that connects the partners within the place, as well as influencing key priorities across the Lancashire and South Cumbria Health and Care Partnership and connecting each place to the wider system. This function will include shaping the culture of the partnership through a population health management approach to the planning and delivery of services; holding each other to account for delivery; acting as place-based and system-wide integrators and catalysts for change; brokering challenging conversations between partners; and ensuring that decisions are made in the best interests of the place. It will need to encompass the expertise and experience of place-based commissioning and provision.
- Use this system management approach to support a collaboration of providers across different sectors and multiple organisations to build seamless, integrated services that respond to the health and wellbeing needs of local residents.
- Promote social value in our communities by employing a workforce that is drawn from, and representative of, the population in the place; by offering fair pay and conditions of employment; by offering employability programmes that support people to acquire the skills needed to work in health and care; and by offering apprenticeship programmes which assist in providing employment now and creating the workforce of the future.
- Promote, embed and demonstrate compassionate leadership across all services within the place.
- Build a culture of rapid improvement with a shared, consistently applied methodology; a management system that aligns improvement activity to priorities and ways of working; and a set of leadership behaviours which supports an engaged and empowered workforce.
- Implement accountability frameworks that incentivise evidence-based care provision and improved outcomes for individuals and for the population as a whole, shaping priorities and decision-making.
- Support effective place-based organisational development programmes, recognising the need for increased support during large-scale and/or sustained periods of change.
- Ensure systems are in place to provide comprehensive organisational development, coaching and mentoring support for leaders to facilitate the transition from organisational to place-based leadership behaviours and decision-making.
Listening to the voice of our communities
Our residents and communities are a fundamental part of our partnerships and their voice and lived experience is vitally important in creating the culture of a social movement in our neighbourhoods and places, in ensuring that residents’ needs are heard and understood, and in shaping services that meet local needs. Place-based partnerships will:
- Ensure local engagement is culturally appropriate, in line with the demographics of the place.
- Engage with residents to ensure co-production in health and wellbeing needs assessments, delivery plans, operating models and service redesign / transformation activities.
- Listen to feedback from patients, carers, service users and residents to ensure that services are evaluated from quantitative and qualitative perspectives, and that this feedback is used to inform future service provision.
- Engage with residents (and our workforce, many of whom are residents themselves) to encourage a social movement that fosters and enhances an increased responsibility for health and wellbeing and mobilises communities to support each other better.
- Proactively work with communities to create a greater sense of accountability to the local population for the quality of services provided and the resultant outcomes.
- Seize the short-term benefits in restoration and incentivise change to build the culture and capability for the medium and long term.
Planning integrated services
A more integrated approach to the planning of services across all sectors will support more efficient and effective use of resources. Place-based partnerships will:
- Lead the creation of a fully integrated, place-based delivery plan that is able to respond to:
- National strategies, plans, standards/targets.
- The requirements of national and regional regulators.
- Lancashire and South Cumbria Health and Care Partnership strategies.
- Existing place-based strategies.
- Place and neighbourhood-based health and wellbeing/joint strategic needs assessments.
- Join up population intelligence capability, and health and local authority planning, including joint commissioning, transformation and at-scale change programmes, quality improvement, service delivery and empowered communities.
- Ensure that actual and potential inequalities are identified and addressed in all aspects of service planning and provision.
Delivering integrated services
Patients, service users and our own workforce often describe their frustrations at the fragmented nature of our service provision. A key shift in the transition to significantly increased partnership working should be the removal of unnecessary boundaries between services and professions. Place-based partnerships will:
- Work with partners to ensure the delivery of high quality, safe, affordable integrated services, tailored across the differing needs within the place footprint at neighbourhood/PCN, district and place.
- Ensure that all partners work together so that services will be predominantly focused on improving health and wellbeing through a population health management approach which will include self-care, preventative action, vulnerability reduction, anticipatory care, community-based models of care and support, long term condition management using digital technology, and addressing the wider determinants of health and wellbeing with clinicians and professional groups working at the top of their licence to support complex care in the community.
- Ensure that all partners work together so there is an operating model for the place that includes standard service offers and minimum standard specifications within a place to reduce health inequalities and unwarranted variation within that place and, where appropriate, across the places within the Lancashire and South Cumbria Health and Care Partnership. These service offers and standard specifications will be outcome focused in order to allow for necessary flexibility in delivery and eliminate asynchronous care. The operating model will include:
- Primary, community, acute, mental health and social care working as self-directed teams across organisational boundaries, to deliver services to populations of 30,000 to 50,000, driven by data, mobilising prevention and anticipatory care. PCNs will be at the core of these teams.
- Joining up of civic and community assets, providing partnership multi-disciplinary teams (MDTs) which will include housing, Department for Work and Pensions, voluntary sector support and access to community assets to support people to maintain independence.
- Long term condition management where the focus of specialist/consultant led support is on holistic continuous condition and exacerbation management, aimed at keeping people at home.
- More intensive community support when required to keep people at home, including at times of crisis.
- Elective care, urgent and emergency care, including physical and mental health, providing timely and appropriate access.
- Ensure that all partners work together to provide fully integrated health and care records that are available to all staff involved in the provision of care across the place, with information governance agreements that support and enable integrated working. The ambition is to move towards records that are resident owned.
- Make best use of digital solutions that will support residents staying in their own homes wherever safe and effective, predict need and support effective mobilisation of the workforce, and promote multi-disciplinary working to deliver seamless care.
Population health management
Moving towards a preventative, proactive and holistic approach to the health and wellbeing of our residents is key to improving outcomes and reducing inequalities. Place-based partnerships will:
- Ensure plans are in place to implement a population health management infrastructure and culture.
- Ensure that the place-based partnership uses a population health management approach to service planning, i.e. making use of holistic data from multiple sources to identify the health and wellbeing needs of the population (place and neighbourhood).
- Ensure that a risk stratification approach is used to plan how services can meet health and wellbeing needs and reduce inequalities, including addressing the wider determinants of health and wellbeing such as housing, environmental quality and access to good employment and training.
- Use population data to mobilise the workforce, working to accountability frameworks that demonstrate delivery on outcomes and incentivise prevention and anticipatory care.
- Build a collaborative decision-making process that prioritises investment in anticipatory and preventative care to reduce specific risks and vulnerabilities within the local population.
- Ensure the creation of integrated population health management units in neighbourhoods by building on existing neighbourhood working, community hubs and PCNs, whilst also drawing in acute care specialists who focus on long term conditions and the elderly.
Improving quality of services
We know that many services in our system provide good quality care which is rated highly by patients and services users. It is important for us to build on that and learn from these teams / organisations to provide consistent, high quality care across each place. Place-based partnerships will:
- Ensure all partners work together so that actual and potential inequalities are identified and addressed in all aspects of service planning and provision.
- Ensure place-based performance and assurance is focused on delivering the required improvements in population health, outcomes and inequalities.
- Ensure all partners use an evidence-based approach to care planning and provision, simplifying and standardising pathways across the place and within neighbourhoods.
- Lead the deployment of improvement science at pace and scale to support rapid cycles of change, allowing freedom to act and promoting innovation.
- Create an integrated, place-based plan for the provision of high quality services that meets the requirements of the regulators across the sectors within the partnership.
- Create and maintain an open and transparent culture that encourages incident reporting, management of serious incidents and the implementation of associated learning from incidents across all sectors within the partnership.
- Ensure there is sufficient capacity and that services are of the highest quality to meet required national standards / targets.
- Design and deliver culturally competent personalised care services.
Maximising the use of resources
Resources within each place are scarce and it is therefore important that we use these wisely in order to gain the maximum benefit for our residents. It is therefore proposed that the actions set out below will accelerate the next stage of development. Place-based partnerships will:
- Be collectively accountable for a place-based capitated NHS budget within an agreed Lancashire and South Cumbria financial framework along with any pooled budgets across the NHS and other partners within the place-based partnerships.
- Use a place-based collective prioritisation and decision-making framework to agree the allocation of these financial resources within the place.
- Work with partners to create an integrated, place-based financial plan that supports population-based budgets and demonstrates best value for the ‘place pound’ whilst maximising impact on population health, health inequalities, quality of service provision and outcomes.
- Use contracting and payment mechanisms within the place that are based on incentives, with agreed shared risk / gain models and aligned financial processes, building on the PCN Directed Enhanced Services and local quality schemes.
- Plan and deliver local cost improvement schemes to ensure best value for money.
- Ensure local understanding of community-based physical assets and influence their collective use across partners within the place.
- Make best use of business intelligence / health informatics resources across the place-based partnership partners, and as appropriate with wider partners across the Lancashire and South Cumbria Health and Care Partnership, to provide real time information for use across the place and a single suite of performance / assurance reports.
- Integrate corporate teams to work across the place rather than maintaining separate teams in individual organisations.
Valuing and developing the workforce
The partners within each place-based partnership employ a significant number of people, many of whom are also residents within the place where they work. Partners have a duty to support their workforce and to contribute to the socioeconomic development of the place. There are a significant number of volunteers in each place who make invaluable contributions that should be supported and recognised. Place-based partnerships will:
- Recognise that key partners are anchor institutions in each place, acknowledging the fundamental role they have in advancing the welfare of the populations they serve and the way in which they can support local community wealth and development.
- Be a partnership of employers that proactively supports the employment of our local people by providing equity of access to opportunities and employing a workforce that is drawn from, and representative of, the population served by the place.
- Support fair and equitable pay and conditions of employment including paying a living wage and providing stable employment which offers fair working conditions and promotes the health and wellbeing of all staff.
- Ensure that partners develop and offer employability programmes that provide training and support to help local people acquire the skills needed to work in health and care, and work with community partners to support residents who might otherwise face barriers to work.
- Work with local Academies, schools, Further Education colleges and Higher Education institutions to offer apprenticeship programmes which assist in providing employment for the local community and in supporting the creation of the workforce of the future.
- Work with partners to create a place-based people plan for the recruitment, retention and ongoing development of an integrated workforce.
- Integrate the workforce to support seamless service provision and minimise handovers between individuals and organisations across the partners within the place.
- Provide joint appointments and rotational posts across multiple care settings in order to make best use of, and/or further enhance, skills and experience.
- Support professional development and career progression to staff at all levels and across all aspects of provision.
It must be recognised that without legislative change, certain types of organisations are accountable to specific regulators, with ring-fenced budgets, and will be held to account for delivering certain services and/or functions. Therefore, we need to consider what can and cannot be undertaken collectively, how we will organise ourselves to manage this locally, and how we will respond to our respective regulators. This will require liaison with regional and national teams to support the shift from organisational accountabilities to place-based accountabilities. This is likely to require a new and explicit mechanism for holding place-based partnerships to account for what is in scope of place-based, collective delivery. Partners within a place-based partnership will share responsibilities, risks and resources. This will require some delegation of decision-making to the place rather than organisations, clarity on which partners are delivering which services / functions within the place-based partnership, and changes to current organisational-based leadership structures and governance arrangements.
Delegated decision making
Each place-based partnership will require a framework that defines the scope within which decision-making happens by place-based system leaders operating within parameters agreed by the partner organisations. This is likely to be achieved via a scheme of delegation that is explicit about what will be managed via organisations and what will be managed via the place-based partnership. This will include decision-making across all of the functions of the place-based partnership, and all partners within the place-based partnership.
Supporting governance arrangements
Each place-based partnership will require a structure where it can exercise this delegated decision-making, ensuring that partners deliver what has been agreed, and maintaining appropriate levels of lay/non-executive oversight and
clinical engagement. As part of this process each place-based partnership will need to consider the following requirements:
- The use of formal memoranda of understanding, partnership agreements or alliances to provide clarity on the role and responsibilities of each partner organisation within the place-based partnership.
- A place where delegated decision making from the statutory bodies can be discharged, i.e. a place-based place-based partnership Board that is the decision making group of the place-based partnership, as outlined by a scheme of delegation and enacted by the members of the place-based partnership Board. This may need to be supported by other place-based committees, which could function using a Committees in Common approach.
- A cross-organisational, multi-professional clinical and professional leadership body that allows senior clinicians / practitioners from across the partners within health, social care and third sector within the place-based partnership to make decisions / recommendations on clinical practice, pathways, etc.
- Meaningful clinical, professional and democratic leadership and engagement, to ensure that there is appropriate representation and engagement across neighbourhoods, districts and the place.
- A mechanism for identifying and managing risk for the place-based partnership, with proportionate distribution of risk across partners, and clarity on which partner within the place-based partnership owns the risk along with which partners contribute to the mitigations.
- Systems and processes for partners in the place to hold each other to account for performance and support each other where necessary. These will need to align to the accountability framework within the Lancashire and South Cumbria Health and Care Partnership and the approach agreed with regulators. It should be noted that effective implementation of these governance arrangements may require changes to current organisational constitutions and Terms of Reference of existing organisational groups.
Supporting leadership arrangements
Each place-based partnership will require a leadership team for the place that will be acting independently of any single organisation (albeit that they may continue to hold organisational leadership roles) working to deliver the core aims of an place-based partnership. Each place-based partnership will need to consider the following:
- A place-based partnership Chair who will be responsible for creating productive collaborative relationships within the place-based partnership and across the Lancashire and South Cumbria Health and Care Partnership, and for effective leadership of the place-based partnership Board and its role in ensuring delivery of the core aims of the place-based partnership.
- An executive leadership team with members who have responsibilities across the place (albeit that they may continue to hold organisational leadership roles).
- High levels of clinical and professional leadership and influence, where leaders are acting as a collective voice on behalf of the health and care system.
- Shared purpose and values that have been adopted by the place-based partnership partners.
- Leaders who demonstrate high levels of trust, collectively overcome challenges, celebrate shared success and drive continuous improvement to shared objectives through adaptive change and a learning culture.
- Leaders who role model values and behaviours and cascade down through their teams.
- Leaders who respect that the voice of all partners has equal weight and value.
It is suggested that there will be a need for an ‘Integration Lead’ within each place-based partnership. It is intended that this role will work alongside the senior executives from the partners within the place-based partnership and local communities to:
- Ensure effective integrated approaches are taken to the health needs of the local population – using population health management techniques and building on the experience and expertise within communities.
- Support the development of integration across all services (primary / community / care / hospital / VCFSE) in the place and ensuring that PCNs work effectively to support each neighbourhood of 30,000 to 50,000 residents.
- Work with health partners and local authorities to identify joint opportunities for health and care services to be transformed, building on lessons learned through the response to the Covid-19 pandemic and the potential to use new technology.
- Coordinate local contributions to health, social and economic development – set as appropriate within the context of wider system strategies.
We will continue to keep colleagues, partners and members of the public informed about any developments as early as possible.
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