Putting place into systems

ICSs are probably the best-known, with 42 of these system-wide bodies across England. They are due to become statutory bodies by April next year, though they should have taken over all clinical commissioning group functions by October, including secondary and mental healthcare, as well as some specialised services commissioning. ICSs generally cover populations averaging 1 to 3 million, and will include a statutory NHS ICS body – to take on CCG functions – and a statutory health and care partnership, which will plan for the system’s wider health and care needs.

However, the new model will include sub-system levels based around place and neighbourhoods. The NHS ICS body will be able to establish place-based committees and delegate functions and funding to them – this could be significant sums and include funding for general practice, community services and continuing healthcare. Local authorities could also pool functions and funding with the place-based committees.

The meaning of place and neighbourhoods differ between sectors – local authorities may have their own description of neighbourhood. But in the health service, NHS England and NHS Improvement have adopted distinct definitions for the new three-tier model in the health service:

• Systems (ICSs) will set and lead the overall strategy, manage resources and performance, and carry out functions that should be carried out on a larger scale, such as digital, estates and workforce transformation.
• Place will be a town or district in an ICS area that is generally coterminous with a local authority, covering 250,000-500,000 people. Most changes in the design and delivery of care pathways will take place at this level, alongside population health management interventions. At place level, the NHS will work with local authorities, community health services and voluntary and community organisations.
• Neighbourhood will be the smallest area, typically covering populations of 30,000-50,000. These are focused on the delivery of care, with primary care networks (PCNs) and multidisciplinary community teams forming at this level.

As an example, as Chris Naylor (pictured), King’s Fund senior fellow in health policy points out, Sheffield Clinical Commissioning Group is coterminous with the city council. However, under the new model its area will become one of five places within the South Yorkshire and Bassetlaw ICS.

‘In the NHS the accountability and money will be at ICS level, but it’s not appropriate for everything to be sitting at that level. ICSs will have to delegate some money and authority back down to local levels,’ he says.

Partnership working

In some parts of the country this will be straightforward, with local partnerships already well established. However, the picture could become messier in some rural parts of the country, where there are two-tier local authorities – a county and district councils. Place could mean the area covered by two or three district councils.

‘In some areas, where the partnerships are well developed, place and place-based working will be straightforward and a matter of building on what already exists – in others, it is something that is being constructed now. Given how long it takes to build relationships and trust between organisations, that’s significant.’

Mr Naylor said place-based commissioning may not necessarily mean the formation of new organisations with a legal base. ‘Some areas have already built some kind of partnership working structure that brings together local government, the NHS and others.’

Suffolk and North East Essex ICS, for example, covers a population of 1 million and two upper tier local authorities. There are three places, which reflect pre-merged CCG footprints and patient flows to acute providers. Each place includes more than one lower tier authority. Overall, there are 25 PCNs.

Mr Naylor continues: ‘One question that remains is how these structures will interface with the ICSs, and what mechanism ICSs could use to delegate some of their budget back down to that place-based level.’

NHS Providers chief executive Chris Hopson has referred to ‘a crowded pitch’ at local level, which he said will include ‘the continued legal existence of CCGs’. Most observers believed the formation of ICSs and their assumption of CCG duties would mean the abolition of CCGs. However, NHS Providers point to NHS England and NHS Improvement documents on integrated care, which suggest ICSs would be established partly by ‘repurposing’ CCGs and the new NHS ICS body would be ‘an evolution of existing CCGs’.

With 106 CCGs in 42 ICSs, it’s possible repurposing will mean that CCGs become these place-based committees in some areas.

This may tie in with the direction set out in the integrated care white paper, which seeks to allow ICSs to establish local structures to suit the needs of the population. A handful of different structural models are likely to emerge from this permissive approach to sub-ICS levels.

‘Place and neighbourhood are likely to happen differently in different areas,’ Mr Naylor says.

‘In principle, the ICSs will set the strategic direction and do the work that’s best done at scale. Place is where most of the work that’s needed to join up services needs to happen.

‘We are getting a clear message from NHS England that it’s focusing on the establishment of ICSs, but it also seems to be saying that place level is really important too in terms of joining up services, understanding and working with communities, and in terms of the social and economic effects that influence health and wellbeing.’

See System clarity