The Integrator: The influence of ‘place’ is being chipped away

Many at NHS England and integrated care boards — and elsewhere — have been keen to talk up the importance of “place”, but reality has often lagged behind. Now, in some areas, nationally mandated management cuts are threatening the already tenuous influence of this sub-system level of decision making.

The power of place is not starting from a strong position: HSJ analysis early this year found only six ICBs had place representatives as full members of their board; and just eight had delegated them any kind of significant budget and decision making.

And it appears to be falling further, as the steep running costs reduction required by the previous government and NHSE bites into ICB staffing budgets.

Most glaringly, due to our coverage and outcry on the patch, is the move by Buckinghamshire, Oxfordshire and Berkshire West ICB to axe its three “place” directors and centralise their teams, with an assistant or deputy left to cover each place. The plans, which are the result of an ICB decision without local authority input, sparked outrage in Oxfordshire – one of the ICB’s three places.

Oxfordshire County Council, not afraid of being outspoken, is highly irritated – and you can see why. They feel they had made strong development and progress at place in recent times, which they are at risk of losing.

BOB’s chief executive Nick Broughton insists that the system is focused on strengthening work at place-level but acknowledged: “In common with other ICBs, we need to balance place resources with the need to effectively deliver our core, system level responsibilities.”

The nature of place, of its shared investment and workload, means there are inevitably knock-on effects from such changed for partners – and it is meant to be a shared enterprise. Yet within ICB structures (owned by the NHS), local authorities appear to sometimes be getting little to no say on significant changes.

Split picture 

Some ICBs are making the vast majority of running cost cuts in more palatable areas, such as estates savings and co-locating teams, or cutting vacant posts. But others are left only with difficult conversations: fewer staff means something has to give.

It’s a truly split picture: just under half of integrated care system leaders surveyed by NHS Confederation in a recent report felt their system devolves decision-making to the most local level.

BOB has drawn the most public ire, but is not the only ICB watering down its presence at place.

As one ICB place director put it: “Lots of the systems up and down the country appreciate the work at place-level, and many are thankfully continuing to invest in. But you can see how tough financial decisions would lead to some disinvestment in place, because I suppose it can seem to some ICBs like an easy area to cut, pretty removed from their every day.”

Cornwall and the Isles of Scilly this year switched its place leaders from senior figures with dual hats across the ICB and system — often clinical directors based in the three patches — to what are now ICB-employed band 9 roles, who are not board members but full time. Sussex is also overhauling its place leadership this year, seemingly with more power and decision-making capability at provider level, although it is unclearly how that will land.

In some areas, staff cuts will hinder progress at place simply due to limited management capacity. In contrast, many ICBs — often the much larger ones with multiple places — have stronger delegation, and healthy partnerships with local authority and voluntary sector organisations, with no sign of backing down.

A U-turn brewing

Watering down place seems to be contrary to many national signals about NHS and ICBs’ priorities.

The new government is making noise about devolution, promising to local government that it will “expand devolution further and faster”, though it’s unclear on whether this would see any meaningful shift in power when it comes to health.

Labour ministers appear to want ICBs to focus on developing out-of-hospital services and prevention — tasks which lend themselves to place partnership — and think less about performance managing hospitals. 

Tom Riordan — who has done more than most to champion the role of place as Leeds City Council CEO — has just joined the Department of Health and Social Care in a powerful role as second permanent secretary; and NHSE has recently appointed trust CEO Therese Patten as its new national director for place development.

On the other hand; the orders also keep coming down for the centre for ICBs to keep an iron grasp of trusts’ spending and perfomance — something which lends itself more to a system-wide grip.    

Some areas of the country are working in a way that’s closer to the devolved vision than others. Several ICSs with combined authorities and devolution deals are already co-developing and delivering plans of work to improve local population health.

But not all areas are as naturally set up for the shift. Those without metro mayors — and particularly those with disparate local authorities that don’t naturally fit together — face tensions between individual councils/places and the new mayoral powers.

After all, the financial squeezes which test these relationships aren’t going away any time soon.