Acting as one, delivering as one

Speaking at a recent Good Governance Institute (GGI) webinar, former health secretary Patricia Hewitt, author of the recent Hewitt Review into integrated care systems and chair of the Norfolk and Waveney Integrated Care System, said she saw the three crucial system success factors as being purpose, people and place.

Since the conception of integrated care systems (ICSs), GGI has been highlighting the importance of ‘place’ within systems as the true action centres where most of the work set out in the plans and strategies will be delivered. GGI has written extensively about the governance of place, the concept and practice of subsidiarity, and linking place to purpose. Place was also the focus of our 2022 Leaders Forum.

For all its importance, place is one of the least prescribed components of ICSs in the legislation and guidance. Consequently, places have developed in different ways and at different speeds across the 42 ICSs, with varying levels of delegated authority and scope. There is no single correct approach but there are plenty of examples of good progress.

Here we set out one such example, the place-based partnership approach of Bradford District and Craven Health and Care Partnership.

The following article was written by Shak Rafiq, Associate Director Communications and Involvement, Bradford District and Craven Health and Care Partnership, and James Drury, Director of Partnership Development, Bradford District and Craven Health and Care Partnership.

If you’d like to find out more about their work, or you want to discuss the developmental support GGI can provide, please get in touch.

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Our Bradford District and Craven Health and Care Partnership has a vision where all partners ‘act as one’ so that we can help people stay ‘happy, healthy at home.’ We are proud to be a partnership that includes two acute trusts, one community and mental health trust, two local authorities and thousands of community groups that form our vibrant voluntary and community sector (VCSE) as well as 13 primary care networks covering 71 GP practices and a strong independent care sector.

We have four Ps underpinning our strategy – purpose, place, population and partnership – which is based on the principle of bringing decision-making closer to communities as much as possible.

A journey that started in 2012

For many integrated care systems and place-based partnerships, the journey began when sustainability and transformation partnerships came into being around 2015. We had started our collaborative approach as early as 2012, just before clinical commissioning groups went live.

Our initial partnership working was focused on improving outcomes for older people – we found that having a smaller scope that was of shared importance to all partners was a good way of getting started.

By 2017 we had a partnership strategy ‘happy, healthy at home’ and a partnership structure in place, including a shared leadership group at chief executive level, and several collaborative programmes of work.

Between 2018 and 2020 we focused on increasing the shared ownership and participation in our partnership work. This meant that the leadership of our collaborative work moved from being largely CCG or local authority led, to becoming led by a wider range of partners, including NHS providers, the VCSE and independent care sectors, and primary care.

At the same time, we deliberately sharpened the focus of an increasing number of roles on partnership working, so that it moved from being an activity that a few people did regularly to becoming just the way we do things round here, with everyone playing a part. This was evident in the recruitment of any leaders to our NHS trusts, which was done with a specific intention of them being system leaders.

Two things were critical to this development. Firstly, a focus on locality-based health and care partnerships, and secondly our Strategic Partnering Agreement. Together these steps helped us to shift thinking from commissioner/ provider to ‘what can we each do to improve for our people?’, and from transactional to transformative. We created transparency and inclusion in the use of resources and a sense of mutual accountability for the results of the whole system.

The years of austerity have had a particular impact on us. We are home to one of the youngest cities in Europe, Bradford, and in Craven we have one of the most rural areas in the country, comparable to northern Scotland. We also have significant health and social inequalities. For example, in Bradford we have a highly vulnerable population, with 247,000 living in the 20% most deprived wards and 147,000 in the 10% most deprived wards. Bradford is also the fifth most income deprived and sixth most employment deprived local authority in England. Acting as one is the only way we can meet these challenges head on.

Moving to our Act as One ethos

Although our journey began in 2012, it’s worth fast-forwarding to the start of the pandemic, when we socialised our Act as One ethos, which remains part of our place-based partnership’s way of working – and indeed our corporate logo.

We started with a strong governance structure in which everyone has an equal voice, and we were trailblazers in ensuring we had a seat at the table for our non-statutory partners, including the voluntary and community sector and the independent care sector. These non-statutory partners are critical in delivering our vision and they are also uniquely placed to help discussions involving NHS and local authority partners so that we have a balanced approach to decision-making, highlighting any unintended consequences.

We have benefited from West Yorkshire ICS adopting the principle of subsidiarity – it’s given us the freedom we needed to accelerate our integrated working at place.

We started doing this with a very early version of a provider collaborative, which in turn paved the way for our Act as One system transformation programmes. These programmes ensured that there was equal representation at programme boards and steering groups for all partners. And they’re now changing following our strategic priorities re-set programme, which we’ll come back to later.

A vibrant voluntary and community sector

With more than 5,000 community organisations across our place, we recognise it is difficult for statutory partners to engage effectively with all of them. We have been developing an infrastructure for the VCSE supported by bodies who act as a conduit between our decision-making bodies and community groups.

To support this, we have a VCSE rep on our partnership leadership executive and on our Bradford District and Craven Health and Care Partnership Board (a committee of NHS West Yorkshire Integrated Care Board). While we recognise that this approach may not cover such a diverse VCSE, we have benefited from the VCSE voice at the decision-making table and this is aided by a VCSE health and care forum, again ensuring issues from the wider VCSE are escalated as needed. As a system, our larger organisations have funded this role so that our VCSE system lead can focus their effort on leading and connecting our VCSE with the work of our place-based partnership and not worry about competing for funding for this key strategic role.

What is exciting is an agreement that we will use our combined health and care budget of just over £1billion to support prevention and earlier intervention as the default in all pathways through something we describe as our community health investment standard. We are working through the governance on this, but it will be a real game-changer and it’s something we are firmly committed to, despite the financial challenges we are experiencing.

Aiding this community-centred approach are our six localities that are co-terminus with local authority boundaries. They are built upon 13 neighbourhood level community partnerships. Our community partnerships bring together VCSE partners, primary care networks and a range of agencies to ensure we can deliver agile services closer to home, building on local population health profiles.

Shifting priorities

Earlier we alluded to a system-wide move away from the transformation programmes we set up. Our strategic priorities re-set programme is designed to help us meet the challenges we anticipate for our Bradford District and Craven Health and Care Partnership.

These challenges include meeting our core responsibilities to improve the health and wellbeing of our communities, as well as our colleagues, and to deliver sustainable change across health and care so that we can achieve our vision to keep people ‘happy, healthy at home’.

Our focus is on delivering the best possible outcomes, including reducing inequalities, for our communities and for our colleagues.

To help us understand how we can meet future challenges, we commissioned two independent reviews of our place-based system. The first was done by Mike Farrar, who worked with key colleagues across our partnership to understand what they believed would help us build on the strong foundations we have in place locally.

The second report was by David Hambleton, who was asked to focus on the work we do in our communities, which can also be described as out-of-hospital care and support. Both reports, alongside national guidance such as the NHS Oversight Framework and regional guidance through the NHS West Yorkshire Integrated Care Board, have helped to shape our thinking around our future five priorities.

Our five priorities are:

• access to care;
• healthy children and families;
• healthy communities;
• healthy minds; and
• people development.

Next steps

We have started to set up or build on existing infrastructure to ensure appropriate governance rigour is in place and that we can move on implementing the changes we are planning. We are exploring how we can use our West Yorkshire ICS’s principle of subsidiarity and play it out locally. One of our proposals would see the programme boards for each of these priorities taking on delegated budgets and responsibilities on behalf of our place-based partnership board. This could present opportunities such as pooled budgets, provider collaboratives and alliances and shared decision-making.

We will also use the findings of GGI’s review of involvement across the West Yorkshire Health and Care Partnership. This will help us further strengthen the citizen voice in our decision-making and ensure we are focused on outcomes when carrying out our involvement activities. We have already reflected on the feedback to consider how we can improve the way we run our citizen’s forum and are working on a process that brings together community insight from all our partners.

We know that the true test of our place-based partnership will be during the tough times, and we are expecting and preparing a few of these – that’s when we will have to demonstrate how acting as one is second to none.