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Place-based systems of care A way forward for the NHS in England

The NHS is facing growing pressures, with finances deteriorating rapidly and patient care likely to suffer as a consequence. It is also developing new care models designed to deliver services more appropriate to the changing needs of the population. The NHS is seeking to tackle these challenges in the context of organisational arrangements that are more complex and fragmented than at any time in its history. The question is how to adapt these arrangements and make them fit for purpose while avoiding another damaging reorganisation.

This paper argues that providers of services should establish place-based ‘systems of care’ in which they work together to improve health and care for the populations they serve. This means organisations collaborating to manage the common resources available to them.

The approach taken to developing systems of care should be determined by NHS organisations and their partners, based on a set of design principles that we outline in this paper. These principles include developing an appropriate governance structure, putting system leadership in place and developing a sustainable financial model. Government and national bodies in the NHS should work to remove the barriers that get in the way of working in place-based systems of care and should themselves work in a co-ordinated way to support the development of these systems. This includes creating stronger incentives for systems of care to evolve to tackle current and future challenges.

Fundamental changes to the role of commissioners are needed to support the emergence of systems of care. Commissioning in future needs to be both strategic and integrated, based on long-term contracts tied to the delivery of defined outcomes. Scarce commissioning expertise needs to be brought together in footprints much bigger than those typically covered by clinical commissioning groups (CCGs), while retaining the local knowledge and clinical understanding of general practitioners (GPs).

Systems of care hold out the prospect of NHS organisations developing services that are financially and clinically sustainable and putting in place new care models
that are able to improve the health and wellbeing of the populations they serve. The alternative is for each NHS organisation to adopt a ‘fortress mentality’ in which it acts to secure its own future regardless of the impact on others.

The argument of this paper is that collaboration through place-based systems of care offers the best opportunity for NHS organisations to tackle the growing challenges that they are faced with. It will, however, require organisational leaders to surrender some of their autonomy in pursuit of the greater good of the populations they collectively serve, and national leaders to act urgently to enable systems of care to evolve rapidly.