By Charlotte Burnett, Alistair Robertson, Anne-Marie Gregory, Hamza Drabu & Sarah Foster


Published 30 September 2021


The Health and Care Bill 2021 (“Bill”) is first and foremost concerned with legislating for changes that will better enable delivery of the NHS Long Term Plan (“LTP”). At its heart, the LTP proposed:

“A new service model in which patients get more options, better support, and properly joined-up care at the right time in the optimal care setting”

In the vast majority of cases this will be in a patient’s local community. Accordingly, arrangements at place level within an ICS will be vital to achieving the transformational change that is envisaged by the LTP. 

Place-based partnerships should build on existing arrangements given that this is where the greatest progress has been made over the last few years. Local health and care leaders will therefore want to avoid shoe-horning current productive relationships into new structures that may jeopardise achievements to date.

There is also the conundrum of whether places within an ICS should be able to adopt differing governance arrangements. Adopting different arrangements could result in:

  • Overly complex arrangements
  • Disparities in administrative burden and overheads between places
  • Different representation from stakeholders

Clearly it is a tall order for emerging ICBs to meet all the demands that have been placed on them between now and April 2022. However, skimping on time spent building consensus about place-based partnerships will be a false economy, significantly impacting the ICS’s ability to operate in the long run.

NHS England and the Local Government Association’s recent guidance Thriving places sets out a number of expectations for place-based partnerships:

  • A strong steer in favour of places within an ICS mirroring Local Authority boundaries
  • Broad-based membership of place-based partnerships, going beyond primary care, NHS bodies and Local Authorities to include representatives of the public, social care providers and the VCSE sector along with a wider range of “community partners” (discussed in our article here).
  • Requiring places to manage delivery of funding commitment - e.g. the Mental Health Investment Standard

Local leaders will have to take into account the expectations and reconcile them with facts on the ground.

Local Authority alignment would seem to offer the most stable model for place in the medium to long term, for a range of reasons, including:

  • Existing Health and Wellbeing Boards could be expanded to offer seats to the broader range of stakeholders who will not be directly involved with decisions at place
  • The place-based arrangement could be closely aligned with s.75 partnership arrangements with the Local Authority
  • The Bill makes provision for future changes to responsible commissioner rules, aligning these with the usual residence rules which determine eligibility for Local Authority services

The process of establishing the ICB will need to take into account the emphasis on subsidiarity - that strategies should be developed and decisions made as close to local communities as possible except where arrangements at scale deliver demonstrable benefits. This could be interpreted as giving places significant influence over new ICB joint forward plans and such expectations will need to be addressed. System leaders need to invest in relationships with stakeholders at place, giving them assurance that their voice will be heard. 

The Bill requires that ICB constitutions should specify the arrangements for the discharge of their functions, which on our reading must necessarily include a description of arrangements at place which addresses many if not all of the points we have raised above. On current timescales, draft ICB constitutions must be submitted to NHS England in December 2021. 

How we can help:

  • Assisting with drafting ICB constitutions
  • Supporting workshops on developing place-based arrangements
  • Support with the contractual arrangements for place-based partnerships
  • Supporting the design of interfaces between different parts of the ICS
  • Assisting in the development of provider collaboratives