This guide has been produced by the Local Government Association (LGA) and NHS Clinical Commissioners (NHSCC) to provide key prompts and actions for local leaders to promote strong localised decision making across health and local government.
We have long advocated the benefit of taking decisions as close to the communities they impact as possible, such as through our shared vision for health and care integration – ‘Shifting the centre of gravity’.
The events of 2020 have highlighted the need further, both in requiring health and care partnerships, to respond in unison and at pace to the COVID-19 pandemic, as well as ongoing implementation of the ambitions in the NHS Long Term Plan around primary care networks (PCNs), place-based partnerships and the ongoing establishment of integrated care systems (ICSs).
Subsidiarity and the response to COVID-19
During COVID-19 response, what worked well is local place-based planning and delivery, when it was allowed to flourish.”
Health and care partnership director
The relationships we have built up have paid dividends during COVID. We’ve worked together for our residents.”
Leader of a county council
In our ‘Six principles to achieve integrated care’, the LGA, NHSCC and partners brought focus to subsidiarity. The six shared principles have been well received by health and care leaders, who have found them helpful in testing whether their own partnerships are underpinned by the right principles and values. In developing this guide, we are responding to local authority and clinical commissioning group (CCG) leaders who have asked for practical guidance to put the principle of subsidiarity into action in their areas.
Subsidiarity − Subsidiarity − system leaders are committed to making decisions at the most local level, as close as possible to the communities that they affect. Accountability mechanisms for new health and care partnerships will build on existing structures, including health and wellbeing boards and local authorities, clinical commissioning groups and provider organisations. New governance structures are open, transparent and locally accountable. From ‘Six principles to achieve integrated care’
The principle of subsidiarity is important because it ensures:
- there is clarity about which decisions are best made at a local level in order to respond to the needs of individuals and communities, and which decisions are best made at a more strategic level to achieve economies of scale
- local communities are involved in making decisions about services that affect them
- decisions are made once, are empowering, accountable and transparent.
Where this is working well: learning from local systems
This section summarises lessons and insights from local systems, interviews and a roundtable of system leaders. It includes short examples of how decision making has worked in practice at neighbourhood, place and system level.
Relationships, purpose and priorities
- Trust is an essential ingredient for building effective relationships, ensuring decision making power can be effectively shared and ceded, and making sure rules or organisational structures do not get in the way
- Relationships are also key for keeping the focus on place rather than individual organisations and are crucial for overcoming the differences in statutory frameworks and accountability between the NHS and local government.
- A shared purpose can come from having a few shared objectives that matter to citizens, rather than a geographical footprint; where geography is the glue, this footprint has to make sense to citizens.
- Leaders at all levels have to shape and own the changes; this cannot be imposed
- a shared language of what ‘place’ and ‘neighbourhood’ mean is essential to building relationships and shared ways of working.
- Local politicians and clinical leaders can be a huge supporter and driver of place-based change when engaged at an early stage.
Integration proceeds at the speed of the trust we have in each other and trust cannot be shortcut.” - Strategy and system development lead
Subsidiarity is not about devolving power – it is about agreeing where power and decision making should reside to be most effective and achieve the best outcomes.
Accountability, governance and delivery
- Do not fixate on footprint sizes or whether a service is specialist or locally based – in mental health for example, clinical services may operate sub-regionally, while improving wellbeing and social connection is best delivered at a neighbourhood level. There is not a national template for this, and each area will need to decide according to local system architecture.
- Think local first – neighbourhood and place are the footprint at which most health and care are delivered.
- Use governance structures to enable change – focusing too much on governance undermines the drive for transformation and turns the endeavour into a management exercise rather than a way of achieving real change for people and communities.
- Joint appointments or other shared arrangements can work well if the system is clear about their purpose, but they cannot fix broken relationships or force integration.
Focus on characteristics of the model of shared vision and values and not the organisational form or contract.” – CCG chief officer
Decision-making in practice
The examples given below show the principle of subsidiarity in practice at the neighbourhood, place and system level. They demonstrate that while some decisions are best made at a local level, in order to respond to individual needs and involve communities in the planning of services and decisions which affect them, others are better addressed at a more strategic level, to work at scale and resolve complex, system-wide problems.
- In Sefton, technology is being used to link individual care homes virtually to community health and general practitioners (GPs), including allocating PCN leads to each care home to provide weekly check-ins, personalised plans and medications support.
- Staffordshire and Stoke-on-Trent PCNs worked collaboratively with community providers and local authorities to develop and implement multi-disciplinary team meetings for care home residents as part of the national Directed Enhanced Service contract.
- Social prescribing has been used across Somerset to address the social, emotional and practical needs of people with long-term health needs at the community level. Community connectors link people to information, peer support groups, voluntary and community groups, and social networks where they live to help improve their health and wellbeing. The Compassionate Frome Project, established by a Frome GP practice, uses health connectors who act as a bridge between the individual’s medical and social needs and community connectors to link people with support including help with housing and debt problems, as well as choirs, exercise classes and lunch clubs.
- Birmingham’s Neighbourhood Networks Scheme aims to connect people to local activities and services on a neighbourhood footprint, based on Birmingham’s constituencies and wards. The scheme helps over 50s to access community-based support which can promote wellbeing and a better quality of life through community-based prevention and early intervention services.
- Across Manchester city, 12 integrated neighbourhood teams (INTs) were created to deliver more integrated health and social care on a neighbourhood footprint for people with complex health and social care needs. INTs work closely with the city council, local housing associations, police and voluntary and community organisations to support people on a wider range of issues which also impact health and wellbeing, such as debt, social isolation and physical inactivity. The Manchester Local Care Organisation aims to co-locate health and social care staff across the INTs in integrated neighbourhood hubs to enable them to work collaboratively around the needs of local people.
- In Hackney and the City of London, local authority, hospital trust and CCG colleagues worked closely together to transform out of hospital care, including creating a joint health and care Integrated Independence Team. This work has been underpinned by integrated commissioning arrangements, integrated governance, strong involvement of councillors and a clear transformation programme agreed by all partners.
- In Bradford, local commissioners and providers from all sectors have signed a strategic partnering agreement which sets out the framework for roles, responsibilities, leadership and decision making in the integrated care partnership. Decisions are devolved as close as possible to where support takes place, and Bradford utilises 13 community partnerships made up of primary care, social care, the voluntary and community sector and local communities.
- Plymouth’s health and wellbeing board has overseen the establishment of integrated commissioning and provision across the city. Joint commissioners are co-located and work under a Director of Integrated Commissioning, with an integrated fund, and risk and benefit sharing arrangements. Most adult social care services have been transferred to Livewell South West, an integrated community health and care provider with a single point of access, locality-based services and improved secondary care discharge pathways.
- Nottinghamshire uses place-based groups involving county and district councils, the NHS, the voluntary and community sector and local people to support its ambition to achieve ‘healthy and sustainable places’ as part of its joint health and wellbeing strategy. The work is coordinated through a Healthy and Sustainable Places Coordination Group which reports to the health and wellbeing board and serves as a conduit between the board and local communities. Examples include place-based food initiatives, insight work into the barriers to physical activity, health in strategic planning and community resilience.
- The Buckinghamshire, Oxfordshire and Berkshire West ICS workforce group was set up primarily to support providers and help to facilitate staffing levels across the whole care system, including care homes, using a memorandum of understanding to facilitate the relationship between partners.
- West Yorkshire and Harrogate Health and Care Partnership comes together at the West Yorkshire and Harrogate level only when it makes sense to do so and regulates its working relationships using a memorandum of understanding. The partnership works locally unless an issue passes one of its three subsidiarity tests: working at scale is necessary to achieve a critical mass to get the best outcomes; where variation in outcomes is unacceptably high and working together will help to reduce variation and share best practices; or where working at scale offers opportunities to solve complex, intractable problems.
- Dorset ICS developed the Dorset Care Record, a single, confidential system allowing health and care professionals across the county to see the same information. Joining information in this way means that people no longer need to repeat their story to different teams and ensures a more comprehensive and up-to-date understanding of their whole needs, helping to deliver a better standard of care.
- The East London Midwifery Recruitment and Retention Programme has been used to tackle previously high vacancy rates for midwives across the system. The programme uses a careers ‘passport’ to allow midwives to gain managerial and clinical skills across a range of services and enables them to work across different settings and trusts across North East London. The success of the programme is reflected in low vacancy rates across all units.
We wouldn’t have achieved this if individual places led on this.”“Doing it at scale makes a difference.” - Comments on the implementation of the East London Midwifery Recruitment and Retention Programme
How to ensure decisions are made at the most appropriate level
The questions below encapsulate the learning and experience of local systems for leaders to ask of themselves and their partners to help develop effective decision making.
We do not offer a national template on the level at which decisions are made regarding different services, functions and strategies. Decision making will look different depending on your relationships, priorities, partners and footprints.
These questions prompt consideration of the key themes which have been universal in our discussions with leaders across the NHS, local government and their partners from all parts of the country. You can use these questions to reflect on how decision making is working locally and where partners may want to direct their efforts or make improvements.
- To what extent are your decisions taken once, transparently and publicly, involving communities and focused on the key issues that matter to them?
- To what extent do your decision-making structures enable the voices of those with lived experience of services, frontline staff, people from marginalised communities and organisations outside of health and social care to inform an understanding of key issues and population needs?
- Do you agree as partners which decisions and funding sit at the neighbourhood, place and system level? Is there a clear rationale for making decisions at system level rather than more locally (eg to solve cross-system issues or benefit from economies of scale)?
- To what extent are shared health and wellbeing outcomes the starting point for determining your governance, form and structure? Or is it your governance structure that determines your priorities?
- Are you actively building coalitions of partners to work towards shared outcomes? Have you reached a shared understanding of the organisations involved and the level at which decisions are taken?
- Do you actively create space and time to build relationships outside of formal meetings? What value do you collectively place on fostering strong relationships between organisations at all levels, and between communities and organisations?
- To what extent do your decision-making arrangements enable trust to be exchanged mutually up and down lines of authority? Staff implementing policy should be given the infrastructure, permission and support to work locally and flexibly.
- Have you devolved funding to the level at which decisions are taken, and removed unnecessary senior signoffs? If not, what are the barriers to doing so? Are you working actively to remove these barriers?
- Are all partners aware of the differences in budgets, governance and accountability across organisations? Do your decision making structures take account of these differences to avoid slowing decisions or damaging relationships?
- Do you share data among partners to build a shared understanding of key issues and population needs? If not, what are the barriers to doing so and are you taking urgent steps to remove them?
We ensure effective public involvement especially [of] minority groups who are rarely engaged. We live stream all our boards and meet in public too and we invite local bodies to participate in all our local initiatives.” - ICS communication and engagement lead.
LGA and NHSCC
The LGA and NHSCC are committed to promoting localised decision making and ensuring that local systems have the flexibility and power to make the decisions that are right for them.
The LGA Care and Health Improvement Programme team can support local systems with their ambitions around localised decision making and to implement the principles outlined in this guide.
This support will be tailored to local needs and could include:
- facilitated gap analysis/self-assessment work to reflect on decision making, identify gaps and opportunities, and agree next steps
- design and implementation support to develop or embed practices, services or behaviours
- support to identify local priorities and where decisions need to be made to have the greatest impact on local people
- support to set up joint appointments, commissioning or funding arrangements
- access to good/new practice as it emerges and tools to assist in implementation
- expert peer mentoring for local leaders.
You can read more about the Integration support offer and Better Care Fund bespoke support programme offer on the LGA website, or contact your Care and Health Improvement Adviser for more information or to discuss support.
NHSCC regularly works with the LGA’s Care and Health Improvement Programme team to design and deliver bespoke workshops and peer review support to embed and share good joint working between local authority and NHS commissioners. NHSCC supports opportunities for cross learning between CCG and elected members, such as through the annual Health and Wellbeing Board event, and hosts a number of member networks specifically for CCGs to support learning and provide webinars on current issues. For more information visit the NHSCC website.
National action to localise decision-making in health and wellbeing
There is much that leaders at neighbourhood, place and system level can do to make sure that decisions are taken as close as possible to the communities that are affected by them.
As well as supporting health and care leaders to be effective and inclusive decision-makers through our joint improvement and development programme, we also work together at national level to influence the policy framework for health and wellbeing.
- Build on what exists – as NHS architecture evolves, policy makers must ensure that the reforms build on the good relationships that have been built between CCGs and councils at place level and the strength of local leadership by bringing together elected members alongside clinical leaders.
- A mature approach to oversight and assurance will empower local areas to have the headspace they need to prioritise local delivery, population need, collaborate and learn collectively.
- Flexibility and a permissive approach will be critical for supporting systems to collaborate and embed a principle of ‘local first’ when health and social care services are planned for populations.
- Embed a parity of esteem between the different sectors of the NHS and between NHS and local government. Reflect this in the governance and decision-making structures of new NHS bodies such as ICSs and PCNs and in reviewing existing governance, for example health and wellbeing boards.
- Establish shared objectives between the NHS and local government, to foster joined up working ie, explore shared duties to address health inequalities.
Government and national partners should see their role in the centre as unlocking leadership solutions locally and not provide prescribed direction for local areas.” - Strategy and system development lead