A cure for everything and nothing? Local partnerships for improving health in England

25 years of partnerships

Numerous national policies have promoted collaboration between NHS, local government, and other agencies to improve health and care over the past 25 years (table 1). These policies have varied in aims and approach, from more narrowly defined initiatives to coordinate local services for older people and people with complex needs, to broader programmes targeting improvements in social and economic factors shaping population health and inequalities.

Some partnerships were mandated by policy makers (such as health and wellbeing boards, established across the whole country in 2012), while others were voluntary initiatives (such as integrated care pilots, in place between 2009 and 2011 in 16 areas). Local agencies have typically been required to work together to develop a strategy for improving health and quality of services in their area—and sometimes have been provided with extra funding to help do so. Some programmes involved stronger national direction over the content of local initiatives than others. For instance, recent “vanguards” of new care models received national funding and support to develop three broad models of health and social service integration, including collaboration between general practices, hospitals, social care, and wider community services.11

Area based partnerships proliferated from 1997 under New Labour governments—including health action zones, Sure Start local programmes, and local strategic partnerships. These policies were combined with a national strategy to reduce health inequalities in England and major public investment in the NHS and social programmes.121314 Policies to encourage local partnerships continued under coalition and Conservative governments—including a series of initiatives to better coordinate NHS and social care services, such as the Better Care Fund—but explicit aims to reduce health inequalities appeared less prominently. Partnerships since 2010 were implemented in the context of austerity in public spending,15 and national policy makers often prioritised objectives of improving efficiency and reducing use of hospitals and other services.16

The new integrated care systems (fig 1) mix elements of these previous partnership policies, combining a narrower focus on coordinating health services for patients with broader ambitions to address social and economic determinants of health for populations. The result is a broad and ambitious list of objectives for the partnerships, including to improve population health, improve healthcare services, reduce inequalities in health and healthcare, improve productivity and value for money, and support broader social and economic development.1 Collaboration between agencies and integration of services are seen as mechanisms to do this.

Fig 1

Organisation of health and care partnerships in England’s integrated care systems. Each integrated care system will be made up of two bodies: integrated care boards, responsible for controlling most healthcare resources in their area, and broader integrated care partnerships, responsible for developing an integrated care strategy to guide local decisions

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Integrated care systems have existed informally since 2016—developed in response to the fragmentation of the English NHS and as part of a broader shift in policy away from provider competition as the route to improve services.31718 In these early partnerships, NHS engagement with local government and other community partners varied widely, with local government not always treated as an equal partner.19 Patient and public involvement was often lacking,19 and few local plans described interventions linked to social and economic determinants of health.2021Integrated care systems will be expected to produce new five year plans in 2023, setting out how they will deliver the ambitious objectives given to them by national policy makers.22

Evidence on local partnerships is limited

Despite this long history, evidence that local health partnerships deliver the kind of benefits that policy makers typically expect is lacking. Overall, there is little high quality evidence to suggest that collaboration between healthcare and other agencies improves population health.8910 For example, a recent umbrella review found most studies assessing the effect of collaboration between healthcare and non-healthcare agencies on health outcomes such as quality of life or health equity found no, mixed, or limited evidence of benefit.¹⁰

Evidence of impact on health services is also mixed—though some studies suggest closer integration between health and social care can improve access to care and patient experience.1023 There is little difference in effects reported between UK and international studies.1023

This does not mean collaboration is a bad policy. In theory, collaboration could help local agencies combine skills and resources,242526 manage interdependencies and share risks,2728 and—ultimately—tackle complex health problems that cannot be dealt with by a single organisation.293031 Most major health challenges facing society fall into this category—and tackling them depends on policy action beyond the reach of healthcare systems.32 Collaboration may also help improve efficiency by reducing transaction costs—for example, by making it easier to share information and develop processes between agencies.333435

But making collaboration work in practice is challenging, influenced by power, resources, governance issues, policy context, and more.10 Lack of trust between NHS and care home staff, for example, can hold back joint working.36 Evaluating the effects of collaboration is also conceptually and methodologically tricky.3738 As a result, the benefits of collaboration may be overstated, hard to deliver, and hard to measure—or some combination of the three.

Although evidence on the effects of collaboration is thin, a mix of studies identify factors influencing how local partnerships function—for better or worse.10 These factors can be grouped into five overlapping domains related to motivation and purpose, relationships and cultures, resources and capabilities, governance and leadership, and external factors (box 1).10 Data linking factors in these domains to collaboration outcomes are limited, but some factors are likely to have a more powerful influence than others. For example, good communication between local agencies may help coordinate complex interventions. But broader political decisions about the level and distribution of funding for the NHS, local government, and other social services will fundamentally shape local resources available for improving health and reducing inequalities. For example, closer integration between health and social care services is little good without adequate funding or staff to deliver them.

National policy choices shape local partnerships

Current policy in England emphasises the role of local agencies and “places” in improving population health.13940 But the role of national policy and political choices is often underplayed,41 particularly in a highly centralised state like the UK, where many powerful levers for improving health lie at a national level. For example, most public spending, including social security, is managed by central government,42 and recent reforms to social security may have contributed to increased psychological distress among unemployed people in England.4344 Local partnerships are strongly shaped by national policy choices and must be understood within the broader political and economic context in which they are developed.

Comparing partnership policies in England between two decades—the 2000s and 2010s—helps illustrate the point. A mix of local partnerships were developed in England in the 2000s (table 1). These partnerships were part of a broader national strategy introduced by central government to reduce health inequalities by supporting families, engaging communities, tackling poverty, improving access to services, and action on underlying social and economic factors—backed by major increases in investment in the NHS and other public services.121314 National policy on NHS resource allocation also increased the share of healthcare funding in more deprived areas. Evaluations of the area based partnerships implemented during this period found little evidence that they achieved their objectives45 and identified various implementation issues.46 But more recent evidence suggests the broader collection of policies may have contributed to modest reductions in health inequalities over time.47484950

Local partnerships continued through the 2010s, but the national policy context shifted. Compared with historical spending increases of around 3% a year, government spending grew at 0.3% a year in real terms between 2009-10 and 2019-20.51 Spending on public services fell by 7.8% in real terms. Healthcare was relatively protected (though NHS spending in England still grew at less than half the long run average).52 But other services, such as housing and local government services, faced major cuts. As a result, the capacity of local government to improve health shrank substantially. Public health budgets, for instance, fell by a quarter per person from 2015 to 2020, with funding falling furthest in more deprived areas.535455 And central government lacked an overarching national strategy to tackle widening health inequalities.56 Local partnerships faced challenges trying to improve health with dwindling resources57 and struggled to deliver narrower objectives to reduce unplanned hospital use. 58

Lessons for England’s new partnerships

The allure of cross-sector collaboration is long standing and understandable. But evidence suggests that policy makers should not expect too much from the new integrated care systems in England. Local agencies can learn from the various factors that have helped or hindered past collaboration efforts—such as the role of trust, communication, and clear decision making processes between agencies—to provide the best chance for success.

They can also learn from the mistakes of earlier versions of integrated care systems in England, including limited involvement of local government and other community partners in NHS planning processes, and “lifestyle drift” in strategies for improving population health. 2021 The covid-19 pandemic appears to have enhanced joint working in some parts of the country, but the strength of collaboration varies widely, and weak involvement of social care and others beyond the NHS persists.59

But while there are lessons for local leaders, the effect of local partnerships will ultimately be shaped by national policy choices beyond their control. And these currently fall short. Government has set ambitious targets for reducing health inequalities in England but has so far failed to deliver the policy changes or investment needed to achieve them.606162 NHS spending is planned to grow by around 3.5% a year to 2024-25, close to the historical average. But spending on social care is barely enough to keep up with demand, public health funding is flat, and local government spending is on track to be smaller in 2024-25 than in 2010.6364 There is also a risk that the most visible national pressures—such as the six and a half million people waiting for elective care65—dominate policy priorities. Without sufficient funding or a clear national strategy for reducing health inequalities, integrated care systems risk being set up to fail by national policy makers. The government’s forthcoming “health disparities” white paper—expected later in 2022—has a lot of ground to make up.