A place for everyone

Place is a common buzzword in discussions about integrated care – but what does it really mean and how do we use it to improve public services?

The notion of place as a construct in which to deliver services has become particularly prevalent in the discussions around integrated care.

Often synonymous with the principle of subsidiarity, this emphasis on place is based on an eagerness to deliver services and take decisions as close to the population as possible. The idea is to ensure that the public sector services of the future are tailored and can most effectively address inequalities at the most local level.

At a recent National Commission summit on the topic, we delved into some of the practical issues standing in the way of creating the right conditions for place-based governance. A stimulus paper for the event can be found here.

Place in the pandemic

There are some good examples of how such devolution – particularly in the NHS – has worked to wonderful effect. During the pandemic, the parts of the NHS that worked best were those that have been devolved. Compare how well the vaccination programme has worked, based on a local delivery model, compared to the centrally coordinated Test and Trace programme, for example.

For all the promise of place, however, there remains a lack of belief in the narrative behind it and questions about whether it can live up to expectations. A number of challenges emerged from the summit and our research, which impede its successful development.

In its current form, place is little more than a conceptual aim with lots of muddled ideologies and ambitions for what it is and how it should be constructed.

Top-down approach and governance

There appears to be a clear disconnect between what is decided at the top, in central government, and what is achievable on the ground. This is sometimes call place-blind initiative.

The decisions made at the top may seem clear, precise and achievable, but it is an entirely different picture at the local level. This can be due to the complexity of the arrangement, the lack of funding or simply a lack of understanding and grassroots knowledge at the top of how place works or what is happening on the ground.

It is important for central government to change its narrative around place and to begin adapting its high-level conversation to those being had at a more local level. If ideas and structures are developed by taking into account what is implementable at local level, then those structures can be developed far more quickly and efficiently.

One of the emerging issues is a lack of a general understanding and ambition around governance. While governance can be a massive enabler to the successful construction of place, the fact that there is not one clearly articulated notion and definition of governance can provide the first barrier.

At the National Commission summit, one guest made the point that a person’s ideology around governance is determined by where they have spent most of their career – whether in central or local government, or across other sectors. If thoughts are conflicted from the outset, then we face an uphill battle before conversations have even started.

Power of the community

If we are to take anything positive out of the COVID-19 pandemic, it must be the incredible tenacity and power we have seen emanating from our communities. They have rallied together like nothing we have seen since the Second World War.

Including the community and adopting an approach more focused on population health can mean bringing more than just the standard players into caring for the population. It’s about casting a wider net to bring in community assets such as parks and using the people as an asset themselves. Community knowledge may currently be the most under-utilised resource in delivering care.

One area where this has been done well is Wigan. Here there was an agreement between local leaders to develop an approach in which people were provided with investments in their communities in return for a promise to take advantage of the development. As more exercise areas were developed, for instance, the local population then agreed to use them more to benefit their own health.

A community-based asset approach will not see results overnight, but it is an effective way of delivering better outcomes for any population and is one way of using the community to the betterment of society. Such an approach would be very difficult to take at a national level – a blanket rule could not hope to cover all the local variations across the country. Using the power of communities is key in developing resilient place.

Part of the challenge of good governance around place is about being very clear when bringing people together and ensuring there is clarity of purpose. There are many mechanisms for this, although finding the right one can be difficult as there are an infinite number of voices to be heard. More information can be found on citizen engagement here.

Illuminations:

• We must agree a national and cross-sector definition of what place is for it to ever become what we want it to be.

• Organisations need to give up their power for the greater good for place to take shape and have the desired impact.

• There should be agreement across the public sector specifically on what governance is and what it means.

If you have any questions or comments about this briefing, please call us on 07732 681120 or email advice@good-governance.org.uk.