Place in integrated care: the noble aim of subsidiarity

To make a success of place-based working, organisations will need a rigorously applied organising principle to avoid confusion and duplication. Subsidiarity could be the answer.

Place remains a relatively open field. Government guidance around the NHS’s move to integrated care has offered little on the subject. Even with additional information, leaders will still have plenty of room for manoeuvre in the way they shape the most local levels of ICSs. This is both an opportunity and a risk.

As we have said before, place has the potential to be the most impactful site and vehicle for influencing population health and wellbeing.

This freedom at place could allow organisations to cultivate a keen sense of belonging among staff, communicate population health responsibilities to the public and use local knowledge among various sectors and residents to shape services to specific neighbourhood needs. It will help partners to avoid a one-size-fits-all approach to NHS restructuring.

But the lack of a clearly articulated vision could lead to confusion, overlap and a failure to make the most of this fundamental shift in England’s healthcare structure.

Subsidiarity can be viewed as a way of recasting the actions performed across a system. But by looking deeper into the concept, we can see how it can provide both functional and conceptual grounding for place-makers looking to radically change the country’s approach to the provision of healthcare and provide wider social value to their communities.

Providing social value

Crucially, place-based working must not be treated as just another restructuring of healthcare, but as an approach that has real potential to bring a step-change to the public’s receipt of and relationship to public services.

This is because working with organisations outside the statutory sector is intimately linked to the needs of residents, creating one workforce sewn into the community and genuinely allowing the public to shape their local services – with the aim of affecting not just interventions, but the day-to-day lives of the public and the determinants of ill-health – represents a shift from narrow service delivery to a wider objective of providing social value.

This is indeed a necessary aim. The social, economic and health impacts of the pandemic are deep and will be felt for years to come. Local institutions will need a new approach and a new mindset if they are to overcome them.

Subsidiarity can be key

To do so, organisations will need a clarifying principle that crystalises their aims and provides a framework for roles and responsibilities at each level of a system. Here, subsidiarity – the idea that every function and decision should be undertaken at the most local level – can be key.

Subsidiarity is rooted in the Catholic moral and social principle that the greatest dignity and human flourishing comes when people and groups have the freedom to undertake actions in the way of their own choosing. This reflects the Aristotelian tradition that freedom is required for people to cooperate and create a human society working to a common good of individual or group fulfilment. Subsidiarity fosters this freedom to work towards a societal goal.

Importantly, subsidiarity is not about higher levels empowering those below. Subsidiarity dictates that local groups should have the power to organise their own work, make their own decisions and create their own structures, rather than just being assigned power by employers. This puts the onus on local teams to feedback to change working structures whenever it is needed.

Applying subsidiarity to a system presents a range of practical advantages, including:

• allowing objectives to be adapted to address local problems

• enabling feedback on actions and instructions from higher levels

• increasing access to local informal knowledge

• delivering wide-scale solutions to issues in a place eliminating the risk of widespread system failure

• providing maximum scope to local groups to solve problems in a way that suits them

• clarifying roles and responsibilities

• reducing duplication and promotes legitimacy with the local population.

Where can subsidiarity be applied?

When adopting a place-based approach, subsidiarity can be useful in numerous ways – going beyond simply providing a principle for the level at which responsibilities should be discharged.

When attempting to create a singular workforce subsidiarity can form the basis of the sense of belonging and agency as they have greater agency to craft services.

It can also be an excellent principle for public engagement, not only emphasising the involvement of community groups, but also on tailoring services to local needs. Bottom-up feedback can act as a principle for both formal and informal public engagement.

Finally, and perhaps most importantly, it provides a clear conceptual basis from which organisations can branch out beyond narrow service delivery towards the wider provision of social value to communities, at a time when it is most needed.

Illuminations

• Place presents the opportunity for organisations to look beyond the narrow delivery of care and collaborate to provide a wider social value to their communities – subsidiarity can be central to delivering this aim.

• Rigorous application of subsidiarity can be instrumental in clarifying roles and responsibilities at different levels of an ICS, reducing duplication and aiding precision in governance.

• Subsidiarity can serve as a wider principle for systems, organisations or places looking to provide wider social value beyond the limits of typical interventions or services.

GGI and Allocate Software will soon be publishing People in Place, a national report highlighting the role of subsidiarity in helping people committees meet local skills and people challenges.

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