Foreword

This document has been developed with national stakeholders, and partners from places within integrated care systems (ICSs) to support the development of shared outcomes at place level.

It is a toolkit designed to share experience and insights across the health and care system so that places can develop an approach to shared outcomes that builds on what others have done while also customising and adapting for local circumstances.

Purpose and background

Purpose

‘Places’ are geographic areas that are defined locally, but often cover around 250,000 to 500,000 people, for example at borough or county level. Place level is the engine for delivery and reform.

Organisations collaborating at place may include local government, NHS bodies, voluntary and community sector organisations, social care providers and others. There is wide agreement that collaboration and innovation at place is vital to delivering more efficient and joined-up services and supporting the success of ICSs as a whole.

Shared outcomes have proved to be a powerful means of bringing organisations together across the health and social care system to deliver on a common purpose. Where outcomes are agreed at place, they can enable organisations to address the needs of their local populations with a focus on health improvement – while also reinforcing shared efforts to meet national outcomes and requirements.

We have found shared outcomes to be a powerful tool for both understanding and focussing on the particular needs of our population, and forging common purpose across our partner organisations. The process of working together to develop shared outcomes has been a critical part of building relationships that underpin our successful ‘place partnership’.

Matthew Kershaw, Chief Executive of Croydon Health Services NHS Trust, and Place Based Leader for Health.

This toolkit seeks to support places within ICSs in the development of their own local shared outcomes frameworks and includes case studies of good practice, suggestions for overcoming challenges and example frameworks to help guide the development of locally-driven shared outcomes. This document also sets the context for shared outcomes within existing national oversight and outcomes frameworks and suggests models of delivery for places to consider.

Background

In recent years, and particularly during the pandemic, we have seen the power of collaborative working. By pooling resources, ideas and energy, health and care organisations have explored different ways of working together to deliver services and provide for their populations.

Collaborative working supports people to live healthier, more independent lives and is why we introduced the Health and Care Act 2022, and published our integration white paper (Health and social care integration: joining up care for people, places and populations, to put in place a legal framework and policy direction to support systems to deliver the ambition of integrated services.

Shared outcomes are a powerful mechanism for making integrated services a reality. Since the publication of ‘Health and social care integration: joining up care for people, places and populations’ we have heard about the journeys many places have undertaken to develop their own shared outcomes, and the value this has had. Population health outcomes are medium- to long-term outcomes, and although in many cases it is too early to identify the direct impact of shared outcomes on population health, we have heard anecdotally encouraging examples of their impact in promoting cultural change, mutual accountability, shared understanding and collaborative working.

We know that these outcomes are most likely to be effective when they are set at a local level, reflecting the needs of local populations and providing the opportunity for local partners to harness local energy and resources. While there is value in planning and decision-making at a broader system level, places act as the foundation of system-level thinking and are a significant driver for improving population health and tackling inequalities.

This toolkit is designed for use with place level in mind. Although place governance and accountability arrangements vary locally, this toolkit aims to be helpful regardless of the nature of local arrangements. In addition, we recognise that neighbourhoods (with populations of around 30,000 to 50,000), multi-disciplinary neighbourhood teams and primary care networks are integral to places delivering improved outcomes for their populations, and therefore delivery plans for shared outcomes frameworks and the associated metrics should be developed in collaboration with neighbourhoods.

How local outcomes can support national and system level priorities

The Health and Care Act 2022 marked an important step in the government’s ambitious health and care agenda, setting up systems and structures to support health and adult social care organisations to work together. It is enabling, permissive and flexible and aims to empower local health and care systems to deliver for their communities, including through developing shared outcomes to reflect their populations needs.

Shared outcomes and local priorities sit alongside the delivery of national priorities, which for the NHS have been set out in a focused form in the recent mandate to NHS England and in NHS planning guidance.

Aligning national and local shared priorities

Locally-driven shared priorities that complement national priorities will support the delivery of the 4 purposes of ICSs:

1. Improve outcomes in population health and healthcare.
2. Tackle inequalities in outcomes, experience and access.
3. Enhance productivity and value for money.
4. Help the NHS support broader social and economic development.

Priorities are driven by organisations’ statutory responsibilities. For example, in the NHS, priorities are set out in the NHS Long Term Plan and the government’s mandate to NHS England. At place, the health and wellbeing boards are responsible for setting out place-based priorities, and have statutory responsibilities to assess the health and care needs of their local populations through a joint strategic needs assessment (JSNA) and produce a joint local health and wellbeing strategy (JLHWS) for how they will meet those needs. The health and care system also has several different but overlapping national outcomes frameworks such as the NHS outcomes framework, adult social care outcomes framework, and the public health outcomes framework.

Healthcare systems around the world (and other parts of the public sector) have for some time recognised the benefits of a stronger focus on outcomes in planning, service management and the identification of opportunities for improvement. While we will always need to consider and measure both inputs and outputs to some degree, a focus on outcomes is likely to bring us closer to an understanding both of what matters to people, and what works. Where outcomes are formulated in a person or population centred way they also help to forge partnerships by encouraging partners in different sectors to consider what their contribution to the shared outcome could be as part of a wider effort.

One of the most powerful messages from places that are making good progress in the development of shared outcomes is that a joined-up approach across integrated care boards (ICBs), integrated care providers (ICPs) and place based partnerships supports the delivery of both national and local shared priorities, and ensures cohesiveness across the various strategies and oversight frameworks throughout system and place level. For example, place partnerships should consider the integrated care strategies and joint forward plans of the ICP and ICB respectively when setting shared outcomes, while ICPs and ICBs should also have regard to the priorities local leaders are setting at place via the work of the health and wellbeing boards and shared outcomes.

Plans and strategies at system and place levels should reflect outcomes and priorities set out in national frameworks such as the NHS Mandate, the NHS Oversight Framework, the Adult Social Care Outcomes Framework, the Better Care Fund Framework, the Public Health Outcomes Framework and the Care Quality Commission Single Assessment Framework. System-level plans and strategies, including the Joint Forward Plan developed by the ICB and the integrated care strategy developed by the ICP, should complement place-level plans such as place-level shared outcomes and the joint local health and wellbeing strategy developed by the health and wellbeing board.

The focus on outcomes has been reflected in the Health and Social Care Select Committee’s report into ICSs, and the Hewitt Review report. These reports highlighted the importance of locally set shared outcomes with both recommending that DHSC publish the shared outcomes toolkit as soon as possible. Additionally, the Hewitt Review specifically recommended a significant reduction in the priorities set in the new mandate to the NHS.

Just as the government has provided the NHS with a more focused set of priorities in the mandate published in 2023, through this toolkit we are supporting places and systems to develop local outcomes and priorities that are as impactful as possible for local people. Government recognises that national and local priorities play an important role in delivering the 4 purposes of ICSs and we expect ICSs, places and organisations to ensure they are delivered in a complementary way. As places progress with their shared outcomes frameworks, we will consider how the balance between nationally mandated and locally-driven priorities is working in practice. As our understanding develops, we will review emerging commonalities in place shared outcomes that may inform the development of national shared outcomes.

Models of delivery

Shared outcomes support joined-up delivery between partner organisations at place level (and other levels where appropriate) and complement existing national oversight and outcomes frameworks. We have seen 2 predominant models for developing and governing shared outcomes: using the health and wellbeing board, and place partnerships. We expect further models to emerge, with places choosing a model most suited to their needs and local circumstances.

Using the health and wellbeing board to agree place shared outcomes

The Health and Social Care Act 2012 introduced duties and powers for health and wellbeing boards to agree and publish JSNAs and JLHWSs. These statutory duties have not changed following the introduction of the Health and Care Act 2022. In some systems, the place and health and wellbeing boards are coterminous, and place based partnerships may wish to use the JLHWS as their primary mechanism for delivering shared outcomes. The benefit in this approach for these places is clear in that the function of shared outcomes may already be served through the health and wellbeing board’s (HWB) work and need not be duplicated. The JSNA assesses the needs of the local population and the HWB has a duty to show how they will meet those needs through specifying outcomes in the JLHWS. These documents already bring together partner organisations working at place level, and the place partnership may be satisfied that this strategy meets the aims and intentions of shared outcomes as set out in the integration white paper and in this document.

Place based partnerships – setting shared outcomes

Other places have utilised place-based partnerships to develop shared outcomes, perhaps using the JSNA and the JLHWS as a foundation. One benefit of this approach is that the place partnership can then consider additional local strategies that may be relevant for their populations when agreeing the outcomes. For example, Solihull have set out in their shared outcomes framework (PDF, 497KB) the local strategies that have fed into the development of its framework, including their dementia strategy, mental health strategy, the recovery plan, JLHWS, as well as strategies that affect wider social determinants of health such as the Solihull Council plan, their cycling and walking infrastructure plan, road safety strategy and so on.

This approach could also benefit places that have geographical challenges where more than one health and wellbeing board and therefore more than one JSNA and JLHWS falls within its footprint. In this scenario an additional framework for developing and delivering shared outcomes adds benefit in bringing those various assessed needs from the respective HWBs, in addition to other place strategies, into one overarching set of shared outcomes.

Principles

The following principles are common among systems that are making good progress in the development of shared outcomes, regardless of which delivery model the place partnership decides is the most appropriate for their local area.

Principles of a shared outcomes framework:

1. Focused on the population at place level (or other system levels where appropriate).
2. Creates a shared vision and brings organisations together.
3. Supports relationships and cultural change.
4. Minimises burden to organisations within the place.
5. Focused on local outcomes, not organisational processes or outputs.
6. Complements existing responsibilities and regulatory frameworks.
7. Embeds organisational mutual accountability for delivery and progress.

Implementation

The development of shared outcomes is an iterative process comprised of several stages. Time is needed to develop each stage rather than rushing through the process to achieve a set of outcomes. The journey of developing the outcomes is as important as the outcomes themselves, and developing them should not be seen as a tick box exercise that place partnerships need to deliver in as short a time as possible.

Places will be at varying stages in building their partnerships and developing shared outcomes. The experience of those who are further ahead suggests it is important that places invest in the process of developing their shared outcomes, approaching engagement in this as a meaningful way of furthering integrated working arrangements, and recognising that there is the likelihood of further iteration and evolution of the framework over time.

The IWP sets the expectation that places should be implementing their shared outcomes framework from April 2023. However, we recognise that some places will already have well established shared outcomes frameworks with delivery plans for meeting those outcomes, while others that are earlier on in their development may not yet be at this stage. With this in mind, the government expects that from March 2024 all places are able to evidence the work they are undertaking to develop shared outcomes. For some places, this evidence may include place board minutes, partnership agreements, or the set of overarching aims or commitments they have made to their partner organisations. Going forward, shared outcomes are referenced as evidence in the Care Quality Commission (CQC) single assessment framework and this evidence may be considered as part of CQC ICS reviews and assessments.

Process

The suggested process of developing shared outcomes can be summarised into 5 stages as set out in Figure 1 below. Phase 1 centres on relationship building and agreeing a collective mission. It is comprised of stages 1 and 2, during which relationships are built and shared understanding leads to agreeing a small number of high level, overarching aims and outcomes. A partnership agreement may be developed.

Phase 2 focuses on the development of the outcomes framework itself. It involves agreeing priorities linked to the overarching aims and/or outcomes agreed in phase 1. From there, partners set out how the priorities will be delivered, and the measurables used to monitor progress. A delivery plan may map out how organisations and services will collectively deliver the priorities.

Figure 1: suggested process for developing shared outcomes

Relationship building and building shared understanding

Creating the environment for partnership working and taking steps to embed this in organisational cultures are the building blocks for developing shared outcomes. Strong relationships are the foundations from which partners can build a shared understanding of the overarching aims and outcomes that are agreed upon. Partners should be able to understand their organisation’s role in delivering the outcomes, reflected in their own strategies and delivery plans.

But it is more than this. Shared understanding includes organisations understanding the different statutory obligations, working environments, operational priorities and cultures of their partners. We have heard examples of how places have developed their relationships and understanding across organisations and one important message stood out: it takes the investment of time with equal commitment from partner organisations to foster these relationships to enable change.

We have heard that the time leaders spent with each other outside of formal meetings was more beneficial for furthering relations than coming together semi regularly in a formal meeting. As one person said:

Time spent getting to know each other and their organisation’s roles and responsibilities has been invaluable.

Some places have committed to partnership working and the development of relationships and shared understanding through building this into job descriptions and responsibilities, viewing this as a good way to embed a partnership focus into organisational culture. This adds a further purpose to avoid this focus being driven only by a small number of people, to ensure that working in partnership endures beyond changes in staff and creates collective responsibility in driving cultural change across organisations.

Other mechanisms have included setting up leadership programmes with a specific focus on relationship building.

Place leaders have told us that the process of setting and delivering shared outcomes is most effective when it involves all levels of staff including front line workers. As well as having it as part of job descriptions we have heard that it could be built into continuing professional development and/or annual appraisals as a mechanism to promote and embed relationship building through all levels of the workforce, from place leaders to staff in front-line delivery roles.

Agreeing overarching aims and outcomes

Creating the foundations for partnership working and taking steps to embed this in organisational cultures are the building blocks for agreeing the overarching aims and outcomes. Place leaders and partnerships can build on these relationships and networks to develop shared outcomes, taking into account their cross-organisational understanding of priorities and opportunities. Setting a small number of strategic outcomes which can be easily understood in the context of each partner organisation is helpful in bringing clarity of vision which can be built into a coherent narrative through strategies, plans and communications.

Partnership agreements, such as the one developed by the One Wolverhampton partnership below, can support this process and are useful for setting out the purpose and principles of working together and how this will be achieved. This does not need to be an administratively burdensome process or a legal document. Examples include agreements between partners including resource commitments or mutual aims. It can be a particularly helpful document if there are staff changes in leadership roles, and reviewing and committing to it could be incorporated into the induction process for new starters. It can also be used as a mechanism to reflect on the commitments at place board meetings, particularly if any challenges in partnership working arise; recommitting to the values, and principles in the agreement could help forge a way forward through those challenges.

Agree a set of priorities linked to the overarching aims and outcomes

With the overarching aims and outcomes agreed, partners can build on these to create a more detailed set of priorities, bringing into focus how the agreed outcomes will be visible. Places may choose to outline these in a separate delivery plan – linking the organisations and people who deliver services to the priorities and in turn to the outcomes.

This can give organisations and staff a sense of how the immediate priorities relate to the longer term overarching objectives and how different organisational metrics can be viewed as part of achieving this. For example, if reducing obesity is an outcome in the framework, then the delivery plan would set out each organisation’s responsibility in delivering on that outcome and the associated metrics to achieve this. So primary care might look at level of referrals to weight management services, secondary care may focus on access to bariatric procedures, mental health trusts might report on referrals to nutritionists or inpatient occupational therapy services, and so on.

Another way of describing this may be a logic model, which shows how actions in different parts of the system lead to short or medium term outputs, and eventually into the collaborative delivery of shared outcomes.

Places could consider setting a trajectory of what they want to achieve over a 3 to 5 year period and set an initial timeframe for piloting the delivery plan with reviews at 6 monthly or yearly intervals. Reviewing delivery plans more frequently (such as quarterly) may be counterproductive as sufficient time may not have passed to detect any measurable change. Places could also consider how the timing of their reviews align with the development of other strategies or reviews at place and system level so it does not add unnecessary administrative burden. For example, places could align their reviews to the review of joint forward plans and integrated care strategies, or whenever a new JSNA is completed.

Set out the ‘how’ – delivering the priorities

As partner organisations work to deliver organisational and statutory priorities, they will also be working to deliver or contribute to the shared outcomes that have been mutually agreed. ‘Health and social care integration: joining up care for people, places and populations’ stressed the importance of clarity of accountability at place, to support the delivery of outcomes. We have heard there can be a challenge in embedding accountability for shared outcomes across organisations, with each organisation focused on its own priorities and statutory duties, therefore disincentivising accountability for collective priorities.

The Health and Care Act 2022 did not prescribe the governance for place arrangements, instead local areas can determine what works best for their populations. The majority of places have set up either a place based partnership, or a place board as a formal committee of the ICB and either can work equally successfully in determining and delivering local outcomes.

Place based partnership

In this arrangement there will likely be an individual place partnership lead who is responsible for the overall delivery of the partnership, including shared outcomes. It may be that the place partnership appoints a separate designated person as a single person of accountability for shared outcomes as proposed in the integration white paper.

We have heard that having one person who is accountable across different organisations supports the delivery of shared outcomes and helps to overcome the challenge of individual organisations focussing on their own organisational priorities.

Organisations at place cannot deliver integrated health and care services and shared outcomes alone. There needs to be a clear sense of shared and mutual accountability and the place partnership should consider how this is promoted through its partner organisations and delivery plans. One place leader reflected to us that their shared outcomes framework:

…has been a part of holding us together and accountable to each other.

One way of achieving this could be to set out mutual accountability as one element of a partnership agreement that all organisations have signed up to.

Formal committee of the ICB

Some systems have chosen to set up place arrangements as a formal committee of the ICB. Place committees often include local health and care leaders, alongside representatives from the wider health and care community. As the Health and Care Act 2022 does not prescribe the nature of these committees, systems are able to determine the local membership and functions of these committees.

In this model, members of the place committee share accountability for the delivery of shared outcomes.

The arrangement chosen will not change the current local democratic accountability or formal accountable officer duties within local authorities, those of the ICB Chief Executive or relevant national bodies, such as the ability of NHS England to exercise its functions and duties.

Regardless of the local model chosen to ensure outcomes are delivered, we encourage places to be transparent with their local populations about the development of shared outcomes and how they propose to deliver them. Place partnerships could do this by publishing their framework on the ICS website in a similar way to how health and wellbeing boards publish their JSNAs and JLHWSs.

If place partnerships are not at this stage in their development, then it is up to the place partnership to consider what might be appropriate to share, for example board meeting minutes that demonstrate the conversations being had at board level to develop shared outcomes.

Similarly, places should be able to demonstrate how they have involved their local populations in the development of their shared outcomes frameworks. For example, when developing their outcomes framework East Sussex undertook focus groups including patients, the public and carers, and ran participation groups, to ensure co-production.

Determining the measurables

We have heard that finding ways to measure outcomes is one of the challenges to agreement over shared outcome. Firstly, we heard there is a tension between short term ‘must do’ deliverables and longer term outcome measures. Secondly, we heard that process measures can be easier to identify than outcomes which are usually reported over a longer time period and may be visible to different partners within a place. Third, we heard there was a challenge in placing equal importance on shared outcomes, as opposed to individual organisations’ statutory key performance indicators (KPIs). One place leader reflected:

Even if we locally determine that there’s a much bigger priority in an area, there’s only so much we can do to influence the organisations to pay attention to that because they’ve got their other responsibilities.

In these scenarios it may be useful to think about how the shorter term outcome metrics and KPIs can be used to demonstrate measurable difference for achieving longer term aims and how different organisations’ metrics can feed into the demonstration of this. This reinforces the benefit of an overarching place level delivery plan proposed in step 4 of Figure 1 above, to draw together the different strands of organisational delivery, and demonstrate the measurables that can be used across organisations. This delivery plan may form part of local shared outcomes frameworks, or be part of other local governance such as the health and wellbeing board.

We have heard that some places have tried to collate data across organisations and share insights in order to address the challenges of measuring longer term outcomes. For example, North Somerset are developing a library of qualitative insights.

A similar approach has been taken by Hampshire and Isle of Wight in using the work of the health and wellbeing board to set priorities and support data collation to measure progress on health inequality.

We also heard that some places have commissioned surveys to gain qualitative insights from their populations to measure impact. It was noted that to be a meaningful exercise surveys of this nature would need to be repeated annually to provide the necessary outcome measures. We have heard there are challenges with this due to financial pressures, but this is something places could consider doing if their budget allows.

Finally, some places have expressed a need to move away from metrics that measure or count numbers of activity, such as accessing a service or delayed discharge for example, and instead set measures that focus on personal experience of the service, such as satisfaction levels or how often people have to repeat their story. Some areas have started to build these metrics into their review process for determining success.

Croydon health and care partnership – demonstrating the interaction between place and system level priorities

One Croydon has developed a shared outcomes framework that supports delivery of their health and care plan and uses metrics from national outcomes frameworks including the Adult Social Care Outcomes Framework, Public Health Outcomes Framework and NHS Outcomes Framework as well as some locally developed metrics.

Croydon health and care plan (financial year 2019 to 2020 to financial year 2024 to 2025): outcomes framework

Table 1: proactive and preventative (PP):

Number	Indicator	HCP priority or project
PP1	Proportion of adults who are overweight and obese	Healthy weight
PP2	Proportion of people who report good life satisfaction (response score of 7 or higher)	Mental health
PP4	Proportion of people with type 2 diabetes who received all 8 care processes	Long-term conditions
PP5	Unplanned hospitalisations for chronic ambulatory care sensitive conditions (rate per 100,000 population)	Long-term conditions
PP7	Proportion of adult social care users who have as much social contact as they like	Mental health
PP8	MMR for 2 doses at age 5	Immunisations
PP10	Emergency admissions due to falls in people aged 80 and over (rate per 100,000)	Falls
PP11	Hypertension: % of estimated prevalence diagnosed	Long-term conditions

Table 2: localities (L):

Number	Indicator	HCP priority or project
L1	Deaths which take place in hospitals – all ages	End of Life
L2	Proportion of people with long term conditions feel supported to manage their condition	Support the development of practices and primary care networks to join up primary care and community services
L3	Estimated dementia diagnosis rate (aged 65 and older)	Dementia care
L4	People who use services who have control over daily lives	People having control and/or strengths based approach
L5	Delayed transfers of care from hospital that are attributed to adult social care	‘Living independently for everyone’ (LIFE)
L6	Proportion of people aged 65 and over who were still at home 91 days after discharge from hospital into re-ablement and/or rehabilitation	LIFE

Croydon Health Inequalities Outcome Framework (HIOF)

Croydon wanted to understand its inequalities from the bottom up and to do this they developed the HIOF. Improving healthy life expectancy and improving the gap in life expectancy are 2 strategic goals of the Croydon health and care plan, as well as being a wider priority at South West London ICS level.

Croydon is the largest London borough in terms of population with approximately 390,800 residents. 51.6% are from black and minority ethnic (BME) groups, they have the highest number of looked after children in London and the lowest healthy life expectancy in South West London. 40% of all Croydon residents fall in the Core 20, and 50% of the Core 20 most deprived residents in South West London live in Croydon. Core 20 refers to the most deprived 20% of the national population as identified by the national Index of Multiple Deprivation (IMD).

South West London ICS are keen to implement this approach across all places in South West London ICS to gain proactive insights into health inequalities across all places within the system to drive future prioritisation. In addition, South West London ICS has agreed a plan to develop a South West London HIOF, and this has featured in the first South West London Joint Forward Plan. This is a key example of how place level outcomes and data analysis can support the development and delivery of system level priorities.

Figure 2 below, created by One Croydon Health and Care Partnership, lists the indicators applicable to cardiovascular disease that could be used in a shared outcomes framework informed by health inequalities. The list is not exhaustive and is for illustrative purposes only. It begins at the bottom of the pyramid with broad indicators including wider determinants of health (employment, household income) and healthy behaviours (physical activity, healthy food). Moving up the pyramid, the indicators are more specific to cardiovascular disease (for example, cardiovascular disease related hospital admissions.)

Figure 2: indicators applicable to heart disease

Examples of shared outcomes frameworks

Leeds population board

Leeds has set its own shared outcomes frameworks around population boards. Working on a population segmentation model Leeds has 9 population boards each with their own outcome framework with aligned outcome and process measures. The outcome measures focus on local population needs and were developed first at the micro level, before linking to system goals at a meso level, and then linking to the strategy and ambitions of West Yorkshire at the macro level.

The 9 population boards include maternity, children and young people, end of life, serious mental illness, neurodiversity, cancer, frailty, long term conditions and healthy adults. An example of an outcome framework for frailty is included below.

Table 3: frailty population outcome framework

Goal 1: reduce avoidable unplanned care utilisation through a focus on keeping people well.

Goal 2: increase early identification and early intervention (of both risk factors and actual physical and mental illness).

Outcome	Outcome measure	Process measure
Living and ageing well defined by ‘what matters to me’	Data from the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health and the P3CEQ survey response (a measure of person centred coordinated care)	–
Identifying and supporting all people in this population group and assessing their needs and assets, as an individual and as a carer	% of the population who have mild, moderate and severe frailty Length of time people spend with mild frailty (rather than progressing to moderate or severe) Number of medications people are taking (moderate and severe frailty)	Proportion of people living with frailty who have had a ‘collaborative care and support plan’ review and/or advance care plan in place Number of people living with frailty who are identified on the system as carers and have evidence of a health check review in their own right as carers % of people who have had a medication review (moderate and severe frailty)
Reducing avoidable disruption to peoples lives as a result of contact with services	Number of days people have contact with acute services: - overall - planned - unplanned	Falls resulting in admission Average length of stay (planned, unplanned, MH) % planned and unplanned admissions (separate focus on Leeds and York Partnership NHS Foundation Trust) % of people living with frailty going to A&E Readmissions within 21 days (physical and mental health) 2 hour community response target Measure focused on deconditioning

Example from One Wolverhampton

Population health and wellbeing – right care, right place, right time:

1. Well: enable healthy choices and communities, ensure equitable coverage of universal services, identify risk and need earlier.

2. Chronic needs: enhance self management and support in primary care, delay complications, reduce exacerbations, identify issues early.

3. Complex needs: provide personalised care planning and case management, integrated team working, focus on quality of life, dignity at the end of life.

4. Acute illness and/or injury – ensure people receive care in the appropriate place.

Service user experience: put people at the heart of what we do:

1. Ensure service users, families and carers feel heard and well informed about their health and wellbeing, services and their conditions.

2. Provide person-centred, holistic care, and capture outcome measures that matter to people.

3. Ensure access to care is equitable, particularly for groups who are often excluded.

System infrastructure – work better together:

1. Have partnership oversight of resources and outcomes, to make the most of the Wolverhampton pound and ensure distribution is equitable.

2. Develop, attract, train and retain a workforce fit for the future.

3. Support integrated team working at a local level, using integrated data to drive coordinated care according to need.

Solihull

Solihull’s shared outcomes framework and its approach: Developing a shared outcomes framework for Solihull (PDF, 610KB)

Croydon

One Croydon’s shared outcomes framework can be found in the One Croydon health and care plan.

Places may wish to use the following resources and sources of support developing their shared outcomes framework. Some of these resources may relate explicitly to shared outcomes. Others can be used to support places on each stage of their journey towards developing a shared outcomes framework, for example through fostering greater shared understanding and collaboration.

The Leading Integration Peer Support Programme

The Leading Integration Peer Support Programme is a joint venture between the NHS Confederation, the Local Government Association (LGA) and NHS Providers. It delivers a range of free, bespoke support for local health and care systems, strengthening leadership and accelerating partnership ambitions at system, place and neighbourhood levels. It includes peer reviews, workshops, critical friend support, mentoring and best practice sharing. One workshop covers integrated leadership, focused on enabling local system leaders to identify their shared vision, commitment, leadership and accountability to achieve a fully integrated local health and care system. As well as bespoke support, the offer includes leadership support (including councillor and directors of adult social services mentoring), an annual leadership summit, support to regional virtual networks (for ICP and/or place Chairs, HWB Chairs and so on), leadership essentials programme for political leadership of place within ICS and/or ICP context, and ‘action learning sets’.

See The Leading Integration Peer Support Programme.

Leading Healthier Places

Leading Healthier Places, delivered by the Local Government Association, is a support offer to HWB Chairs and other lead members, focusing on the implications of ICSs for local government and HWBs. It provides bespoke support for single HWBs or neighbouring groups of HWBs in the footprint of an ICS. HWBs are key partners at place, and play an important role in bringing organisations together, setting common goals and visions, and providing accountability.

When Worlds Collaborate is also part of the Leading Healthier Places offer of support which addresses differing cultures and relational challenges between the NHS and local authorities as a barrier to integrated working. It is for local NHS and local government leaders to build mutual understanding and effective engagement as place-based leaders in care, health and wellbeing. The workshop explores the organisational differences between the 2, including governance arrangements, finance and culture. It is up to date with legislative changes, so that it reflects the current context and current pressures so that it feels relevant to participants. The local context can be added to help facilitate and inform discussions about priorities and focus for partnership working – with the additional understanding of the differences in resourcing, decision making and so on, so that expectations of each of the partners is based on realism and the art of the possible.

See Leading Healthier Places.

The LGA is also currently developing a high impact change model (place) that will be designed to assist and inspire local leaders as they navigate forward from the recent changes in the care and health landscape. The high impact change model device has already been successfully used in other policy areas and the focus is place leadership.

The Place Forum

The Place Forum, delivered by the NHS Confederation, strives to inspire strategic leaders to integrate care at place through sharing innovative practice, facilitating interaction between place teams, and offering opportunities to influence policy development. Partners in the forum benefit from peer learning sets, peer networks, access to examples of place-based models, and thought leadership sessions.

See Place Forum.

NHS England’s Population Health and Place Development Programmes

NHS England’s Population Health and Place Development Programmes have provided practical support to accelerate and embed adoption of population health management (PHM) across ICSs and place, building on existing efforts and tailored to local needs. Rooted in action learning, the programmes have equipped participating places with practical tools, techniques and approaches that embed and deliver effective PHM and have generated learnings for other systems and places.

This learning and insight can be accessed via NHS England’s PHM Academy. The PHM Academy, provides a range of materials supporting the adoption of PHM and the development of place-based partnerships and integrated neighbourhood teams including case studies, blogs, podcasts and e-learning modules.

A further phase of direct support to a small number of exemplar sites, to be rolled-out in 2023 to 2024, will focus on place and integrated neighbourhood team development, accelerating the implementation of the Fuller Stocktake and Thriving Places vision. It will build capability across a number of key enablers including;

• distributed leadership development and cultural transformation, integrated governance and partnership working

• the use of linked data and application of PHM to enable intelligence driven care

• population-based planning and the creation of person-centric shared outcomes and metrics

Further learning and good practice will be captured and shared via the PHM Academy website, as the programme is delivered.

FutureNHS

The FutureNHS website hosts a menu of support currently available to ICSs, including support for working at place. Support ranges from:

• structured national programmes (large and small scale)
• networks and communities of practice
• online resources: toolkits, case studies, podcasts, guidance
• subject matter experts (SMEs)
• informal and peer support

Support may be delivered directly by NHS England (NHSE) or by key partners including NHS Providers, the LGA, Association of Directors of Public Health (ADPH) and NHS Confederation. The menu of support will be updated on a regular basis (quarterly) as new support offers come on-stream.

Fingertips (Office for Health Improvement and Disparities)

Fingertips is a large public health data collection organised into themed profiles.

National outcomes frameworks

NHS outcomes framework

Adult social care outcomes framework

Public health outcomes framework

Conclusion

The development of shared outcomes and partnership working in the delivery of these outcomes continues to play an important part of local integration, helping to maintain the focus on local priorities and improved outcomes for their populations. We will continue working with systems and places to understand progress in the development and delivery of shared outcomes, to gain further insight into the role of shared outcomes in integration.

We would like to thank partners in local systems and other organisations for their time and insights in the development of this toolkit.