This document provides lessons on developing an STP (Sustainability and Transformation Plan) and ACS (Accountable Care System) through place-based integration of the NHS and local government. It outlines common challenges to working together such as organizational complexity, differing statutory requirements, and short-term targets conflicting with long-term plans. The document proposes a framework for working well together with shared leadership, commitment to shared visions and plans, governance structures for place-based working, and shared accountability for agreed plans. Practical actions include agreeing shared financial and delivery models, metrics, and contractual forms while pooling resources and incentives.

1. Practical lessons to develop an STP and ACS
The NHS and Local Government: working well together in place –
John Bewick OBE

2. The NHS and Local Government:
Working well together in place.
Learning drawn from:
• 'Stepping up to the Place' Local Government Association / NHS local
integration workshops x 16
• Health and Wellbeing Board leaders programme x 8
• Better Care Fund advisor x 3 years
• Local STP development, local ccg development
John Bewick OBE

3. Place based integration is not new:
an enduring opportunity to take.
• The Black Report 1980. Socio economic impact on health
• The Wanless Report 2002. Fully engaged society.
• Total Place agenda 2010. Collaboration or bust?
• NHS 5 Year Forward View 2014. Placed Based Commissioning
Always encourage seeing public resources in a place as one
Always encourage avoiding unnecessary illness, dependency and acute care
National policies, plans and organisations come and go: the needs of
population in place remain. Passion to do well for local people endures

4. Coming together in place: planning
opportunities and challenges.
• HWB strategy
• Devolution
• Sustainability and Transformation Plan/ Partnership, Accountable
Care
• Better Care Fund/ Health and Social Care integration 2020.
There has never been one plan, challenge is to achieve local
coherence. Meeting local population need in place remains the
key test.

5. Working together feels tough : top 8
common challenges.
• Organisational complexity, historic relationships and quality and financial
sustainability drive the degree of challenge in working together. sometimes not
overtly recognised.
• Organisational statutory requirements are strong, system statutory requirements
far less so. Voluntary system agreements are less developed.
• The strategic integration role of HWBs and other place based planning forums
varies greatly, including which organisations are in the room shaping the way
ahead.
• Without strong shared culture and behaviour, agreeing a shared purpose around
public need and then delivering beyond organisational interests is very
challenging.
What differentiates systems is if energy goes into working to overcome challenges
or being adversarial within them.

6. Working together is tough : top 8
common challenges
• Organisations break out of agreements and defaulting to defending their positions,
often at the stage when system vision moves to practical implications for
organisations.
• Contract negotiations, Cost Improvement Programmes and hitting targets in the
short term run alongside longer term transformational plans and partnerships.
• Systems varyingly agree on which population planning footprints are needed for
which transformational challenges. Planning footprints and delivery footprints are
sometimes confused.
• The requirements of national regulators on organisations is sometimes difficult to
reconcile with having a long term coherent place based plan.
What differentiates systems is if energy goes into working to overcome challenges
or being adversarial within them.

7. Working well together in place : a
framework.
The essentials:
Shared leadership : levels of trust and behaviour
Shared commitment : shared vision and agreed plans
Getting it done : place based working arrangements: governance
and programme management
Shared accountability: keeping to the agreed plan

8. Working well together in place : a
framework con’t.
Build partnership strength through doing practical things well
together:
• Agree the local place based financial position and opportunity
• Agree top common metrics of success
• Agree the local care delivery model
• Agree organisational form to better deliver the care model
• Agree to put energy into sharing gains, not shunting risk
• Agree enabling resource pooling, incentives, contractual forms

9. The NHS and Local Government: Working well together in place.
John Bewick OBE