In July 2023 we launched Provider collaboratives: Improving equitably, delivered in partnership with Q and supported by the Health Foundation and NHS England. The programme aims to support senior leaders in provider collaboratives as they develop shared improvement approaches with an equity lens embedded from the outset. With provider collaboratives playing a critical role in realising the benefits of system working, and with the launch of NHS IMPACT last year, there's an increasing interest in how continuous improvement in partnership might help meet the unprecedented challenges facing the service.
Since the programme started, we've seen a growing understanding from participants that "It's not quality if it doesn't include equity", and a consistent commitment to move from ambition to action. The challenge is 'how' with an appetite for practical ways to embed an equity lens into shared improvement work. It is early days, and our programme is showing that provider collaboratives – at different stages of maturity - are all grappling with a wide range of issues as they seek to deliver improvement at scale.
Despite the challenges, provider collaboratives are inspired by making a tangible difference, improving quality and increasing equity for patients, with hopes to accelerate equitable improvement through their work, with a recognition that relationships and shared learning are key to this.
Through our programme, we have so far engaged with over 80 trusts working in partnership. We are now in our second phase, where we are working closely with five provider collaboratives, their senior leaders and board members in a bespoke peer-learning and coaching programme. With more insight to come, here we share some of our learning so far.
Building a shared purpose and vision
Collaboration is unlikely to change practice in a sustainable way quickly. It takes time to make it a routine way of working.
THIS Institute
Provider collaboratives recognise that working at scale provides them with opportunities to tackle really 'sticky problems' and show tangible improvement for their local populations, particularly when it comes to tackling inequalities. Whilst people are keen to make progress, everyone acknowledges that driving improvement at this level takes time. Providers are grappling with how to deliver improvement at pace and show impact, whilst also having the time to engage meaningfully with all stakeholders including place partners and local communities, build relationships and really embed an equity lens into work from the outset. There are also additional challenges when working with multiple providers. For example, prioritising an area to work on is more complicated as providers want to tackle improvements that all partners feel they have a stake in.
Members tell us that data can be an invaluable tool to help decide where to focus energy and that it's important to take the time to ensure data is fair, accurate and standardised. For organisations to make meaningful comparisons, investment in the measurement of improvement and the development of data dashboards helps, so that teams can learn from each other and understand which interventions are working. However, we know often this data may be fragmented, incomplete, and difficult to access due to differences in information collection, analysis, weaknesses in data collection methods, and information governance barriers, such as different systems not communicating or lack of data sharing agreements. Despite this, members know not to let perfection be the enemy of good. As one programme participant said, "Data, while important, shouldn't stop us trying or working with what we have today". Members also report that enhancing visibility on data and coming together as partners to make sense of it can act as a motivator, as it can drive curiosity as to why there are differences or gaps. Senior leaders can help reduce barriers to sharing data and emphasise the importance of robust and accurate data collection in their organisations.
Members have also stated that national bodies have a role to play by ensuring funding, regulatory and performance frameworks reflect and incentivise the importance of collaboration. Currently members feel they are not recognised if they put in effort to support improvements where impacts are shown in another organisation.
Investing in people and culture
The journey to build any culture is years in the making.
Virginia Mason Institute
We know that building relationships and trust are vital to embedding improvement in an organisation, and members report the same is true for collaboratives. There are rich opportunities for providers in collaboratives to learn from each other and understand different organisational cultures and ways of operating. However there are also challenges when it comes to investing in people and building a new collaborative culture. For staff who identify primarily with their employing organisations, it can take a significant shift in mindset to engage equally with the goals of their provider collaborative. This requires strong communication and leadership to align staff behind shared strategic priorities and values – programme participants have said aligning behind a commitment to equitable improvement can help galvanise this support.
When it comes to investing in supporting people to use improvement methods and principles, collaboratives must often pull on existing trust resources, meaning staff are trying to deliver on provider collaborative goals on top of their existing priorities. The result can be that progress on shared goals may not happen as quickly as everyone would wish. Collaboratives also recognise that for impactful progress to be made, everyone needs to commit and understand their role. However engagement can vary between providers, with the risk that progress is only as quick as the least engaged partner. This underlines the critical role of boards in actively championing the provider collaboratives goals, purpose, and priorities.
Developing leadership behaviours
Leadership needs to drive the vision for the provider collaborative as the engine room for improvement.
Lancashire Teaching Hospitals NHS Foundation Trust
Senior leaders are vital to creating an improvement culture, showing the way and illuminating the path for others. Speaking to members, we know that it takes time to build an improvement culture, and once built it can be difficult to sustain if there are high levels of change at board level. Key to this is good improvement capability and training at board level with all being aware of their role in developing a strong organisational improvement culture, and responsibility not sitting solely with the senior responsible officer.
When it comes to developing leadership behaviours there are some great instances across provider collaboratives. In the West Yorkshire Association of Acute Trusts, each provider chief operating officer (COO) takes responsibility for one strategic priority for all providers in the collaborative e.g. 'elective waits'. This way of working was only possible due to the 'cultural readiness' work they did in the beginning to build relationships, trust and candour. Cultural readiness work is defined as planned and deliberate efforts to establish and maintain a shared set of values that all organisational members can align to. This shift in behaviour of one COO making decisions for the collective has allowed them to tackle large-scale problems which their data analysis told them could never be achieved individually. It has also withstood changes in personnel. They work collaboratively for the good of all; 'If one fails, we all fail'.
We have also heard from non-executive directors (NEDs) how keen they are to support improvement at scale. NEDs are acutely aware of their directors' duty to promote the success of their own organisation, and understand their role in strategy, challenge and assurance-seeking in order to achieve this. They are now required to balance this legal duty with their organisation's new statutory duties to cooperate and consider the wider impact of the decisions they make. Where boards have worked to get alignment between system partners on their wider shared goals, it is easier for NEDs to navigate situations where a decision might be made that is the right choice for people across the community, but might not be in the more narrowly defined interest of the organisation.
Building improvement capability and capacity
They have different improvement methodology and training to us, that could be seen as adding complexity, but we see it as an opportunity to benefit from each other.
South Warwickshire University NHS Foundation Trust
Members tell us it can be a challenge to provide improvement training and support to all staff, particularly as improvement teams can be relatively small compared to the size of the organisation. Despite this, provider collaboratives are embracing the opportunities to work in partnership to build improvement capability and capacity. Together with other partners in their integrated care system (ICS), people are thinking creatively about how they can use existing resources to train staff. Through the Norfolk and Waveney Integrated Care Board Quality Faculty, we have seen how they have an open door to training which allows staff to receive improvement training from other providers in their system. There are also great examples of provider collaboratives offering improvement training to patients, carers, communities and voluntary, community or social enterprise organisations (VCSEs). Building improvement capability in partners is important for equity as it allows them to truly engage and co-produce, design and implement improvements as equal partners and to bring in different voices and perspectives on the needs of the communities served by the provider collaborative.
To streamline collaboration, some systems are agreeing on an improvement methodology so all staff are trained in the same methods and speak the same improvement language. In other systems people are appreciating that a diversity of improvement methodologies can bring different strengths and perspectives to their work. Due to clinical pressures, some improvement teams are focusing on training non-clinical staff, prioritising clinical staff where improvement can best help them to meet high priority safety needs or breaking down training into 'bitesize chunks' so staff can more easily fit this into work schedules. In addition, to help with supporting staff after they have received improvement training, organisations are identifying and embedding 'Quality improvement champions'. In all cases, there is a recognition that when working at scale there needs to be a common language and understanding of the principles of improvement so that there are fewer barriers to staff working together across organisational boundaries.
Embedding equity into improvement
Embedding equity is about us working harder to make it fairer.
Barnsley Hospital NHS Foundation Trust
Throughout the Provider collaborative: Improving equitably programme, it has been clear that tackling inequalities is high on the list of priorities for members, but we often hear one of the challenges is knowing where to start. Data analysis is useful to identify inequalities, but it requires local knowledge and partnership to understand the root cause of those issues. When working on inequalities at scale, public health expertise at provider level helps to make sense of data and inform population health management strategies. For example, West Yorkshire Mental Health Learning Disability and Autism provider collaborative directly employ a public health consultant looking at health inequalities. This was a role which was championed by the senior responsible officer for the collaborative and chief executive of one of the trusts, Dr Sara Munro, of Leeds and Yorkshire Partnership NHS Foundation Trust.
Some members are keen for ICSs to take a lead on convening partners to decide on what the priorities are for their local systems in tackling inequalities, so providers can work together along clinical pathways. Others are taking the decision to focus on one issue at a time to build up momentum and show impact. Pedro Delgado (vice president, Institute for Health Improvement) articulated that senior leaders need to decide whether they frame equity efforts as "Inch wide, mile deep" or "Inch deep, mile wide". The former involves using data to understand who is getting left behind, a more granular focus on helping specific cohorts of patients and building bridges of trust with communities that you will be working with.
There is also high value in enriching quantitative data with qualitative insights. Qualitative insights can help to answer why inequalities are occurring by listening to the most marginalised communities and can also provide meaningful insights on how to tackle these challenges. Members stress the need for the skills and courage to engage directly with patients and communities to better understand how inequalities are impacting their experience to inform their work. Members recognise the importance of co-production to ensure equity is embedded into improvement interventions and a need to proactively consider how to hear from those who are least likely to be engaging with healthcare services.
At our third event, Alice Forsythe of Virginia Mason Institute (VMI) shared some tools developed by VMI that leaders and teams can use to systemise equity into their organisation cultures – these include equity pauses which were used by their surgical team to identify access barriers for patients on their waiting list and design solutions to these barriers. At our first event, Beckie Burn (associate director – transformation at Lewisham and Greenwich NHS Trust), shared some high-impact actions board members can take. Specifically for equity, this involved questions board members can ask themselves when signing off initiatives such as, 'What does our data tell us about how this issue affects different populations?', 'Can we focus this project on the groups most disproportionality affected?' and finally only signing off initiatives that have considered and embedded addressing inequalities. It has also been key for board members to understand and discuss the difference between equity and inequality.
Looking to the future
Given this work is still in its early days, there is more to learn about what is required to create an enabling environment for equity-focused, locally led improvement across provider collaboratives. Providing opportunities for peers to come together to share their progress and challenges, and ensuring these lessons are shared across the provider sector, is crucial if we are to harness the full potential of provider collaboration to tackle deep-seated inequalities and drive sustainable improvement. Attendees have shared with us that our events have helped by providing further evidence, practical tools and real-life examples of how data is crucial, shined a light on the importance of building board awareness and buy-in, challenged them to look beyond their day-to-day operational pressures and most importantly given them encouragement it can be done.
As we move forward to the second phase of the programme, our aim is to build on the learning so far by working with five provider collaboratives to delve deeper into understanding the prerequisites for equitable improvement through provider collaboratives. Through this programme we'll continue to share widely with members what we are learning.
Learn more about our Provider collaboratives: Improving equitably programme and catch up on our previous events and resources.