Now that integrated care systems are fully up and running, attention turns to the hard work of putting the theory into practice. There's plenty of enthusiasm among trust leaders, system leaders and managers for the idea of integration, and for collaboration over competition as the guiding principle for organising healthcare systems.
With all NHS trusts now part of at least one provider collaborative, there is a strengthened constellation of partnerships to help deliver on this transition. But evidence shows that for all its potential benefits, making collaboration work is not straightforward. It requires careful planning, ongoing relational work, and monitoring and reflection to make the most of it. For partnerships in the process of setting themselves up, having gained clarity of purpose and alignment on priorities, thinking through the 'how' of collaboration is becoming all the more important. So what can NHS trusts working in provider collaboratives learn from existing models of collaboration to foster high-impact alliances that make the greatest contribution to the quality and safety of care?
Collaboration in theory
The idea that collaboration might offer advantages in organising health and care is not a new one. Networks, partnerships and other collaborative forms have long been suggested as an organisational alternative to competitive markets and hierarchical bureaucracies, and particularly as a means of facilitating speedy decision-making and productive knowledge-sharing among those involved. In practice, though, collaborations often have to coexist with those other organisational forms, and contend with them in seeking to influence the behaviour of the people involved. It's a significant mindset and practice shift to share responsibility and ideas about how to improve services with your neighbouring trust when, until recently, they competed with you for patients and income.
Specific forms for collaboration are many and varied. Two of the most well-known within the field of healthcare improvement – improvement collaboratives and communities of practice – also illustrate the variety of approaches that can be taken to collaboration, depending on the purpose. Improvement collaboratives are usually convened for specific purposes, especially where there are unwarranted variations in quality of care, and hence scope to share good practice for improvement. Communities of practice tend to be more organic and less specific in their objectives: a means by which people with a common interest can come together to develop their skills as practitioners. Both, however, have particular value as a means of sharing the 'know how' of healthcare practice: the things that we know, tacitly, make a huge difference to the quality of what we do, but which are often experience-based and context-dependent – and so are much more easily shared through trusting dialogue than abstracted into instructions or guidance.
There is some evidence for the value of both approaches, and some common lessons that apply to both. It is important, for example, to consider how relationships and power dynamics outside the collaboration might influence how people behave within it, and to be clear about ground rules, expectations about interaction and required levels of contribution. For collaborations that involve specific intended outputs especially, it is important to be clear about responsibilities and accountabilities, and even to have means of incentivising positive contributions and discouraging negative ones. A real risk in collaborative situations is that some partners do more than others, and the fact that all may share equally in the outcome of a collaboration regardless of their input can encourage 'free-loading' or result in inertia.
Making collaboration work for improvement
In short, an important initial step to making collaborations work effectively is getting past any idealised views that they should be self-organising, and that left to their own devices, they will inevitably do good. For provider collaboratives, the challenge then becomes achieving the right balance between 'top down' and more organic movements for change. Beyond this point, what else is important to securing the promise of collaboration?
One important lesson is the potential of long-term, data-informed collaborative efforts. Collaboratives such as the Vermont Oxford Network in the United States make use of high-quality process and outcomes data, submitted by members, to identify variations and inform changes that, over time, have demonstrably improved quality of care across the network. Even in the competitive context of US healthcare, the building of trusting relationships through time – together with clear rules about how to collaborate – can create improvement.
In the UK, of course, the predecessors to integrated care systems learned how to contend with competing pressures over several years, with varying degrees of success. The chance for NHS trust leaders to learn from each other, as well as from other recent collaborative ventures such as primary care networks, should not be missed: with no obvious blueprint or formula for success to turn to, these experiences of making the best of what's available in challenging contexts will be vital.
Within provider collaboratives, leaders might consider opportunities to form collaborative programmes around areas where good practice is known but actual practice is variable.
Within provider collaboratives, leaders might consider opportunities to form collaborative programmes around areas where good practice is known but actual practice is variable – particularly as this affects marginalised groups. But they shouldn't expect results overnight, and they will need to resource such activities: without the right leadership, facilitation, programme management and attention to measurement, they will flounder. The chance to incorporate parts of the system that are not so well versed in improvement methods but which are crucial to the good functioning of the system – for example the care home sector – is particularly auspicious. But equally, offering practitioners time and space to organise for themselves, for example through communities of practice, also offers promise in terms of both practice development and staff contentment.
Of course, none of these activities comes without significant effort, and trust leaders working in partnership might quite reasonably focus on those where measurable impact is most likely. They will also need to consider how best to bring others into these collaborative spaces, including those whose voices have been less heard: local authorities; voluntary-sector providers; patients, service users and the public. Carefully considered objectives, the right skills and resources, and meticulous – but patient – management of programmes will be vital in making a success of collaboration.