When you talk to system leaders about their experience of the COVID-19 pandemic, they are quick to tell you how collaboration with other organisations was critical to their response. Whether it was mutual aid to share personal protective equipment between neighbouring providers, CCGs supporting health and care organisations with infection prevention and control measures, or primary and community care teams providing enhanced healthcare in care homes, collaboration took on a whole new meaning.
So much so that it has become one of the national policy buzz words in the development of integrated care systems (ICSs). In this context, it implies a specific focus on 'horizontal' collaboration, whereby the same types of providers come together at scale (either ICS or multi-ICS level) to tackle unwarranted variation, deliver more effective use of resources and support high quality, sustainable services. These same providers are also developing 'vertical' integration at a more local level between NHS, social care and local authority partners – often referred to as place-based partnerships. CCGs have a key role to play in both of these arrangements – moving away from transactional relationships with providers towards collaborating on the design and implementation of these new ways of working.
NHS England and NHS Improvement has high aspirations for how provider collaboratives will operate and what they can achieve.
NHS England and NHS Improvement has high aspirations for how provider collaboratives will operate and what they can achieve. While providers and commissioners broadly support these national ambitions, they have some concerns about the proposals as currently framed. One of those concerns is that NHS England and NHS Improvement sees the benefits of this collaboration at ICS level primarily for acute and mental health trusts, when we know that community providers also operate at scale and must have a voice in ICS decision-making. We also need to consider what these proposals mean for regional providers, including ambulance and specialised services.
NHS Providers and NHS Clinical Commissioners recently convened a roundtable of trust and Clinical Commissioning Group (CCG) leaders to discuss how trusts are collaborating on this horizontal axis, and how commissioners have supported them to develop these arrangements. This discussion highlighted five key enablers of collaboration.
Firstly, there was clear recognition around the table that the new world of system working will require new and collaborative leadership styles. Building a shared narrative and vision around a commitment to working together, grounded in the benefits it will bring to local communities, will have a significant impact on the success of collaborative ways of working. This vision is essential as partners unite most effectively around a shared purpose. This is partly why the COVID-19 response was a catalyst for greater collaboration. ICSs, provider collaboratives and their constituent organisations will do well to find a common challenge to address and a clear purpose going forwards.
When designing provider collaborative arrangements, the focus must be on achieving the desired outcomes, rather than on the underpinning governance infrastructure.
Secondly, form must follow function. When designing provider collaborative arrangements, the focus must be on achieving the desired outcomes, rather than on the underpinning governance infrastructure. Much of this work will develop organically from the ground up, as local areas design what makes sense for their local communities, services and geographies. Trust and CCG leaders are clear that the answer does not lie in a one-size-fits-all model.
In addition, the importance of good relationships – and the time taken to build them – cannot be underestimated. Trust and CCG leaders emphasised strongly that relationships built on trust and mutual respect were crucial, especially when tackling the most challenging issues together. Establishing lead providers on different work programmes, moving to open book accounting and tackling specific tensions to overcome barriers in other areas, were all cited as practical ways of developing those relationships.
In addition, trust and CCG leaders both talked about the need to reframe the commissioner/provider relationship. Those systems that have taken a collaborative, rather than a transactional, approach to planning services have been able to move further, faster. We must move away from the usual commissioning cycle of planning, purchasing and monitoring services, to collectively assessing population health needs, designing services to meet those needs, allocating resources and working together on implementation.
It was clear that service quality improvements and financial savings can be driven by chief executives modelling the right behaviours and ways of working.
Last but by no means least, senior and clinical leadership buy in across organisations is essential. It was clear that service quality improvements and financial savings can be driven by chief executives modelling the right behaviours and ways of working. Believing in the mission and purpose of the collaborative is essential for senior leaders to bring their organisations and staff along with them.
We expect NHS England and NHS Improvement to release guidance on provider collaboratives soon. However, trust and CCG leaders want maximum local flexibility to develop the right arrangements for their local populations, staff and services. They also need the right resource – both funding and people – to develop and deliver these new arrangements, as current leadership capacity is under strain. NHS England and NHS Improvement has a tall ask as well – creating an enabling policy and legislative framework that supports more collaborative ways of working at local level. Finally, systems need time to develop the right relationships, behaviours and ways of working to make collaboration the success we all want it to be.
NHS Clinical Commissioners and NHS Providers will continue to work closely together to support our respective members to navigate this complex landscape of different types of provider collaboration, sharing learning and good practice along the way.