West Yorkshire Association of Acute Trusts (WYAAT) was formed in 2016 by the six acute hospital trusts, foundation trusts (FTs) and NHS trusts, working across West Yorkshire and Harrogate[1]. As such, WYAAT is an established collaborative, keen to share their experiences and learning with others. It is part of West Yorkshire Health and Care Partnership Integrated Care System.
The road to its formation started with exploratory conversations between the chief executives of the six trusts, who asked their respective company secretaries to consider the opportunities and options for formally working together. The company secretaries sought legal support and drafted a Memorandum of Understanding (MOU) setting out the terms of their collaboration – the original of which remains in use (with only a few minor wording tweaks), having been regularly reviewed.
Each of WYAAT’s members contributes an annual fee to fund WYAAT’s management, staff and activities. The contribution is proportionate to the turnover of each trust.
Initially, WYAAT explicitly decided to focus on what they term ‘soft’ projects and programmes, such as developing shared procurement to derive savings from bulk buying (which has more recently evolved to include all providers across the integrated care system (ICS)). This work enabled relationships to form and for people below board level to see the benefits of collaboration. This laid the groundwork before WYAAT began to tackle more difficult areas, and gave time to establish mutual trust, respect and candour.
WYAAT’s first 'big difficult decision' recommended to its members was a reconfiguration of vascular services, moving from three arterial centres to two. This was a success, further cementing the relationships and ethos of collective accountability for doing the best for patients across the footprint, ahead of the interests of individual organisations.
Some notable achievements so far include:
- A workforce portability agreement, allowing staff to move between trusts to deliver clinical services.
- Shared and coordinated international recruitment, training, and apprenticeship management.
- Creation of cross-WYAAT posts such as anaesthetic associates, and clinical practice educators in radiology.
- Securing funding for educational grants, shared digital solutions, transformation of aseptic services and endoscopy training.
- An elective recovery programme, supporting trusts to transfer over 500 patients in 2022-23 to an alternative hospital to receive earlier treatment.
- Establishing numerous clinical networks and non-clinical networks of subject-matter experts and planning to deliver seven community diagnostic centres across the area.
WYAAT’s members pride themselves on their collaborative ways of working and they set an expectation that leaders new to the trusts will actively sustain this ethos. When recruiting to senior posts in WYAAT or its members, it’s made clear to applicants that they are applying for a role in a system, and need to be on board with working with partners at place, the ICB and others.
How are decisions made?
WYAAT is governed by committees in common with each organisations’ statutory committee consisting of its chair and chief executive. Committees in common meetings are three hours, held quarterly with a formal agenda and reports. The six trusts opt into projects or programmes of work, and output of the discussion requiring formal support is presented to the relevant trust boards for governance and approval. The committees in common hold no delegated authority from respective boards, but do oversee and control programmes and priority activities underway, underpinned by a risk framework.
Company secretaries of each trust are involved to ensure consistency of approach, and paperwork, between WYAAT meetings and the flow to board meetings in their own organisations for appropriate decisions as required. For governance purposes, identical paperwork goes to trust boards after being reviewed by the committees in common. A log of 'previously asked questions' appended to paperwork helps reduce the need to repeat discussions that have already taken place. The company secretary from the trust of the chair of the meeting is in attendance along with a second company secretary from another member trust to support the minute taker. The company secretaries hold a short meeting within a week of the committees in common meeting to ensure the flow of information for approval to respective trusts’ board meetings, for governance.
WYAAT has its own director. The director is supported by a small team: a medical lead, finance lead, analyst, communications manager, and programme management support. The director and their team are employed by one of the participating organisations. A chair of one of the members chairs the meeting on a rotational basis, as defined in the MOU.
Below the committees in common sit a programme executive, made up of the six chief executives, which meets monthly to oversee and steer work across each of WYAAT’s priority programmes. Both the committees in common and programme executive are decision-making groups in relation to existing programmes and priorities, but proposals for new work or changes of direction go back to each organisation’s board for approval following recommendation at the committees in common.
Four advisory sub-groups sit beneath this, feeding into the programme executive:
- Strategy and operations group.
- Directors of finance group.
- Clinical reference group.
- Chief digital and information officers.
Informal networks of all executive peer groups have been established to enable relationship building, discussion and identification of opportunities for collaborative working. There are also established clinical and non-clinical networks below executive level. Together, these arrangements enable suggestions and queries about joint working to reach the committees in common.
Each of WYAAT’s 12 agreed priority programmes – spanning corporate services, clinical support, and clinical services – has a programme board with people and resources allocated as required. Programme boards are each chaired by a provider chief executive and include employees from other organisations within the ICS where relevant. These programmes are run using standard programme management processes and report up through the WYAAT structure. Updates, for example on progress and risk management are shared back to the provider boards; any feedback or challenge from those boards fed back into the WYAAT structures as required.
It remains of great importance to each of the trusts within WYAAT that they retain organisational autonomy. The trusts have no plans for closer structural integration, though they continue to review that the structure and approach is still fit for purpose to deliver shared objectives. The flexibility and focus that the structure enables, as well as retaining the local control and incorporating non-executive oversight and challenge via trust boards throughout decision-making is supported by the six trusts.
Retaining the autonomy of the organisational boards strengthens buy-in to the collaborative and its priorities, because each are explicitly and freely chosen as priorities for each organisation. The structure allows individual trusts to opt out of particular programmes if that makes sense for them – however no recommendation has failed to be approved by member boards to date.
Each chair’s integral involvement in the WYAAT governing committees in common is intended to give the organisation’s non-executive directors (NED) confidence in any proposals, as well as enabling board discussion and NED buy-in before proposals are fully formed. The director of WYAAT attends each member’s board from time to time to engage with the full board, including NEDs, on WYAAT’s activities, progress and plans.
Their approach enables careful communication, consensus building and development of ideas between members before a proposal formally reaches the trust boards for approval. Proposals are often initiated by the sub-groups of directors from each organisation, other advisory groups, or programme boards, before being refined into recommendations by the committees in common. So, by the time the committees in common make a recommendation to members, the trust boards are usually well aware of the rationale behind any proposal.
WYAAT does not itself seek to engage with governors from its FT members. This happened through those FTs’ own interactions with their councils.
How do you engage with other system partners?
WYAAT is one of a number of collaboratives in the ICS, alongside a mental health collaborative, community collaborative and a hospice collaborative all of which, along with the West Yorkshire Combined Authority, engage with the integrated care board (ICB) and integrated care provider (ICP). WYAAT has a partner member representative on the ICB, and each trust is a partner within the ICP. Strategically, WYAAT has worked closely with the ICB on its five-year joint forward plan.
WYAAT acknowledges its strong relationship with the ICB, whilst remaining independent of it. Much of WYAAT’s business can be conducted within the collaborative, for example decisions relating to workforce portability or digital deployments, while keeping system partners informed and engaged where relevant. WYAAT will also make recommendations to the ICB where appropriate - for example about their vascular services programme or Community Diagnostic Centre investment.
There has been a change of approach since the ICB has been put on a statutory footing and NHS England (NHSE) has sought to devolve more to the ICB and hold it accountable for system level, and trusts’ performance. In a complex landscape, the operating model requires further development to clarify responsibilities and accountabilities between the ICB, NHSE, places, trusts and WYAAT.
Each trust is a partner member in its local place and therefore most place engagement is through this route. Alignment of WYAAT with places is an area for further development as the ICB operating model evolves further in the future.
What’s next for the collaboration?
The trusts within WYAAT are satisfied with the form of collaboration they have selected and have no plans to change it. The respective trust boards have considered and discounted setting the collaborative up as a wholly owned company, or pursuing a group model, or merger. They prefer to focus on deriving benefits from their relationships and networks, retaining organisational autonomy, and avoiding the transaction costs of a focus on structures at the expense of delivering their priorities.
WYAAT’s director has been liaising with all trust boards around WYAAT’s strategy for the next five years: seeking both input and buy-in, approaching boards directly seeks to ensure members' NEDs and all executives are properly engaged in its development. This was timed to incorporate, and where relevant reflect, the ICB's strategy.
WYAAT is also looking more closely at how risks are managed within and across the association, with a view to being joined-up with any system risk management framework in the future. Risks affecting all members are those linked closely to the delivery of quality and cost-effective acute services in West Yorkshire: for example delivery of elective targets and oncology capacity, as well risks such as those due to Reinforced Autoclaved Aerated Concrete (RAAC) and the impact of climate change, alongside the risks of delivering projects or programmes of WYAAT work. WYAAT is planning to bring the company secretaries of each of its member trusts together to lead a new piece of work assessing risk appetite, and adopting common risk language for a risk management framework for WYAAT committees in common. This may support the ICB in risk management across the system if they were able to establish a sound way of doing this across the association.
Interactions at place continue to need attention and more needed to be done to ensure WYAAT’s programmes were aligned with work at place, and understood by place leaders.
What’s the one piece of governance advice that you would share with others?
Lucy Cole, director of WYAAT, and Jo Bray, company secretary of Leeds Teaching Hospitals NHS Trust told us: "The success of WYAAT is based on a desire to work together for defined outcomes, which is the primary driver and can be underpinned by an appropriate governance model. Define the desire and outcome and don’t get lost in the governance and delegation. WYAAT holds no delegated authority from its six respective trust boards."
[1] Airedale NHS Foundation Trust, Bradford Teaching Hospitals NHS Foundation Trust, Calderdale and Huddersfield NHS Foundation Trust, Harrogate and District NHS Foundation Trust, Leeds Teaching Hospitals NHS Trust, Mid Yorkshire Teaching NHS Trust