Many systems have been keen to develop elective hubs to add capacity as they grapple with long waits for patients across their local area. As a key vehicle for trusts to work together to deliver on system priorities, provider collaboratives are well-placed to manage this type of initiative.
Provider collaboration exists in a variety of forms across the NHS, focused on different operational, clinical, and corporate priorities. NHS England expects greater collaboration between providers (NHS England, 2024a), and trusts are seeking out opportunities where collaboration can bring about the greatest impact for patients, and improvements to operational performance. Providers tell us that coming together around a shared purpose and agreed priority has supported collaboration across systems, brought trust leaders together, and laid the groundwork for future collaborative work. Provider collaboratives have also enabled the establishment of the joint governance and working cultures required to take on major capital projects, by establishing decision-making forums and shared values or principles.
The success of collaboration in delivering elective hubs has been driven by a number of factors including targeted investment, a focus on system-wide capacity and mutual aid and a system approach to workforce planning. These are detailed below.
Targeted investment
Integrated care boards (ICBs) have a significant role in capital planning, and the needs of acute, ambulance, community and mental health trusts must be given appropriate consideration as part of the operational capital prioritisation process. But the rising backlog maintenance bill – which currently stands at £11.6bn (NHS England, 2023) – means much of the available allocation is for operational, rather than strategic capital spending. The £1.5bn made available to create elective hubs has therefore been vital as it has enabled trusts to access capital from outside systems' stretched operational capital allocation.
Targeted investment has eased pressures on system resources and supported providers to collaborate. As set out in the case studies in this report, the acute provider collaborative in North West London (NWL) secured £9.4m in TIF funding to develop the NWL elective orthopaedic centre, with partner trusts supporting through additional revenue funding to pay for day-to-day running costs such as staff and consumables. For the Hertfordshire and West Essex system elective hub at St Albans City Hospital (part of West Hertfordshire Hospitals NHS Trust) meanwhile, the capital requirement for the hub is approximately £25m, £22m of which has been approved by NHS England from TIF funding. The system agreed to provide capital funding to support this, with each partner acute trust and the ICB agreeing to use system capital budgets to fund the remaining cost.
It is too early to measure the specific impact of elective hubs, but the decline in the overall waiting list from its September 2023 peak – driven by a focus on trauma and orthopaedics – demonstrates the improvements that can be brought about even in the context of sustained pressure, when a key priority is identified, and the NHS is supported to focus on it.
The Healthcare Improvement Studies (THIS) Institute is currently in the process of identifying the features of surgical hubs that are linked to higher performance and the impacts of these features on other aspects of the care they provide, as well as how they fit into wider hospitals and healthcare systems.
System-wide capacity
A key consideration for those applying for TIF funding was how the investment would provide system-wide capacity for planned care. Systems were asked to consider the current and future demand on their planned care services alongside how and when services will be fully recovered in line with the elective care delivery plan.
In their proposals, trusts and systems were asked to avoid variation in waiting times across populations. Inequalities of access are created by variation in waiting times for elective procedures, which can vary considerably between hospital sites in the same system. System-wide elective hub sites which receive referrals from across a number of trusts can therefore be instrumental in addressing these inequalities of access for local populations. This requires systems to have a detailed understanding of where the health inequalities are in the system, and the factors impacting them. As well as a good understanding of the waiting times, where these are the greatest, and where access may be exacerbated by gaps in capacity.
To do this, hubs have looked to address variation in waiting times by collaborating through sharing patient lists and transferring staff to other locations to address the longest waits across their system. To make this possible, trusts have expanded on approaches taken during the Covid-19 pandemic to provide 'mutual aid' where possible to tackle long waits and balance demand and capacity.
The hubs are also able to deliver wider system benefits, as the transfer of elective activity to hubs can free up theatre capacity within the trusts' non-hub theatres. This means other complex procedures which the hubs do not undertake can be prioritised in other sites. The hubs therefore do not only provide additional capacity for HVLC procedures; they support systems to plan activity more broadly, and address pressure points across surgical pathways.
Plans for elective hubs have also been specific in addressing system challenges articulated through joint forward plans and integrated care strategies, as many systems continue to grapple with elective waits and geographical inequalities in access.
Workforce planning
Hubs cannot succeed without adequate, protected staffing, but they share the challenges that exist across the NHS in attracting and retaining staff. In response, when they set up their hubs, trusts embraced new workforce roles and models across surgical, anaesthetic and theatre teams to ensure staffing is sustainable, and to help fill vacancies where recruitment is difficult. The staffing requirements for hubs differ depending on their design and location, as well as the specialties and range of procedures being undertaken.
A number of staffing models are available to providers, from creating substantive posts, to flexible, portfolio or visiting arrangements. For hubs which are managed through provider collaboration, shared approaches have been chosen.
For example, the NWL acute provider collaborative (APC) has chosen to pursue a 'visiting' workforce model, in which the surgeon travels to the elective hub to perform the operation. For example, if a patient is identified at Chelsea and Westminster Hospital NHS Foundation Trust and suitable for their procedure to take place at the hub at Central Middlesex Hospital (part of the London North West University Healthcare NHS Trust), the surgeon would travel to the hub to carry out the procedure. To support this, individual providers may schedule a pre-agreed number of lists on set days at the hub, led by their surgeons.
In South East London, in collaboration between five providers in the system, two new operating theatres were opened at Queen Mary's Hospital in Sidcup, to provide capacity on behalf of the whole system. The hospital site is run by Oxleas NHS Foundation Trust, a mental health and community trust, the surgical support staff are provided by Dartford and Gravesham NHS Trust, while surgeons travel in from Guy’s and St Thomas’ NHS Foundation Trust, King’s College Hospital NHS Foundation Trust or Lewisham and Greenwich NHS Trust.
Staff passports are one tool that will help systems and regions ensure that staff from multiple organisations can access a surgical hub. Staff passports facilitate movement of staff between organisations by sharing vital information (such as registration details, occupational health status, or confirmation of a persons’ right to work). Using an electronic staff passport increases the flexibility of the workforce model while maximising staff access to training opportunities. This can be particularly effective for doctors and nurses in training, ensuring they have suitable surgical training opportunities. The nationwide roll-out of the Digital Staff Passport will take place from July 2025. However, evaluations of the pilot sites describe these benefits, particularly supporting a system-wide approach to mobilise staff across systems and support system-wide initiatives such as elective hubs.
Our new report Providers Deliver: achieving value for money also looks at how the efforts of trusts must be matched by a commitment from government for capital investment to modernise buildings, equipment and technology in order to unlock greater productivity gains.