Partners involved in this vertical integration:
- Airedale NHS Foundation Trust
- Bradford Care Alliance Community Interest Company
- Bradford Care Association
- Bradford District Care NHS Foundation Trust
- Bradford District Voluntary and Community Sector Assembly
- Bradford Teaching Hospitals NHS Foundation Trust
- City of Bradford Metropolitan District Council
- NHS Bradford District and Craven CCG
- Primary care providers
Background
The seeds of today's partnership were sewn back in 2011 when local health and care organisations came together to create an 'integrated care for adults' programme. The partnership brought together the providers, local authority and commissioners at the time to implement this piece of work following the Health and Social Care Act 2012. They collaborated in their own way in response to local population needs, which did not always fit into the mould of national policies and programmes, such as the new models of care vanguards.
Helen Hirst is the chief officer for Bradford District and Craven CCG and the senior responsible officer for the ICP development work in West Yorkshire and Harrogate ICS. She tells us how "in our context, the CCG is seen as the collaborator pulling the partnership together, which is a bit different to how some other systems operate." In 2015, the CCG made a commissioning policy decision to not use competitive procurement as a first option, and instead work with their provider market. This evolved into a unified approach to funding and commissioning services across the partnership and influences their ICP today.
Setting up the collaboration
Helen tells us one of the early projects was their transforming diabetes programme. She says, "the programme has had its challenges, but it brought the providers across acute, community, primary care and mental health together – and that was the key objective." She says it also "brought commissioning into a different space where we were facilitating and supporting providers and their services." While the transforming diabetes programme did not achieve all its intended outcomes, it did demonstrate that collaboration was part of how the system and system partners worked.
In 2017/18, a strategic partnering agreement was in place between the providers, local authority, voluntary and community sector and the three CCGs at the time. Helen says, "we decided to close our financial year in a collaborative way, and from then on we didn’t have individual contractual discussions." Helen also tells us how the CCG decided to use the system wide surplus to support providers as well as investing in projects such as the 'Reducing inequalities in communities' programme. Interestingly, this did have a negative impact on the CCG's rating from NHS England and NHS Improvement, but "it was the right thing to do because it enabled us to think more about wider population health."
In terms of the governance arrangements, James Drury, the programme director for the ICP board, tells us how partners across the whole system are part of the decision making process. The board includes representation from the chief executives of trusts, the local authority, social care providers, primary care and the chair for the voluntary sector assembly. The voice of PCN clinical directors is brought in through a clinical advisory board.
Andrew Copley, the system finance director for the ICP, adds that they now have a system finance committee with representation from across the whole partnership. This means there’s a focus on collaboratively managing the total resource allocation for the place.
The impact of COVID-19
Helen tells us how the relationships they have developed over the years made it easier to respond to the COVID-19 pandemic. Out of this partnership approach a new 'Act as one' programme was developed during COVID-19 to help them plan the recovery and restoration of services as well as preparing the ground for the future health and care landscape.
Kim Shutler, chair of the Bradford District Voluntary and Community Sector Assembly, tells us how partners from the ICP came together as part of the COVID-19 response in a different way to elsewhere in the country. There was a seat at the decision making table for voluntary and community sector representatives. She participated in the NHS Gold Command cell leading the operational response and tells us how "the role that voluntary organisations play in the health and care system is recognised here." This has now evolved into a strategic coordination group which has enabled them to mobilise interventions within their communities more effectively, such as thinking about "how we can get health messaging into neighbourhoods, schools and other local community settings."
Mel Pickup, the chief executive of Bradford Teaching Hospitals NHS Foundation Trust who started her role in early 2020, also highlights how "COVID-19 really short-circuited the normal period of time it would have taken to build relationships because we saw much more of each other virtually than we would have in normal times." She discusses how some of the lessons learned from the COVID-19 response around improving remote access to services is being used in the development of new programmes with primary care to keep people out of hospital as much as possible.
The case for change
The 'Act as one' programme has enabled the development of a shared set of workforce principles and policies to allow staff to work together across organisational boundaries to deliver better joined up care, share population health data across partners, and set priorities based on shared data. For example, this enabled the ICP to collectively decide to increase resources to autism services and reduce the backlog in this area, as this was identified as a priority within their system.
Mel tells us how the shift to think more collegiately about population health has enabled them, as an acute trust, to think more about keeping people out of hospital. She uses an example of maternity services to explain the vertical integration with primary care, whereby "our obstetricians and our maternity staff now have a responsibility across the continuum of care to intervene earlier and reduce poor outcomes in maternity services."
Mel also discusses the horizontal integration between six acute trusts across West Yorkshire and Harrogate ICS, and how collaboration at this level alongside place level enables them to explore areas, such as workforce and specialised equipment "to consolidate investments and make their services more resilient, cost effective and improve operational efficiency."
Andrew adds, "it's been an eye opener in terms of how much, as an acute provider, you were focused on your silo mentality rather than wider health inequalities. Now we're thinking more about our total resource and responsibility and looking at how resources can be moved across the system to address wider issues. This is the right thing to do and simultaneously supports our work as an ICP."
Sharing lessons learned
Everyone we spoke to in the ICP discussed the importance of relationships on a personal level, with an emphasis on building trust and having a shared purpose. James adds, “when you start with governance you end up working together within a set of rules rather than a shared purpose and that’s why investing in relationships and unifying our purpose is so important.”
However, relationships are not without their challenges. Helen tells us how in the early stages of their transforming diabetes programme, “it was easy to see how collaboration might work in theory, but in practice it was difficult for partners to let go of their money to support the development of this programme." These relationships take time and effort before gaining traction.
Mel adds, “the delegation of money will always bring with it the challenges of how we distribute it in a fair and equitable way. The hope is that we have done enough of the groundwork to enable us to work through these challenges in a mature way.”
Strong leadership is vital and Kim says, "there are some leaders who will understand the important contribution that voluntary organisations bring to the table, and create a space and opportunity to be inclusive, and this is being filtered down." She adds, "if you really want to address health inequalities and look at making sustainable change, you need voluntary and community sector organisations around the table."
Brendan Brown, chief executive for Airedale NHS Foundation Trust and partnership lead for Airedale, Wharfedale and Craven Partnership, said "We are an incredibly diverse area not just in terms of our population but also our geography and the communities we serve. This means we have to consider the needs of all our people stretching from Airedale and Craven through to Wharfedale and into Bradford. For example, we work across more than one local authority area, so this can be challenging but also offers us a real opportunity to develop those relationships across our place and learn from each other."
Next steps
One way the ICP utilises its leaders to enable collaboration is by taking a distributed leadership approach across its programmes. Mel explains, "we take responsibility to lead a programme focused on specific population needs and addressing unwarranted variation. We cover areas that aren't necessarily within the scope of our day job and we identify touchpoints along the continuum of the programme where working together with our partners across the ICP enables us to be more impactful."
Brendan and Kim discuss some of the key priorities for the ICP going forward, including tackling health inequalities, COVID-19 recovery, and a strong focus on the workforce. From the perspective of voluntary and community sector organisations, Kim mentions that "one of the big challenges for the sector when participating in an ICP to address these priorities is the resource, capacity and time it takes to realistically mobilise quite a diverse spectrum of organisations." She also highlights how the sector is vulnerable in terms of financial sustainability which makes participation in ICPs and ICSs more challenging.
National policy to support provider collaborations
The senior leaders in the Bradford District and Craven ICP are keen to make sure that they continue to build on what they have developed, strengthen the partnership, and deliver benefits for patients and the wider populations they serve. As a mature partnership, they all highlight their concerns around having to change their approach or pause development in areas if it does not align with national policy changes.
Mel notes, "we're quite a mature system and there's a risk that national policy will result in us being shoehorned into a different structure and we will have to reframe the way we work, even though our current arrangements are working well for us and our communities." Andrew adds, "I think we've got momentum to get on with it, and what's stifling our collaboration is some of the national policy changes taking place."