The long quest for closer health and care integration has taken on a new momentum. As this report shows, NHS trusts and foundation trusts are at the heart of this process. They are harnessing a spirit of collaboration, propelled by the pandemic, to find better ways of working. They are joining forces with partners to plan and provide for the needs of their communities, improving care for patients and service users. There is growing awareness and recognition at the centre – from government and national bodies - that providers are the 'engine room' for transformation, with a key role to play as leaders and co-leaders in this fast-changing landscape, and as the point of delivery for services. While important questions remain around the statutory role and remit of ICSs, how they're comprised, and what their governance, accountability and funding will look like, the collaborative arrangements developing within and across ICSs have shown they can operate in a range of functions, forms and footprints that deliver success.
It is because of this variety of approaches – and the different purposes they serve – that we have focused on provider collaboration in its broadest sense: exploring the characteristics of acute 'horizontal' provider collaboratives in the Greater Manchester ICS alongside 'vertical' integration at place in the local partnerships in Bradford and Craven, and Surrey Downs, highlighting perspectives from an ICS level community and primary care collaborative in Sussex, and the increasingly important partnerships between at-scale primary care providers and secondary care – exemplified by the work of the Modality Partnership, showcasing the mental health provider collaboratives such as in South London, and considering the role of ambulance services in Yorkshire and the West Midlands.
A key lesson from these case studies is the importance of leadership in driving the transition from competitive to collaborative ways of working, and the way relationships based on trust and shared objectives can transcend institutional barriers of governance, form or structure. The Acute Hospitals Alliance within the Bath and North East Somerset, Swindon and Wiltshire ICS highlights the shared commitment of three chief executives to deliver benefits for patients and staff by developing mutual understanding and playing to the strengths of each organisation. The importance of building trust across leadership teams is also a key theme of the South London Mental Health and Community Partnership in resolving new funding and commissioning responsibilities, and in the Dorset ICS where close working between NHS partners and colleagues in local authorities has been important in identifying and tackling deprivation and isolation.
While some of the relationships behind provider collaboratives go back many years, there is no question that the imperatives presented by the pandemic provided a powerful catalyst to develop these partnerships. The effect was neatly summarised by Andrew Ridley, speaking as the local care senior responsible officer for the North West London ICS, who said, "it put the finger on the fast forward button, so suddenly the theoretical questions stopped being theoretical and the 'them and us' mentality ceased."
Pandemic pressures forged closer collaboration over workforce, PPE and other equipment, it spurred progress on digital and clinical partnerships, and work to address inequalities. In the community provider collaborative across the Sussex ICS, work on the vaccination programme consolidated relationships across primary, secondary and social care, fostering a common purpose for delivery. And in the West Yorkshire and Harrogate Mental Health, Learning Disability and Autism Services collaborative, the pandemic provided a powerful stimulus for organisations to share and learn from each others' approaches to improve services for patients in their care.
Another key ingredient for successful provider collaboration is an unrelenting focus on a shared vision, with organisations working in a way that is right for their local patients and populations. Provider collaboration leaders in the Somerset ICS describe how coming together has allowed them to plan and move resources into prevention and early intervention services. And in the Bradford and Craven ICP, the 'Act as one' programme has delivered better joined up care, with a more collegiate approach to population health exemplified by work "across the continuum of care" to improve outcomes in maternity services.
One of the features of provider collaboration is the way in which it has brought together different parts of the provider sector: hospitals, mental health, community and ambulance trusts, along with other partners to deliver better care, closer to home, for patients and populations. They bring their own pressures, priorities and expertise to these collaborations, as evidenced by these case studies. The ambulance perspectives – as seen here from West Midlands and Yorkshire – highlight the challenges of working across multiple footprints, including at region, ICS, place and neighbourhood levels.
The West Midlands example highlights the opportunities for population health management and reducing health inequalities, acting as an integrator across the system. The Yorkshire case study also points to the way collaboration has helped to focus attention on the inequalities agenda.
Provider collaboration – in its many manifestations – is driving integration and delivering benefits for patients. But as we have seen, it requires commitment, strong leadership and a clear shared vision. It takes time and patience to build the right relationships, to develop and embed collaborative ways of working, and deliver improvements. Glen Burley, chief executive of the Foundation Group of South Warwickshire NHS foundation Trust, Wye Valley NHS trust and George Eliot Hospital NHS Trust, has this advice for those looking to move to more collaborative ways of working, "Don't try and design an end game situation, because everything keeps changing. The key enabler is to focus on incremental improvements."
So what needs to happen now? It is clear that providers want a flexible and enabling national policy and legislative framework that will build on, rather than disrupt, existing arrangements, while providing clarity on how accountabilities will sit alongside those of the statutory ICS, and trusts and foundation trusts. The recent white paper indicated that budgets and decision-making would be devolved increasingly to provider collaboratives and place-based partnerships, but the timing and nature of this needs to be worked out locally. For providers to come together as collaboratives and partnerships, acting as the engine room of transformation within ICSs in the way envisaged, they will need to be appropriately resourced.
They will also require ongoing support to share best practice and learning from peers. For this they can count on NHS Providers to play its full part as its provider collaboratives support programme takes shape in the coming months.