Partners involved in this provider collaboration:
- Sussex Community NHS Foundation Trust
- East Sussex Healthcare NHS Trust
- NHS Brighton and Hove CCG
- NHS East Sussex CCG
- NHS West Sussex CCG
- Brighton and Hove PCN
- East Sussex PCN
- West Sussex PCN
Background
The Sussex Health and Care Partnership covers a population of over 1.7 million people across three local authorities including Brighton and Hove City Council, East Sussex County Council and West Sussex County Council.
There are currently three collaboratives operating at ICS level in Sussex, including the mental health collaborative, the acute collaborative network, and the most recently established primary and community care collaborative network. They all report into the ICS health and care partnership executive once a month.
Siobhan Melia, chief executive of Sussex Community NHS Foundation Trust, chairs the primary and community care collaborative network at ICS level, and her colleague Kate Pilcher, chief operating officer at the same trust, leads on work at place-level. The network was initially set up in summer 2020 and Siobhan says, "it's been difficult to think forward this year, but now is the right time for us to try and create some headspace".
The primary and community care collaborative network, as Siobhan tells us, has a number of different organisations around the table, including the chief executive at East Sussex Healthcare NHS Trust, executive managing directors from the three CCGs who are responsible for either community services or primary care, and clinical directors from the primary care networks (PCNs). The collaborative also has representation at ICS level, including the director of the ageing well programme and the director of long-term conditions programme. They are also looking to include representation from a director of public health.
Setting up the collaborative
Siobhan explains that the main purpose of the primary and community care collaborative is "to provide strategic leadership and a collaborative approach to the planning and delivery of primary and community care services across Sussex" in line with the ambitions of the NHS long term plan. They operate both at scale and at local level, as they are developing a high-level primary and community care strategy for Sussex, with a view to delivering integrated models of care at neighbourhood level.
The impact of COVID-19
While they had several pieces of work exploring how they could tackle health inequalities before the pandemic, Siobhan says "COVID-19 has undoubtedly shone a spotlight on inequalities on so many levels". Sussex Community NHS Foundation Trust employed a public health consultant for the first time a year ago, and this has enabled them to think more comprehensively about population health, prevention and inequalities. "We are now in a good place to think over the coming year, 'how do we go further and faster with what we've got in place and what we've learned?'".
Siobhan and Kate both highlight a number of positive changes that have taken place during the COVID-19 response that enhanced collaboration, including accelerating digital services, which has transformed how they deliver care to patients in the community. Smaller peer groups across providers and commissioners have been set up to discuss and test potential workstreams before jointly presenting them to the wider network, integrating COVID-19 discharge hubs in line with the government’s hospital discharge service guidance, and now thinking about what recovery looks like for the primary and community care sectors.
Siobhan tells us the collaborative's discussions about recovery have largely focused on restoring wider access to primary care services, and for community health services the priority is to tackle the most challenging waiting lists, such as diagnostic services for autism, access to speech and language therapy, pain treatment and musculoskeletal conditions. All the partners in the collaborative want to ensure they effectively restore access to services and address the backlog for these life-changing and long-term conditions, among others.
She also discusses the positive impact of the COVID-19 vaccinations programme on primary care engagement with the ICS. She says, "we now have a weekly ICS programme board meeting to discuss strategy, tactics and delivery of the vaccination programme across Sussex, with a strong focus on addressing vaccine inequality. Representation is from a wide primary and community setting, with a clinical director from every PCN, or the federation representing them, the directors of public health from the three local government organisations, Healthwatch, myself and the ICS system leader". She notes that this may not necessarily be the governance structure that is "here to stay" as the vaccine programme continues to evolve, but the conversations that have taken place have been really balanced and collegiate and highlight the value of coming together.
Siobhan reflects on the impact of COVID-19 over the past year and concludes , "I think there’s potential to get to the point where we can engage on a better footing off the back of how we've had to come together in adversity".
The case for change
Kate discusses work underway at place level in Brighton as an example of effective provider collaboration. They have developed a shared system discharge improvement plan, with a collective focus on delivering key success objectives in four domains, systems and processes, capacity modelling, ways of working and communication. The team is developing shared outcomes for patients rather than looking at organisational components as individual health and social care providers. Siobhan says they are in the early stages of looking at the metrics to determine the level of impact collaboration has had, such as on the referral pathways to a community bed or a patient's home. This will be something they will continue to monitor going forward and they will hopefully then be able to aggregate this work into West Sussex and then expand it to East Sussex as well.
Kate also notes that collaboration means they can share workforce more effectively in Brighton. She explains, "we've had memoranda of understanding in place to be able to share staff across providers throughout the pandemic". They have also looked at workforce in the context of business continuity for care home staff and how they can all support each other to deliver care to the population.
Sharing lessons learned
Relationships built around a shared purpose have played a huge part in strengthening collaborative working. Siobhan points to the partnership they have with acute and adult social care colleagues, and how the collaborative approach of bringing everyone together under a common purpose has really changed things. She also touched on setting up peer groups, including a chief medical officers’ group and a chief nursing officers' group across providers that functions as a forum to discuss ideas before they are proposed to the collaborative network.
Siobhan also reflects on the COVID-19 vaccination programme and how it brought providers across primary, secondary and adult social care together in a way that the incident management response hadn't. She says the vaccine programme enabled a common purpose for delivery, and the recent decision to have frontline GPs 'at the table' of the collaborative has gone down very well.
"I've been a strong advocate since we set up the primary and community care collaborative network to have the frontline GPs, who are very visible in the community here, involved in these important discussions".
Challenges
Siobhan is clear there are challenges around deciding what happens at place, provider collaborative, and ICS level. She says, reflecting on the recently published white paper, "it seems place is going to have a bigger role than we first thought". She also shares some of her thinking around what happens at system level and at place level for community services, explaining that it would be beneficial to agree a best practice standard and funding for community health services across the Sussex ICS, and for places to hold responsibility for delivery, which can then be nuanced to meet the needs of their populations. Kate adds that the thinking around community care in its broadest sense, such as discussions around the number of community beds across the system, needs to be decided at ICS level.
The relationship between the provider collaborative at ICS level and the place based executive partnerships is also an area Siobhan and Kate highlight as a current challenge. Siobhan says there's an ambition at ICS level to be more collaborative and enable decisions to be made in partnership, but notes that there still seems to be a disconnect at place. Kate says, "I think at place level there is still a degree of variation in decision making across Sussex which is possibly a result of still having three CCGs". They both agree that the strategic direction in the NHS White Paper will improve alignment, as there will be one ICS NHS Body across Sussex accountable for the commissioning of services.
Next steps
One of the core projects for the primary and community care collaborative network focuses on population health management, and Siobhan says, "I think we need to step into a space that says we can understand communities in ways that the acute providers can't" and show how we're making an impact to address health inequalities. She hopes to do this in partnership with primary care, the voluntary sector and local government partners.
Siobhan also highlights how it will be important to recognise pathways that interface with the acute collaborative network. She says "our provider chief executives acknowledge the need to remain close on some of the pathway developments within acute services as they will obviously pervade across acute, primary and community services. It is important that some of these pathways are starting to be articulated through the lens of primary and community care, and from the perspective of prevention, rather than just from the lens of hospital appointments, outpatient elective recovery, etc."
They are also looking to review their community bed model and think more creatively about the right place for patients to receive their total pathway of care. Siobhan says there is scope for them to think about the out of hospital model, which Kate agrees will be "absolutely critical for future investment in community services as the right thing for most people is to be at home rather than in a community bed". Siobhan welcomes the fact that collaboration at ICS level and the move to one commissioning organisation creates, for the first time, a Sussex-wide approach to community beds.
National policy to support provider collaboratives
Siobhan highlights that each ICS is very different from the rest, which means that provider collaboration also looks different within each system. She is concerned that the current national policy proposals focus narrowly and predominantly on inter-NHS collaboration, when non-NHS organisations, such as local government partners and a range of voluntary sector organisations including hospices, have a key role in the community sector.
She says, "I don't think all collaboratives need to be structural and to follow the same blueprint. One of my concerns about the white paper is that they will shoehorn structure and make it overly complex, which will get in the way of doing what is right for patients and populations, particularly for primary care". She adds that members of the primary and community care collaborative network have had really helpful discussions during the pandemic, for example planning the community long COVID service, and what this means for primary and community services in the context of projected demand, and she would like to continue in this spirit.
While Siobhan acknowledges that it might make sense for some smaller scale community providers to focus on place, there is a clear case in ICSs like Sussex to bring together primary and community care services at scale to have a strong voice at the ICS table where they can demonstrate their value and influence the overall ICS strategy.