Provider collaboration offers a range of opportunities to improve care and make better use of resources. But – like any change programme – as the ambition and depth of trusts’ collaborative arrangements grow and statutory ICSs develop their ways of working, there will be risks for trust boards to identify and manage appropriately.
Complexity of collaborative arrangements within systems
Trusts in systems are likely to have multiple collaborative arrangements with other trusts and wider partners, which will perform different functions and operate over a range of geographic footprints including place, neighbourhood, ICS and multi-ICS levels. Many trusts will also be part of pre-existing multi-agency collaborations like cancer alliances and other networks, at the same time as also developing collaborations with wider partners such as local primary care services in their place(s). National policy has rightly left scope for ICSs to develop these arrangements based on local needs. However, the complexity and variety of different partnership models within any single system could make aligning priorities in each tier challenging. For trusts and collaboratives operating across multiple systems – and in some cases spanning a boundary between NHSE regions – this potential complexity is magnified. Without thoughtful coordination across collaborative vehicles, there may be a risk that trusts are asked to respond to multiple misaligned priorities that make incoherent asks of their leadership teams, clinical services and operational teams.
Recreating a commissioner/provider split
For several years, a national policy focus on collaboration and integration has seen local commissioners and providers increasingly working together across organisational boundaries – gradually blurring traditional notions of functionally separate commissioners and providers – and using their capabilities to collectively plan and improve care. Some stakeholders highlight a risk that the creation of sector-specific provider collaboratives could reverse this development and less collaborative, transactional relationships could re-emerge between trusts and commissioners. Leaders’ behaviours and mindsets, and the extent to which they maintain a population and system focus when working through collaboratives, will be key in mitigating this risk.
It is also worth noting that provider collaboratives are a varied set of arrangements with some collaboratives, for example some mental health collaboratives, embedding ICBs within their membership and collectively delivering commissioning functions and provision. Some trusts also highlight a need for integration with primary care colleagues, and with social care, which the current national policy focus on provider collaboratives does not seem to facilitate.
Finally, while providers remain keen to work with ICB colleagues to ensure that functions and funding is delegated appropriately to provider collaboratives, this is a complex change programme in itself requiring risk management. Provider collaboratives, and the boards of their component providers, will wish to assure themselves that appropriate resource (and in some instances commissioning expertise) is being delegated along with the functions they agree to lead on behalf of their populations.
Misaligned oversight arrangements and regulatory frameworks
Trusts retain all their statutory duties and liabilities under the Health and Care Act 2022. The development of provider collaboratives does not change this, but it raises new questions about how service performance and care quality can be effectively understood, assessed and overseen. In particular, the oversight mechanisms used by NHS England and the regulatory framework used by the Care Quality Commission (CQC) will require refinement. Both NHS England and the CQC are adapting their approaches to gather more nuanced insights into how effectively services are meeting people’s needs. For trust boards, there are important questions about how collaborative arrangements will be assessed and how that will interact with boards’ ongoing organisational accountabilities. Relatedly, trust boards want to understand how the regulatory framework can support trusts to fulfil the Triple Aim and take decisions in the best interests of the system and its population, even if there are potentially negative consequences for their organisation.
Supporting both high-performing and more challenged trusts
As the provider collaboration agenda develops, there are questions about the role of collaboratives in supporting more challenged trusts. Recent statements from political leaders, including Sajid Javid during his tenure as secretary of state for health and social care, emphasised collaboratives’ capacity to help organisations encountering performance challenges. This builds on experience over the last decade, following the 2013 Keogh review into trusts with unusually high mortality rates, of ‘buddying’ challenged trusts with a high-performing peer to support learning and sharing of good practice. Trust boards may embrace driving up quality and access in their ICS(s) by supporting partner trusts. However, it will raise long-standing questions about how their organisational performance will be assessed and contextualised if, through a collaborative, they devote resources to supporting a struggling neighbour. The oversight and regulatory regime will need to support them to make these choices and have the necessary nuance to assess and recognise improvement where it occurs.
Risk management and oversight for trust boards
Trust boards play a vital role in the NHS, providing robust organisational governance and risk management. The development of system working – with trusts collaborating in multiple vehicles and potentially on multiple footprints – is raising new questions for boards about how they can perform their functions and meet their statutory duties and liabilities effectively in this context. For NHS foundation trusts, there are some specific questions regarding how best to involve councils of governors.
Trust board members retain legal liability for decisions made by collaboratives and in turn need to maintain a line of sight to the collaborative(s) of which their trust is part. At the strategic level, trust boards will have a particular interest in some key dimensions of collaborative working – including how the provider collaborative’s strategic priorities are developed; how decisions will be taken within collaborative arrangements; how joint programmes will be resourced; how any disagreements will be settled; and how ICS/collaborative risks will be identified, owned, monitored and managed. Based on conversations with trust company secretaries, we have developed a set of key questions for trust boards to consider in relation to collaboratives. These are intended to support with constructive challenge and meaningful oversight of collaborative arrangements (see box).
- is the strategic direction of the trust aligned to the collaborative strategy?
- is the collaborative infrastructure appropriate and proportionate?
- are collaborative arrangements appropriately resourced to deliver?
- is there a mature (maturing) risk management system?
- what options will a trust have if serious performance challenges occur?
Without careful calibration of trust boards’ involvement in, and oversight of, provider collaborative decision-making – including robust scrutiny and challenge from non-executive directors – there is a risk that boards’ ability to effectively manage risk is eroded as the operating environment for trusts becomes more complex. This reinforces the need for trusts to identify and monitor these risks, and to ensure the governance arrangements they work through, to which trust boards are integral, are strengthened – and not eroded or confused – as statutory system working develops. Governance arrangements must also be proportionate and not unduly complex. Trust boards are adjusting their ways of working to strike a constructive balance in how they operate to support their trusts to realise opportunities stemming from provider collaboration, while also proactively managing the questions and risks which arise through emerging collaborative arrangements. NHS Providers will continue to support trust boards as they navigate this process and support them to share learning.