Building on the nationally identified benefits of provider collaboration at scale, trusts of all sectors see opportunities in this way of working and are involved in multiple collaborative arrangements of different types – some horizontal and others vertical – at place, ICS and multi-ICS level. Consequently, the blend of opportunities that collaboratives can seek to realise will depend on the local context.
In this section we highlight trust leaders’ experience of collaboration at scale depending on their sector and draw out some – although far from all – of the opportunities for each sector, based on trust leaders’ views. We also share trust leaders’ reflections on what this suggests about the roles that provider collaboratives will play in the future NHS operating model as statutory ICSs become embedded.
Mental health providers
For several years, mental health trusts have been working collaboratively to redesign care pathways and improve services. NHS England’s New Care Models programme, established in 2015, brought mental health and learning disability trusts together with wider partners, often using a lead provider model, to improve care for local communities. These arrangements evolved in April 2020 into NHS-led provider collaboratives for specialised mental health, learning disability and autism services, which aimed to provide specialist care in the community and reduce the length of stay in inpatient settings where appropriate. These collaboratives took on responsibility for some specialised budgets and have been able to realise benefits, such as the West Yorkshire and Harrogate mental health provider collaborative reducing length of stay in specialised inpatient care (prior to COVID-19).
The mental health sector therefore has expertise and experience in implementing a collaborative approach, and now aims to build on this to improve outcomes and standardise care; reduce health inequalities; improve use of capacity across providers; reinvest efficiency savings into community services; and shift to a population perspective when designing services. Mental health provider collaboratives will also have an important role to play in ensuring mental health is embedded as a priority in system decision-making.
Some more established mental health collaboratives have already expanded their membership across a wider range of organisations, while others are looking beyond service delivery and considering how they can consolidate back-office functions and provide collective staff training programmes. For example, the South London Mental Health and Community Partnership has taken this collective approach to retention, and its nursing development programme has resulted in a 5% increase in nurse retention rates.
As the national policy direction has shifted away from competition to collaboration, acute trusts have increasingly sought to work more closely together to improve care for local populations. While some acute provider collaboratives were well established prior to COVID-19, and have developed robust collective decision-making arrangements, others have evolved through the major incident response structures that brought trust leadership teams together locally during the pandemic. Their aims tend to centre on planning services at population rather than organisational level to deliver better integrated, high quality and more cost-effective care for patients.
Acute trust leaders tell us they see a clear opportunity to take a system-wide approach to sharing best practice and driving improvements in quality of care and access. As explored earlier, clinicians are working together to develop shared clinical strategies with an emphasis on improvement and standardisation, while some acute collaboratives are already delivering specific priorities for the ICS. Many acute provider collaboratives are also considering how to improve equity of access to timely, high-quality services for their whole population.
Trusts are building on each other’s capabilities, understanding that, by playing to each other’s strengths and working at scale, they are better able to deliver tangible improvements in efficiency, safety and quality for patients.
For specialist trusts and providers delivering cutting-edge specialised services to often relatively small numbers of patients across large geographic footprints, collaboration offers a number of opportunities.
Firstly, there is an opportunity to create communities of clinicians operating in individual trusts and support them to share practice in a systematic way that drives up standards and quality of care and foster a professional environment which supports clinical research and innovation.
Secondly, there is potential to explore new approaches to deploying highly skilled staff across larger geographies, thereby improving patients’ access to specialist care.
Thirdly, the planned delegation of much of specialised commissioning to ICBs, expected to take place from April 2023 onwards, will initiate localised decisions about how substantial specialised services funds are used. Bringing together trusts delivering specialised services could support a collective discussion of needs and priorities, alongside ICBs, including how best to allocate specialised services funding in light of local needs and service capabilities.
Finally, there is scope for collaboratives focused on specialised services to take on a more strategic leadership role, similar to that of NHS-led mental health provider collaboratives, redesigning clinical services, transforming whole pathways of care, and driving education and research across regional footprints, and potentially taking on some functions which previously sat within commissioning organisations.
Although national policy only mandates acute, specialist and/or mental health trusts must be part of a provider collaborative, community provider leaders see similar opportunities to deliver economies of scale and standardise services and pathways. For example, provider collaboratives could have a key role in tackling community care backlogs of over 1 million patients and working with social care partners to address delayed discharges. Collaboration between community providers has therefore been developing with similar aims to other sectors; to reduce unwarranted variation across services, share best clinical practice and support transformation of services. In many areas, a patchwork of service offers exists, and collaboration at scale presents an opportunity to address the variation in community service provision that can result.
As well as collaborating horizontally, community providers also have a significant role to play in vertical collaboratives with wider system partners across primary care, acute and mental health. Some ICSs, such as Sussex ICS, are setting up community and primary care collaboratives at system level to provide a coherent voice for ‘care in the community’ and ensuring services are sufficiently prioritised in planning and funding discussions. During the pandemic, some systems consolidated relationships across primary, secondary and social care to work on the vaccination programme, fostering a common purpose for delivery. These relationships have continued to build as the community sector supports the system in recovering from the pandemic.
Community providers’ involvement in these different types of collaboratives also speaks to their importance in delivering the strategic ambitions of the NHS long-term plan at all levels of the ICS as well as how they can act as an interface between at scale and place-based collaboration. Community provider collaboratives are often leading on the delivery of the Ageing Well programme across the system, including the two-hour urgent crisis response and programmes related to hospital discharges.
Ambulance trusts already operate across several ICS footprints, giving them a unique region-spanning viewpoint. Ambulance trusts are well placed to participate in, and lead, some provider collaborative programmes where it makes sense to do so, such as reducing unwarranted variation in access and quality. In particular, in the urgent and emergency care pathway there are potential improvements which will provide a more integrated experience for patients, which will require collaboration between acute, ambulance and community trusts as well as wider system partners such as social and primary care. For example, Yorkshire Ambulance Service NHS Trust is working as part of the Northern Ambulance Alliance to embed integrated leadership teams within all three ICSs it works across to ensure there is shared knowledge about 999, 111 and other urgency and emergency care protocols.
National guidance suggests that ambulance trusts have a role to play in provider collaboratives because of their rich knowledge of local populations, and their experience of working closely with partners. Trust leaders are keen to realise the full value of their contribution in facilitating integrated provision across services and population health management. West Midlands Ambulance Service University NHS Foundation Trust is looking to realise the benefits of sharing population health data with partner trusts to help prevent patients needing to be admitted to hospital.
Emerging and developing roles of provider collaboratives in systems
National policy has positioned provider collaboratives as central to delivering the aims of ICSs, while leaving scope for trusts and their system partners to define what this means in practice. Looking across the experiences of trust leaders developing collaboratives – and recognising that the roles of provider collaboratives in ICSs are still emerging – trust leaders see provider collaboratives playing an integral part in the future NHS operating model:
- delivering key system priorities, including the forward-looking objectives outlined in the NHS long-term plan (to be refreshed in autumn 2022) and short-term deliverables set out in regular operational planning guidance, as well as contributing to the broader set of objectives focused on improving population health, addressing health inequalities and promoting social and economic development
- providing functions that merit being done once across the ICS, such as leading on digital and data infrastructure, or standardising outcomes/processes which can support local delivery approaches
- amplifying the voice of different parts of the provider sector within ICSs to influence system decision-making. This is potentially particularly important for mental health and community trusts, whose priorities will need to be strongly expressed at ICS level.
- taking on traditional commissioning functions, such as service planning, improvement and redesign, service monitoring and some resource allocation decisions, to improve outcomes for local communities. Provider collaborative arrangements will likely need to evolve over time to enable them to take on more responsibilities.
Finally, the Act facilitates provider collaboratives to take on more formal responsibilities from ICBs, including budgets and functions, via delegation agreements – further recasting the traditional provider/commissioner dynamic. Work to move in this direction is at a relatively early stage, with implementation to begin in 2023/24. Trusts want to explore how collaboratives could evolve, in many cases, from operating through informal arrangements and delivering collaborative programmes of work into more formal entities holding and allocating NHS funding to improve care for communities.