The statutory introduction of 42 Integrated Care Systems (ICSs) in July 2022 reflects a bold attempt to re-design health and care delivery in a more holistic, 'joined-up' manner. NHS England's website has excellent video's describing ICSs and why they have been introduced. These videos highlight the role of partnership between traditionally disparate services to prevent people from becoming unwell as well as delivering the best quality of care at point of need.
The move towards ICSs in England is positive. But past ambitions of partnership working have not lived up to their hype. For integrated care to work, we must pay attention to the development of new and relational partnership behaviours, aligned to a shared and clearly articulated goal. In other words, exhibiting supportive behaviours that foster trust and openness in recognition that better patient outcomes can be achieved by working together than from working alone. But, as others have pointed out: partnership working requires carefully considered objectives, the right skills and resources, and meticulous – but patient – management.
In this blog I draw on the recent evaluation of the NHS-Virginia Mason Institute (VMI) partnership to illustrate how a compact can guide new relational behaviours that build trust and openness alongside collective processes of accountability for successful collaboration.
What is a compact?
A compact is a written promissory document that sets out the reciprocal expectations of collaborating partners. Best described as an 'explicit psychological contract', the compact formally identifies the expected reciprocal behaviours of each collaborating organisation aligned to a shared partnership vision.
'Compact creation' refers to a process of psychological contracting between key stakeholders where deep discussion about the goals of the partnership leads to the formal articulation of a shared vision and an explicit set of reciprocal behaviours designed to enable the partnership to achieve its collective ambition. In the example of the NHS-VMI partnership, senior representatives of then-NHS England and Improvement and the chief executives of the five partner NHS trusts engaged in this process over several weeks before an agreed set of reciprocal behaviours were approved by all members.
Discussions included honest reflections on helpful and unhelpful leadership behaviours and negotiating expectations about the explicit responsibilities each partner adheres to. Aligned to a 'collective ambition for the programme's success after five years and beyond', the NHS-VMI partnership compact clearly set out the responsibilities of each partner under the following headings:
- creating the right environment – act in a way that is respectful, honest and transparent
- fostering excellence – enable and support coaching and development of NHS leaders
- listening, communicating and influencing – listen and act in the spirit of shared endeavour and mutual learning
- leadership - keep commitments on deliverables, timelines and measurements.
These mutual responsibilities are detailed in an abridged version of the compact reproduced below.
Figure 1: A compact formalises the partnership vision and makes explicit reciprocal responsibilities and behaviours of each partner.
| Regulator responsibilities | Hospital responsibilities |
|
Creating the right environment
|
Creating the right environment
|
Fostering excellence
|
Fostering excellence
|
Listening, communicating and influencing
|
Listening, communicating and influencing
|
Leadership
|
Leadership
|
Since the compact should be the product of discussion and reflection among collaborating partners, we recommend using the NHS-VMI compact only as guidance. A compact should uniquely reflect the aspirations and reciprocal responsibilities of the collaborating organisations.
More than a promise – the compact is a mechanism for building trust, managing conflict and staying focused on the shared vision
I was fortunate to observe many of the monthly partnership meetings between the chief executives of the five NHS partner trusts and senior members of NHS England and Improvement during the three-year evaluation. Since 'reflections on the compact' was a standing and concluding agenda item of the meetings, I recall my anticipation of seeing the compact 'in action'. But each time, after everyone in the room (including myself) had verbally shared what they had personally learned from the meeting, I would leave feeling slightly confused.
It was some time before I truly understood how and why 'reflections on the compact' was critical to establishing and maintaining new ways of working. This is what I learned:
Ritualised and v erbal reflections on the compact make visible the ways in which organisations are fulfilling their obligations in line with agreed expectations.
This agenda item required all attendees to highlight what they had learned and what they especially valued from the meeting. Hence, successes became visible in ways that most exchange relationships take for granted. Usually, when organisations and representatives behave in ways aligned to expectations, we pay little attention. By contrast, these reflections fostered trust, a shared sense of celebration, and reassurance that collaborating partners remain committed to shared goals. In sum, this ritualised practice enabled new behavioural norms to emerge in ways that align to achieving shared partnership goals.
The compact presents a mechanism to make visible behaviours that are not aligned to agreed expectations: there will be times in most relationships where behaviours do not align to expectations. The monthly partnership meeting presented an opportunity for participants to 'call out' when behaviours are deemed incommensurate with the expectations outlined in the compact.
Crucially, making failure visible in the context of a safe relational space (a place where individuals feel safe to share challenges faced and receive constructive feedback and support without fear of reprisal – such as the monthly partnership meeting), presents an opportunity for collaborating organisations to discuss what went wrong, making sense of the failure for purposes of shared learning.
Hence, the compact becomes a mechanism for the timely management of conflict, facilitating collective problem solving and ultimately preserving trust. Further, timely management of conflict enables participants to jointly reflect on the shared vision, adjust behaviours as appropriate, and reaffirm their commitment to the partnership.
Can a compact work for trusts in systems?
All relationships depend on trust. Scholars define trust as a willingness to be vulnerable to the actions of another, based on an expectation that the trustee will behave in ways that support and benefit the trustor, irrespective of the ability to monitor or control that other party (cf. Mayer et al. 1995). The NHS-VMI partnership represented a new way of working between hospital chief executives and members of NHS England and Improvement, with whom previous working experiences would be at best considered 'arm's length', and at worst, a chief executive finds themselves subject to intensive scrutiny.
Neither of these scenarios are conducive to partnership working. What this partnership showed was the role of a compact in facilitating emergence of new relational behaviours in pursuit of a shared partnership goal. A compact is relevant for any kind of exchange relationship. What is important is key stakeholders are involved in its creation and the compact becomes a living document with fulfilment of expected behaviours celebrated, and deviations highlighted for discussion and collective problem solving (not blame).
Join us to learn more from the NHS-VMI partnership
Even as expectations for improvement in partnership across wider footprints increases, there remains an opportunity to support provider boards nearer the start of their own trust-wide improvement journey. As one of the only robust evaluations of long-term improvement capability and culture change available, there is a considerable amount of valuable learning from the evaluation of the NHS-VMI partnership to share, beyond that detailed in this blog.
Building on the success of the existing Trust-wide Improvement programme, accessed by 120 trusts so far, later this year there will be an opportunity for members to attend one of a series of small-scale invitation-only events designed to help board members understand the learnings from the partnership and consider how they might apply to their own organisational context.
Contact twi@nhsproviders.org to express your interest in joining these events, and your name will be added to the invitation list and more information sent in due course.
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