Introduction

Understanding the national policy context

The context

The health and care system is undergoing significant changes to the way it is structured, organised and delivered. In recent years, the national policy direction has shifted away from trusts and foundation trusts competing for contracts, as was envisaged in the Health and Social Care Act 2012, towards collaboration as the main driver of improvement. Integrated Care Systems (ICSs) have been established to plan and deliver better joined up care for patients and service users, and better health outcomes for local populations.

As part of these changes, providers have increasingly sought to work more closely together to address common challenges, provide more integrated care pathways, and deliver more sustainable services. This approach has been further accelerated during the COVID-19 pandemic, which saw providers, and wider system partners, supporting each other during an incredibly challenging time. Alongside this the scale and impact of provider collaboration is fundamental in tackling unwarranted variation in outcomes, access to services and experiences, as well as in tackling health inequalities.

The next year will be a key transition period for ICSs, with the government’s legislative proposals aiming to place ICSs on a statutory footing by April 2022 (assuming the Health and Care Bill passes through the parliamentary process as planned). The associated policy frameworks will also change significantly, including the financial architecture, procurement model and regulatory frameworks, in response to this focus on system working and collaboration.

Trusts and the national NHS bodies have high aspirations for how provider collaboratives can operate and what they can achieve by working together. This report aims to identify key themes and share lessons learned from a wide range of provider collaborations spanning different functions, forms and geographic footprints, to support trusts to respond to national policy developments and embed collaborative arrangements within their local system(s).

National policy developments

Recent national policy documents have placed provider collaboration as a key pillar in the development of ICSs. NHS England and NHS Improvement's  Integrating Care paper, published in November 2020, renewed the vision for ICSs, setting an expectation for all trusts to be part of one or more provider collaborative, which will vary in scale and scope. The paper also reaffirmed the shift to strategic commissioning at ICS level, with other commissioning activities moving to provider organisations, provider collaboratives and place-based partnerships.

The Department of Health and Social Care's White Paper, Integration and innovation: working together to improve health and social care for all, published in February 2021, confirmed that ICSs will be placed on a statutory footing from April 2022, but places and provider collaboratives will not have a statutory underpinning. However, there is an expectation that decision making will increasingly be delegated to provider collaboratives and place-based partnerships. The 2021/22 planning guidance (April 2021) also set the expectation that ICSs will firm up their governance and decision-making arrangements this year, with trusts working collaboratively to deliver the NHS' priorities, such as tackling waiting list backlogs.

The scale, scope and complexity of these proposed changes are significant, with trusts at different stages of developing their collaborative working arrangements. NHS England and NHS Improvement’s new guidance on provider collaboratives will focus on supporting at-scale horizontal collaboration. It seems that NHS England and NHS Improvement intends to be flexible rather than directive, with the guidance expected to point to several potential models that are already working well in some areas, including: lead providers, shared leadership arrangements, and a provider leadership board[1]. However, it is important that the complexity, variety, and different levels of maturity of existing collaborative arrangements and functions are considered and built upon.

What does provider collaboration mean? 

State of play in the provider sector

Many providers have already been working together, formally and informally, to deliver more joined up care in a complex network of collaborative arrangements. The level of formality can vary greatly depending on the local context, the size of the ICS(s) that providers are working within, the composition of providers within that footprint, and population needs. While some have been collaborating in this way for over a decade, others are building on new arrangements developed during the COVID-19 pandemic.

In this report we set out examples of a wide range of collaborations taking place across the country to show the complexity of arrangements, including:

• horizontal provider collaboratives at ICS (or multi-ICS) level, for example bringing together acute services, or community and primary care services, across a larger geographic footprint
• vertical integration in place-based partnerships across community services, mental health, primary care and local acute services, as well as other partners such as local authorities and the voluntary sector
• mental health provider collaboratives taking on responsibility for the budget and care pathway of a number of specialised services across an ICS or regional footprint
• group models bringing together several providers of the same type under the same leadership, sometimes (but not always) leading to mergers
• formal vertical integration, with trusts bringing together acute, mental health and community (and sometimes primary care) services into one provider.

The current myriad of provider collaboration arrangements in each ICS cannot be neatly defined. Some provider alliances or boards have different provider types represented on them and many of these arrangements will have been developed of providers’ own volition. One type of provider collaboration does not preclude another, so there may be a group model or merger within a provider collaborative. Some providers are involved in place-based partnerships, at-scale provider collaboratives, regional networks and horizontal/vertical integration.

Sector-specific challenges will also need to be carefully thought through. For example, for providers working across several ICSs, places and neighbourhoods, such as ambulance services, collaboration becomes a complex task when it means contributing to a large array of different partnerships. Many mental health trusts have used the provider collaborative model for a number of years, so their previous experience, progress and challenges will vary to other sectors that have more recently set up collaborative arrangements. Additionally, there is a need to ensure that community providers have appropriate voice, input and opportunity to add value at all the different levels of the collaborative arrangements within local systems.

There are also complications for providers who deliver specialised services across much larger footprints than ICSs. NHS England and NHS Improvement’s Integrating Care paper references an important role for clinical networks and provider collaborations in driving quality improvement, service change and transformation across specialised (and non-specialised) services. At the same time, there are plans to devolve strategic commissioning responsibilities for some specialised services to ICS or multi-ICS level, depending on patient flows. The interaction between providers of specialised services and ICSs needs careful thought. It is incumbent on everyone involved – including NHS England and NHS Improvement – to continue working through the detailed issues to understand and shape the implications of system working in this area.

The case for change

The trust leaders we interviewed are clear that there is a key leadership opportunity for providers to be the engine room for transformation within ICSs and places. National policy on system working has evolved over time, from the original high-level strategic plans to the current recognition that providers are the key delivery vehicle within ICSs. The interviewees highlight several benefits of horizontal collaboration at scale, including tackling unwarranted variation, supporting sustainable services, and accelerating improvements in quality of care. Trust leaders also emphasise the advantages of vertical integration at place, with a much stronger focus on improving population health, tackling health inequalities and engaging with local communities.

Collaboration can also alleviate workforce pressures. Providers are able to create more attractive job opportunities, staff passports and portfolio careers for the health and care workforce when organisational barriers are removed. This creates the potential for providers to improve access and better manage demand and capacity across the ICS, which will be important for the recovery of elective care, meeting areas of under or unmet needs, and other services. It can also enable staff to focus more on delivering high quality care to the populations they serve.

However, the added responsibilities for trust leaders should not be overlooked, and support, time and investment will be needed to ensure there is capacity for them to service all these collaborations and continue leading their individual organisations.

Enablers and barriers to collaboration

Enablers

Our research has shown that there are several factors that enable effective collaboration. A common thread that runs throughout the case studies is the importance of developing strong relationships with partners. In many of these cases, COVID-19 has acted as a catalyst by providing a common purpose for providers and the wider system, bringing together senior leaders more regularly, and removing barriers to enable resources to be shared.

Buy in and alignment across senior leaders is also essential for successful collaboration. It requires leaders to take their organisations and staff with them. Senior leaders also need to have a strong commitment to modelling collaborative ways of working, which helps push forward proposals into action.

Having an unrelenting focus on patients, service users and local communities, including the NHS workforce, is also key, alongside a clear aim to address health inequalities. Trusts must ensure all voices are heard when developing collaborations, and the benefits for patients, staff, individual services and the wider care pathway are clear.

In systems where trusts have agreed to stop competing for contracts, this has opened up difficult conversations about who is best placed to deliver which services, with organisations prepared to "win some and lose some". Developing a memorandum of understanding between partners to provide clarity on the governance, responsibilities and risk-share of the collaboration can help, but it has to be underpinned by the right leadership, relationships and behaviours.

Barriers

While relationships are a key enabler of collaboration, managing competing priorities can be a significant challenge. Equally a lack of clarity around the governance arrangements and accountabilities can also stifle effective collaboration, particularly at ICS level.

Another challenge is working through the commissioning, resource and capacity issues within the system. Some of the case studies highlight the cultural shift required when it comes to risk-sharing and open-book accounting, particularly where there is variation between the performance of organisations within a collaboration (for example, better performing organisations within a poorer performing system). Historically fragmented commissioning arrangements and funding inequities also create challenges, with provider collaboratives looking to address variation in service provision and historic underinvestment in particular providers and/or localities within the ICS. Working through these complexities will take time and will likely require partners within a collaboration to continuously develop and refine their approach. It will also be vital for the national bodies to provide necessary resources and support to ensure the ambitions for integrated care and collaboration have the intended impact.

What are the next steps for provider collaboration?

Much of the collaborative work that providers have undertaken so far has been informal, innovative, and responsive to local needs. Formalising some of these arrangements under a national framework, in a way that is sufficiently permissive and enabling for the range and scale of collaborations already in existence, is a significant challenge, as well as an important opportunity. Several case studies in this report highlight the importance of the new policy and legislative framework being enabling and reducing bureaucracy, rather than further complicating the system architecture. This is the challenge for NHS England and NHS Improvement: to strike the right balance between providing sufficient guidance and best practice to support the development of collaboration, while enabling the appropriate level of local flexibility on the right issues.

There needs to be absolute clarity on how the roles and responsibilities of the ICS NHS body, the Health and Care Partnership, health and wellbeing boards, provider collaboratives, place-based partnerships and their constituent organisations will fit together, without overlap or confusion. There are also details to be worked through to ensure providers across different sectors have their interests fully and properly represented when the ICS NHS body is making decisions. Further questions remain around how multiple provider collaboratives, place-based partnerships and other collaborations will work efficiently together within an ICS, how funding will be allocated and delegated, and how this will be decided particularly within the context of strained resources. There are also examples of collaboration at scale taking place over multiple ICS boundaries, which adds further complexity.

We hope the report supports trusts and their partners – across ICSs, CCGs, primary care, social care, the voluntary sector and local authorities – to consider how they develop collaborative arrangements in 2021/22 and beyond.

[1] NHS England to set three models for NHS provider groups, Health Service Journal, 9 April 2021. https://www.hsj.co.uk/policy-and-regulation/nhs-england-to-set-three-models-for-nhs-provider-groups/7029864.article