Partners involved in this provider collaboration:
- Central London Community Healthcare NHS Trust
- Hounslow and Richmond Community Healthcare NHS Trust
- West London NHS Trust
- Central and North West London NHS Foundation Trust
Background
North West London serves a population of 2.4 million people across eight boroughs including Brent, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, Kensington and Chelsea and City of Westminster.
Four providers within the North West London ICS footprint have operated an out-of-hospital community provider collaborative on an informal basis for at least two years, and conversations within the system are now underway to formalise the existing arrangements.
Andrew Ridley, chief executive of Central London Community Healthcare NHS Trust, and the local care senior responsible officer for the ICS, is leading a programme of work to standardise the community services 'offer' across the North West London ICS as part of this collaborative.
While the North West London ICS functions as the lead ICS for Andrew's trust, the organisation runs services across three other ICSs including Hertfordshire and West Essex ICS, South West London ICS, and North Central London ICS, adding a layer of complexity to managing collaboration across different systems and places.
Setting up the collaborative
Andrew explains that it all kicked off with a conversation between the provider chief executives within the ICS about the variation in non-elective admission rates across the eight boroughs. They began to discuss what they could do collaboratively to address this variation both within the acute trust setting and in the out-of-hospital space.
"It put a spotlight on the fact that there were different community based rapid response services in each of our eight boroughs, each commissioned by a different CCG". They operated to different specifications, and the fragmented commissioning model meant patients in one borough received different services to their neighbours. It was also particularly challenging for other providers, like the London Ambulance Service NHS Trust, which sit in the middle of the patch and look after patients from different boroughs, to refer a patient to the most appropriate community based rapid response service because the landscape was so complex. Similar challenges were faced in the commissioning of community beds, whereby patients could only access the beds in a trust if they lived in one of the boroughs that commissioned those beds.
"So it was that conversation that kicked off a piece of work that started to look at harmonising our rapid response services, their specification and our capability for core community services across the ICS".
The impact of COVID-19
The COVID-19 pandemic accelerated work to harmonise rapid response services across the footprint – each borough now has consistent opening hours, referral pathways and clinical capability. The collaborative had been operating for about a year before the pandemic, but the COVID-19 response and emphasis on collaboration and mutual aid really catapulted community providers' joint working forwards. When the infection prevention control guidance was initially published, the community providers decided to take a unified approach to managing bed capacity across every borough during this period of operational intensity, rather than as individual trusts. Andrew says this has led them to now undertake a formal bed review across the system and to establish a pilot "community bed bureau" to ensure they have the right number of beds and there is consistency in length of stay across all units. "I think COVID has undoubtedly had an amazingly catalytic effect…it just put the finger on the fast forward button, so suddenly the theoretical conversations stopped being theoretical and the 'them and us' mentality ceased…It took away the friction that you normally get when you're trying to manage change".
The case for change
Despite the complexity of provider collaborative arrangements, Andrew highlights that “if you take it to its core principles of collaboration and transparency rather than competition it is discernibly much better.” Throughout the duration of the pandemic, it was clear that trusts were communicating as one system, and Andrew believes this will play a significant role in the elective care recovery going forward.
He also emphasises some of the benefits the shift from competition to collaboration has had for NHS staff. “I think the melting away of competition is quite significant for them because it allows them to focus on delivering services to their populations, and not have to worry about losing their contracts” to another service. They still relate mostly to their immediate team rather than the wider ICS, however Andrew has noticed that his staff do feel a strong association at place level. He also emphasises how important the shift to digital has been in the past year in enabling frontline staff to feel more connected to their wider organisation and senior leadership team.
Sharing lessons learned
Andrew says the work they undertake as a collaborative is very much provider-driven and supported by the wider system, with an ICS local care team that supports change and improvement. All provider chief executives sit on the ICS board and are really engaged in the work of the ICS, as well as the borough-based teams.
He does also stress that the context in London is quite different and complex to other parts of the country. He says, "In North West London there are many trusts operating within a densely populated area, and so fragmentation drives inefficiency and inequity in a way that it potentially doesn't if you were talking about Dorset or Devon." He says, "I would give careful thought if I was running a trust in a different area of the country", and would consider the differences in population utilisation flow, the number of trusts and their catchment size when thinking about provider collaborative arrangements.
He also contrasts the collaboration taking place in the North West London ICS to arrangements in Hertfordshire and West Essex ICS, where the Central London Community Healthcare NHS Trust is the main community provider in the South and West Hertfordshire ICP, with a population of over 600,000. In this context the provider landscape is simpler, with a majority of people receiving treatment at one acute trust, the West Hertfordshire Hospitals NHS Trust, and service collaboration mostly occurring at place level with the ICP in London patient flow is more complicated and requires ICS level collaboration.
Next steps
Discussions are under way to formalise the collaborative arrangements across the community providers in the North West London ICS, and questions have arisen around the scope of the collaborative: should it continue to include just community health services or should it extend to cover other local care services? How does it relate to the existing separate mental health collaborative?
However, it is currently unclear how the community providers would have sufficient capacity and resource to deliver such a large scope. Another challenge Andrew highlighted is around determining how the current at-scale community provider collaboration relates to the ICPs, and how duties and budgets are allocated, for example at place level or through the collaborative.
There may also be an opportunity to explore strategic commissioning functions and expand the collaborative’s remit to address health and resource inequity across the ICS. Andrew pointed to the inequity across the eight boroughs, whereby the outer boroughs have significantly less service provision which is exacerbated by ongoing resource inequity, in comparison to the inner London boroughs.
Devolving budgets to ICPs could help address this inequity. The North West London ICS has eight 'place-based' boroughs, each with a quartet of directors covering primary care, mental health, community health, and the local authority to improve patient outcomes and service delivery. A key challenge is how to strategically move resources and make funding more equitable and needs based across the whole ICS.
National policy to support provider collaboratives
Andrew emphasises the need to keep national policy around provider collaboratives permissive and open to enable different ways of working collaboratively to take shape across different ICSs. He says the national thinking also needs to acknowledge the strategic role of community providers not just at place level but also within at-scale collaborative arrangements. He also says technical guidance could be helpful around governance and accountability, particularly as his collaborative could take on strategic commissioning functions in future and would need to be held accountable for delivering on this. Clarity on who they would be accountable to and for what will be needed if they do receive budget. Furthermore, there are questions around how a collaborative decides what work it would focus on and whether they would need to go through public engagement to prioritise work areas. Evidently, there are still very important questions that need to be answered by community providers and their partners, in a permissive, enabling environment.