Making provider collaboratives work: a little less conversation a little more (integrated) action

By July 2022 all acute and mental health services will be required to become part of a provider collaborative. Other providers, including community services, ambulance trusts, and non-NHS providers, should be part of a provider collaborative where this would benefit patients and would make sense for the providers and systems involved.

NHS organisations have historically worked together to address mutual challenges. However, the potential role and scale of provider collaboratives within integrated care systems (ICS) and the opportunities to deal with the wider challenges facing health and care are new and need to be considered carefully to be effective.

To hear more of our reflections on Provider Collaboratives and future priorities, you can sign up to attend our webinar on 21 June 2022 here.

What are provider collaboratives and what are they expected to achieve?

We have written previously about what provider collaboratives are and expectations for them as set out in NHS England’s guidance.

Under the guidance provider collaborative ambitions include:

• Reducing unwarranted variations in care, including inequalities in health outcomes, services, and patient experience
• Improving resilience via arrangements such as mutual aid
• Better recruitment, retention and development of staff and leadership talent
• Enabling increased specialisation and consolidation to provide better outcomes and value.

Existing arrangements such as the Greater Manchester Provider Federation Board, and NHS led mental health, learning disabilities and autism ‘alliances’ evidence how new collaboratives can be established but the challenges under the new ICS operating model will require different thinking and approaches. For example, many collaboratives are already acknowledging that under the new model they will need to appoint a managing director to ensure that it has senior capacity and leadership resource to operate effectively.  

As the approach to developing collaboratives has been permissive, there are several varying approaches operating across ICSs with some limited to acute or mental health, autism, and learning disability providers, while others include all Trusts across a region. This creates complexity, but also opportunity to work differently. Each collaborative will need to fit into the new NHS architecture under its ICS(s) and the statutory Integrated Care Board (ICB) developing alongside it. 

What should collaboratives look like (form and governance)?

There is no prescribed form in the guidance. Instead, collaborative members should determine what works best using the guiding principles set out. Three models were suggested as existing approaches - provider leadership board, lead provider, and shared leadership models - though these were not intended to be exclusive of other approaches. 

The Bill provides a different legislative palette for integrated working between NHS Trusts and the ICB which should also be considered. Specifically, it will enable ICBs to delegate functions to NHS Trusts, and to form joint committees to take delegated decisions together. This means that other options and opportunities can be considered (along with the current options being used) once the Bill is passed. Bearing all this in mind, what are the key emerging issues that provider collaboratives need to concern themselves with now? 

(1) Where do historic system commissioning functions, staff and resources land?

With the dissolution of Clinical Commissioning Groups (CCG), the Bill has been interpreted by some as the end of commissioning creating the opportunity for providers to take on control and responsibility for the ICS. While the legislation and operation of formative ICBs has not taken this drastic an approach, there are powers in the Bill which would enable an ICB to take a highly delegated approach moving significant functions and resource to NHS Trusts. It will be for each ICB to decide if it wants to do so working with providers in collaboratives, at place and individually.

This raises the question of how (or if) the ICB wishes to utilise commissioning skills developed through CCGs to continue integrated working at scale, and where within the system these resources should sit. The Bill transfers this initially to the ICB but, looking forward, there are competing options for how and where the resource might be used:

• in some areas ICBs might create commissioning structures to support place-based partnerships with further division of the resources for ICS level support and then system-level provider collaborative(s);
• in areas where the provider collaborative structures (and the development of the ICB infrastructure) are more advanced there could be opportunities for commissioning functions, resources and staff currently with CCGs to transfer to support a more integrated approach between the ICB and the collaborative.

There will clearly be many pressures for this resource to sit at either ICB, place or collaborative level. There are also concerns in some systems that losing commissioning skills to provider collaboratives will provide them with a high degree of influence and control in the system and diminish the role of other providers (such as primary care) and place based partnerships. This risk could be mitigated through the ICB retaining funding/resource and allocating it to work with collaboratives though this would not enhance integration and there would be a question over, for example, how efficient it would be for the ICB to administer this approach and where accountability would then sit. Clearly to deliver a more devolved model at collaborative level the provider collaborative should be able to manage funding between a number of providers with robust supporting governance, potentially supported through delegation or contracting arrangements with the ICB and between partner organisations to allow for oversight and clear accountability for delivery. 

(2) Understanding the overall purpose of the collaborative – clarity on the problems it is looking to address

The white paper describes provider collaboratives as being clinically led, with improved patient experiences and outcomes at the heart of the model. However, some clients have expressed concern about the overall purpose and function that their provider collaboratives are expected to fulfil. 

Many successful existing provider collaboratives were driven by the need to address a clearly defined challenge or issue within a local system, the decision to work together to address the challenge usually then being made locally by leaders. Likewise, in the national drive to create specialist mental health provider collaboratives, data indicated a clear need to address the problem of out-of-area placements. This need aligned with financial incentivisation from cooperation, drove mental health providers to collaborate. 

Some current aims being ascribed to provider collaboratives look for outcomes at a system level such as reduction of health inequalities, uptake of successful innovation, alleviation of workforce pressures, and the integration of services with place-based partnerships. There is a risk that too much could be asked of nascent provider collaboratives too soon, and that they could easily flounder and become overwhelmed by the scale and number of these targets.

(3) Working with and avoiding duplication with the ICB 

As provider collaboratives and ICSs work out their roles and functions, avoiding duplication will be important. Many of the outcomes that ICSs might reasonably want to achieve could also be delivered via a provider collaborative. 

Clearly the ICS (via the ICB) will need to work with provider collaboratives as a key element of the delivery model for its ICB five-year plan. However, as ICBs are currently forming and appointing their designate key roles there is a question mark over their approach to provider collaboratives in many areas and who will ultimately be held accountable for delivering which outcomes. The collaboratives and the ICB should be aligned and clear on the role and purpose of the collaborative in the ICS and how it will help to deliver the plan.

Some clarity may come from additional powers under the Bill such as the ICB power to delegate to NHS Trusts as well as the ability for the ICB and NHS Trusts to form joint committees which could be utilised to deliver a more aligned approach to a system collaborative with the ICB. 

With some provider collaboratives spanning multiple ICS footprints, there will be greater complexity to manage in terms of their relationships at a regional level together with balancing the potentially differing needs of their constituent ICSs.

(4) Composition, resources and investment

The guidance summarises perceived benefits for different types of provider in becoming a member of a provider collaborative, many of which relate to overall system goals. For example, acute trusts are expected to make the most of their opportunity to deliver benefits of scale and deliver resilience across a system; community providers, many of which will work across a single system or even straddling system boundaries, will provide an important link between collaborations; ambulance trusts could take advantage of their rich local knowledge to lead programmes to reduce variation across places in terms of access to a variety of services. 

For organisations which cover multiple ICS footprints, there is a question over how they fit into a newly forming web of collaboratives which follow local ICS models. 

There are also concerns about the new resource that will be required to support and engage in provider collaboratives (potentially in multiple collaboratives). An ambulance trust or mental health provider could be engaged in multiple provider collaboratives as well as work at local/place-based partnerships. It is unlikely to be realistic or efficient for the Trusts to expect senior resource spread thinly across many collaborative groups. The governance around collaboratives needs to be designed to assist in this and not create additional groups and meetings replicating existing systems. Infrastructure must be purposeful and streamlined to encourage engagement and clear decision making. 

Collaboratives also need to ensure that there is appropriate representation from members. Given that NHS Trusts remain separate statutory bodies, consideration should be given to how collaborative membership works within the internal governance of the Trust and how the collaborative’s work is reported back. This includes clarity on the roles of non-executives within the structure/delegation and decision making. 

Senior resource is also required, along with day-to-day operational support. Criticism of existing collaboratives has been around the lack of clear dedicated staffing resource (with officers having a ‘day job’ at their Trust in addition to the collaborative) and also structurally in terms of inability to take decisions quickly or to bind organisations into collective decisions. In some existing provider collaboratives (such as WYAAT in West Yorkshire) dedicated director resource and staff is being recruited to develop its operations. These steps will require funding and resources to either be invested by the member trusts or the ICB to ensure that the collaborative can deliver. 

(5) Getting the right balance between provider collaboratives working at system and place-based partnerships

There has been some confusion around how provider collaboratives (operating at ICS level) and place-based partnerships will work together as part of the ICS. 

The principle of subsidiarity which many ICSs have embraced suggests that place-based partnerships should have a clear local focus on the areas where their constituent members can best influence outcomes for their populations with provider collaboratives concentrating on the issues which need a wider focus. Place-based partnerships link in heavily with local government and primary care/PCNs as well as voluntary and community sectors in a way which provider collaboratives (generally as there are exceptions given their permissive nature) would not. 

However, the practical reality is not as clear as the above summary suggests. The guidance suggests that provider collaboratives will be an important vehicle through which systems can deliver. They should also align their priorities with their relevant ICS footprint(s). ICBs are expected to support provider collaboratives to work effectively and cohesively with other local collaborations such as place-based partnerships. The NHS Trusts’ roles should include acting as the bridge between these groups through its membership, to help to ensure integrated working avoiding disconnect and duplication between them. 

The development of the approaches at collaborative and place should be complementary rather than siloed. It will be critical for the partners at both levels to have a common understanding of the resources available for allocation to tackle system priorities, and resource use at both levels can facilitate this. 

Conclusion and next steps 

Consideration of all these factors, together with the additional powers around formation of joint committees and delegation should provide a clearer template for collaborative working across NHS Trusts and systems.

However, despite this there are still some key questions which arise:

• What are the sanctions for an NHS provider which does not actively participate in a collaborative? 
• Does the collaborative set its role itself, with the ICB or does the ICB set it as part of its five-year plan? 
• How will the collaborative manage risks, and accountability - will it look to a delegated approach, use joint committees or more of a lead provider contractual structure to determine its approach?

How different provider collaboratives deliver in practice will of course in large part also depend on the quality of relationships and leadership, the functionality of existing boards, the clarity of vision / leadership and the support and time given by the NHS trusts to develop stronger system working. 

Whilst there is not a one-size-fits-all approach to provider collaborative arrangements it is important that these are developed to respond to the needs of their system and to work effectively with the ICB and place-based partnerships. The collaborative arrangements should then set out clearly how this will work, given that the Bill and associated guidance is silent on the details.