How have provider collaboratives been set up?

Background

NHS England (NHSE) defines provider collaboratives as partnership arrangements involving at least two trusts working at scale across multiple places. They have a shared purpose and effective decision-making arrangements to reduce unwarranted variation, improve resilience and to ensure that specialisation and consolidation occur where this will provide better outcomes and value.

This requirement reflects the policy move away from competition being at the heart of the relationship between organisations across the NHS to one where cooperation and collaboration are valued and emphasised.

In 2014, the NHS Five Year Forward View emphasised breaking down barriers between services and organisations, with the subsequent Dalton review looking at models to support this. Building on this, the Carter review highlighted how efficiencies and quality improvement can and should be delivered through collaboration. Concrete examples of benefit have flowed, especially in the field of mental health, learning disability and autism where NHS-led provider collaboratives have delivered change at scale.

The policy paper Integrating care: next steps to building strong and effective integrated care systems across England was the clearest expression of the importance of provider collaboratives, where it was described as one of the four key elements driving change. 

While guidance has been issued in relation to provider collaboration, the approach adopted by NHSE has been permissive rather than prescriptive, with no element of performance management currently part of the framework. The limited policy requires that provider collaboratives are formal mechanisms, although they remain non-statutory.

Helpful and developmental guidance has been issued, such as Working together at scale: guidance on provider collaboratives, a toolkit for setting up collaborative arrangements and, most recently, draft Guidance on good governance and collaboration. They all reflect the permissive approach.

Our engagement with provider collaboratives

We engaged with members through detailed interviews with professionals fulfilling varying roles in relation to collaboratives and operating across diverse geographies, organisations, collaborative types and collaborative longevity – this has allowed us to garner rich insights into the development journey. 

We undertook 40 detailed structured discussions with colleagues:

• working across all seven NHSE regions in England
• from provider organisations and those employed specifically to support, drive or run collaboratives
• from NHS trusts covering acute, community and mental health, learning disability and autism services sectors
• from primary care including, GP federations
• from integrated care boards
• at chief executive, senior executive and leadership roles, including clinical leadership roles
• in long-established collaboratives and those on the first steps of the journey.

As a result, we were able to gather a comprehensive set of perspectives across many dimensions of collaborative development. One of these was the area of governance arrangements. Our observations on this are summarised below.

The provider collaborative governance spectrum

While undertaking our research it became apparent that there were key considerations that defined provider collaboratives’ approach to governance. This included the extent to which governance arrangements have been given early and/or priority attention, the level of detail at which these are formally defined, the degree to which partners are ceding decision-making, the breadth of areas covered and the extent to which activities take place within a governed framework.

There is no simple ‘good’ or ‘bad’ position on the spectrum, but representing the themes in this way may help partners to think through their current position, what is relevant to them and where they aspire to be.

What picture are we seeing?

• Most provider collaboratives are adopting a consensual, evolutionary and flexible approach to the development of governance arrangements relevant to their context, developmental stage and aspirations. No one size fits all.
• Wide variation across the spectrum, with many at the less developed stage and a relatively small number placing initial and significant emphasis on the development of highly formalised and detailed governance.
• The longest established provider collaboratives tend to have more developed arrangements which have been largely evolutionary and underpin rather than drive collaboration, with governance developed as an enabler rather than a brake.
• Generally limited ceding of decision-making with more joint decision-making on the use of developmental rather than core funding. More evolved arrangements have clearer delegation around agreed programmes of work.
• The focus on governance seems to be greater where there are significant relationship and trust issues to handle or when the provider collaboratives arrangement is seen as a precursor to changed organisational models, including merger.

Issues, challenges and constraints

• There is a need to sufficiently formalise arrangements to move provider collaboratives beyond being simply forums for senior representatives of partners where collective challenges are discussed and shared.
• Developing proportionate governance is the key issue – identifying what the sweet spot is appears to be an issue for many provider collaboratives.
• The level of trust and confidence between organisations affects the nature of governance arrangements – this can be a barrier to shared governance, but shared governance may also contribute to better relationships.
• Moving away from single organisation approaches remains a challenge – governance concerns can be used as a reason not to collaborate or as a means to slow the pace of collaboration.
• Appropriately and constructively bringing non-executive directors from partner organisations into provider collaborative governance arrangements does not appear to have been given significant attention or thought in many settings.

Observations

• While not central to provider collaboratives’ development, clarity on the nature and detail of governance arrangements is seen as important for focused development and the further development of confidence and trust.
• Further exploration and sharing of the myriad governance models, to allow sharing of relevant and good practice, would help provider collaboratives develop smoothly in this field.
• Further formal ceding of authority and delegation of functions and responsibilities will be required to make the most of the opportunities arising from collaboration.
• Governance arrangements should fundamentally be driven by the nature and ambition of the provider collaborative in question. However, underdeveloped governance may ultimately be a brake on development.

Governance development: approaches, themes and future development

Support and policy requirements

• The general view is that governance arrangements should be developed within the permissive framework being applied to provider collaboratives policy as a whole. There is a body of opinion, however, that feels greater clarity of requirement and pace of achievement should be stipulated to ensure that all collaboratives reach a reasonable state of governance maturity with an appropriate degree of formality in their arrangements.  
• Governance approaches, schemes of delegation and governance documentation should be collated and available for sharing wherever possible – this need not be mandated but should be actively facilitated. 

Likely development directions and trends

• The development end state is often undefined or unclear. However, there is a clear sense that the path leads towards more clearly defined and formalised approaches – this is viewed as natural and positive. 
• In only a minority of cases is the trend seen as being the path towards formalised group models or mergers. Collaborative arrangement will become deeper and broader but will remain as collaboratives.
• It is highly likely that there will be a long-term preference for governance arrangements which maintain the essential sovereignty of individual organisations. This will likely not preclude development in specific areas where formal pooling of resources or decision-making authority will be developed – this will most likely be around specific areas of activity rather than in any general devolution.

Further information

Following on from this summary, we aim to produce further pieces exploring some of the key themes and issues identified in more detail looking at their implications, the opportunities presented, any policy support required and the core enablers needed for progress.