Integration and innovation in action: provider collaboration

Background

Integration and collaboration are central features of current healthcare policy across England. Since April 2021 all areas of England have been covered by integrated care systems (ICSs), which bring together local NHS organisations with local authorities, voluntary, community and social enterprise sector partners and others. These partnerships have the task of collectively planning and integrating services that better meet the health needs of their population.

Provider collaboratives will form the bedrock of ICSs and will bring together NHS providers, the voluntary sector and the wider health and care system to plan, deliver and transform services. ¹  Although collaboration across NHS providers has existed for many years, the current policy focus has shone a light on how provider collaboration can drive a more integrated approach to health and care. 

By working together to a common purpose, health, care and voluntary sector organisations can address key challenges and better meet the health needs of their communities. Recent experience during COVID-19 has shown the benefits of providers working together in this way – and why collaboration across providers will be vital to post-pandemic recovery. ²

This report, the latest in our Integration and Innovation in Action series, explores examples of provider collaboration at neighbourhood, place and system level. Based on interviews with leaders and clinicians, it also identifies a common set of principles that underpin partnership working – whatever the size or challenge. 

We are grateful to the NHS leaders who have given their time to contribute to this report and our wider Integration and Innovation in Action series. Our hope is that the insights shared throughout the series will support you with the task ahead, shine a light on the changing way our members are working, and connect you with a community of leaders across the health and care sector.

Success factors

Our provider sector members have long remarked that most of the challenges they face are unlikely to be resolved within their organisation alone. Instead, solutions to multifactorial issues are more often found in collaboration with a range of other partners, including other providers.

Below we explore the impact and learning from different types of collaboration between providers at neighbourhood, place and system level. Informed by a range of interviews, it also identifies a set of common principles that underpin effective partnership working.

Shared purpose

“Having a shared vision and purpose is key. If you haven’t got that then you haven’t got a chance of a successful collaborative venture,” explains Dr Nick Jackson, clinical director for Selby Town Primary Care Network (PCN). For the PCN, this has been mission critical and enabled the network to redirect resource to where it is needed in the community. 

The network unites four GP practices in the North Yorkshire town of Selby to look after a population of 49,792 people. It has joined forces with the local community services provider to focus on improving care for vulnerable residents in care homes. This joint mission has broken down traditional ways of working and fostered a real sense of collaboration. 

For Dr Fiona Goudie from Sheffield Health and Social Care NHS Foundation Trust, aligning organisations around a common goal is vital. As one of 12 national early implementer sites testing and delivering the Community Mental Health Framework at place, providers there are taking a population-based health inequalities approach and focusing on improving mental health access in the PCNs that support the populations with the highest need. 

The collaborative took advantage of the opportunity to partner with the voluntary sector to employ community connectors and health coaches to tackle the integrated mental and physical health challenges for people with serious mental illness

“This has established a vision that everyone can sign up to,” Fiona says. By creating a collaborative defined by purpose, rather than by traditional hierarchical structures or organisational boundaries, partners have removed silo working and reframed the conversation to focus on serving the population of Sheffield. 

They worked within the PCNs to increase the mental health offer at the front door of GP services, offering a way into the mental health system through a more personalised and trusted approach. Rather than being referred to an anonymous clinician in secondary care and having to be seen in a secondary care setting, patients can access mental health services through their nominated GP and be linked up with support from within their local community. 

The collaborative took advantage of the opportunity to partner with the voluntary sector to employ community connectors and health coaches to tackle the integrated mental and physical health challenges for people with serious mental illness (SMI). They used the apprentice scheme to fund ten places on the new clinical associate psychologist programme (graduate psychologists who are trained to master's level), increasing capacity to deliver psychological therapies, and brought in specialist mental health pharmacists to support primary care and focus on medication reviews and deprescribing.

As a result, between June 2020 and August 2021, more than 1,900 patients with complex needs and trauma were seen and provided with wraparound clinical and social support closer to home, delivered by trusted members of the local community. By focusing on the most deprived areas, the collaborative has doubled the mental health access rate for black, Asian and minority ethnic communities – from 11.6 to 22 per cent.    

The collaborative took the system narrative and facilitated partners to work together to improve and deliver the best mental healthcare and support for the residents of the city. For Dr Goudie, structure has mattered less than purpose. The focus on a common goal has enabled greater flexibility to apply bespoke solutions with bespoke partners that best meet local needs. This includes working with the voluntary sector on highly targeted pieces of work for PCN areas in Sheffield.

For the Bath and North East Somerset, Swindon and Wiltshire (BSW) system, this fundamental point on shared purpose has also been a gamechanger. There, three acute trusts faced with long paediatric waiting lists worked together to reduce waiting times for children ready for surgery. They ran a series of all-day surgery lists over three weekends in two theatres within Salisbury NHS Foundation Trust, taking patient from all three acutes – including the Royal United Hospital Bath and Great Western Hospital NHS Foundation Trust.

 “Leadership becomes a lot easier when you have a compelling vision; the problem among the three trusts was very easy to describe and morally compelling to solve,” explains Dr Duncan Murray, deputy medical director for NHS Salisbury Foundation Trust. 

“We had lots of children waiting a long time for surgery, these were vulnerable children often with poor dental health.”  He goes on to say that “there was the sense of inevitability that whatever blockers got in our way we were going to navigate them, and ultimately we were going to realise this vision of getting these children treated by working together in a way we hadn't done before.”

Anna Field, the deputy director for commissioning for BSW, highlights that although the teams didn't know each other very well, this became a priority for all of them, and it “drew people together.” Operational managers within the three hospitals spoke regularly and worked together to resolve issues, such as how to identify and book patients from across the patch and setting up and agreement to share equipment from neighbouring providers due to the large patient list sizes.

As a result, the partnership between the three trusts reduced the total waiting list by 47 per cent for ears nose and throat (ENT) and 44 per cent for oral surgery, of which there was a 78 per cent reduction for those who had been waiting for more than a year for ENT surgery. 

Shared purpose is a galvanising force for partnership working on any scale, however many parties may be involved. Take Greater Manchester, for example, where politicians across the political divide rallied behind the city-region’s devolution deal. “This meant that we were able to work across geographical and political boundaries in common interest,” Sir Richard Leese, the newly appointed chair of the Greater Manchester Health and Care Partnership, told us. 

Clinical leadership

The importance of clinical leadership within collaborative ventures was a familiar refrain among leaders. Supporting clinicians and teams to come together to share ideas and improve communication has ensured that focus is placed on the population they serve, which has made a real difference to patient care. 

In Bath and North East Somerset, Swindon and Wiltshire (BSW) in 2021, there was significant variation between waiting times for paediatric surgery across the patch, with children being seen much sooner in Salisbury than in Bath. Medical directors came together to look at how they could work in partnership to reduce this variation. By nominating a medical director from across the system, they were able to work with lead paediatricians and agree how they could improve the situation for children on waiting lists across the system. 

The approach was to run high volume paediatric surgery over the course of three weekends in a single provider, by sharing equipment, patient lists and a blend of staff from across the trusts, which according to Dr Duncan Murray was quite a significant departure from their normal working practices.

“Collective leadership between senior clinicians and senior managers helped to drive the project forward and supported swift decision-making. Weekly short and sharp project meetings were put in place, supported by documentation of rationale and decision-making for clinical governance,” explains Dr Duncan Murray, deputy medical director at Salisbury NHS Foundation Trust. Giving clinicians the right freedoms and flexibility can drive improvement. Doing so significantly reduced waiting times for children, leading to a 47 per cent waiting list reduction for ears nose and throat and 44 per cent reduction for oral surgery.

This isn’t an isolated case. The Southwest had long grappled with the challenge of healthcare professionals working in silos. Although clinicians knew each intervention for perinates and their mothers incrementally improves the outcome for the baby, they were working separately, delineated by profession. 

A quality improvement and coaching model was used to implement a collaborative approach across the region, meaning that clinicians from obstetrics, midwifery and neonatal teams worked together to change how care was delivered for pre-term babies. The first few months of the programme have already seen increasing uptake in a standardised approach to interventions to reduce mortality rates in babies born before 34 weeks. 

The project has achieved life-changing, sustainable improvements to how the most vulnerable patients are cared for

This success is particularly clear in the area of deferred cord clamping, which in the Southwest is 20 percent higher than other areas of the country. There is evidence that babies benefit from a delay before clamping the cord as it makes babies more stable after birth (reducing the likelihood of a drop in blood pressure) and allows extra blood to be transferred from the placenta, increasing the amount of iron transferred to the baby. ³

As a result, the project has achieved life-changing, sustainable improvements to how the most vulnerable patients are cared for, according to Ellie Wetz, programme manager for the West of England Academic Health Science Network. As of December 2021, 1,094 babies have been cared for using the PERIPrem bundle a (number of interventions that demonstrate a significant impact on brain injury and mortality rates amongst babies born earlier than 34 weeks). Early analysis of mortality and brain injury data shows a 22 per cent reduction in mortality for the smallest and most vulnerable babies in the Southwest compared to aggregated data for previous years. 

In Selby Town PCN, clinicians are leading the way with improving the wellbeing of residents, trialling new models and employing new roles to help take the pressure off GPs. In a joint venture between the PCN and the community services team at York and Scarborough NHS Foundation Trust, they are jointly hosting a dietician role within the PCN, taking the service closer to the patient. 

As part of the collaborative approach the dietician, from the hospital-based team, is located at the local medical practice within Selby. She works with primary care staff and care homes to improve the health and wellbeing of residents through a focus on nutrition. She educates staff on the importance of nutrition and how to recognise when a resident might be at risk of malnutrition or dehydration, giving them the skills to intervene much earlier and reduce the risk of patients deteriorating. 

“It’s great to see the benefits of the work and how empowered the care staff feel after the training,” says Nicola Sumpter, the community dietician. “Recently a care home contacted me to say they had put a plan in place for a resident who had unintentionally lost 15kg rapidly. By commencing the food first and homemade supplement approach they have now gained 3kg and the resident is no longer taking any additional prescribed supplements.”

Trusting relationships

One of the most common themes throughout our conversations was the importance of building trust and relationships. This ranged from working across acute trusts on a shared pathway, to building partnerships between the voluntary sector and health to provide care closer to home for patients with serious mental health illness.

“We are in a better position in terms of partnership working than we have ever been due to the formation of primary care networks,” Dr Nick Jackson reveals. The moved has forced primary care to think outside of the siloed organisations that exist in health, looking upwards and outwards to form lateral relationships with councils, mental health, the voluntary sector and acute around the population health needs. 
“It is a slow process and building trusting relationships isn’t something that can be done overnight,” he admits. “But it is gradually eroding the interfaces between organisations. It’s a process rather than an event.”

ICS chair Sir Richard Leese holds the same view. When discussing the work taking place in the Greater Manchester system, he explains that improvements can often take 20 to 30 years to come through. But as a result of building relationships across the city-region’s health and care system over the last ten years, the system has been able to improve population health outcomes. 

In 2018 more than 8,000 people benefited from holistic, area-wide social prescribing programmes in the first five boroughs they were introduced. Over 250 smoke-free babies were born that year too and 46,500 fewer smokers achieved within a two-year period. ⁴ The prevalence rate is falling twice as fast as the national average.

For Dr Fiona Goudie, who has been working on the Sheffield Primary and Community Mental Health Transformation Programme, “building relationships with partners – including communities – not just organisations” is critical. These should be formed through respect, trust and listening.

“Working with the voluntary sector and treating them as an equal partner was a great step,” shares Fiona. For her, the third sector has been invaluable in supporting the mental health workforce and reaching into communities to reduce the stigma attached to mental health and getting people to seek help. 

Shared risk

When Salisbury NHS Foundation Trust, Royal United Hospital Bath and Great Western Hospital NHS Foundation Trust pooled resources to address paediatric waiting lists, they needed to develop a process (see below) for managing risk to ensure the clinical safety of patients.

By working together, they developed a protocol describing which organisation had clinical responsibility for patients during their treatment. As Dr Duncan Murray, deputy medical director at Salisbury NHS Foundation Trust, explains, the providers took a continuous improvement approach and were open to learning and adapting through the process, such as giving parents longer notice of when their children would have surgery.

A culture of distributed leadership

Good collaboration fosters the right collective culture. “The move to distributed leadership is really important,” according to Greater Manchester Sir Richard Leese. “Rules won’t get in the way if you have proper distributed leadership”. For him one of the most important changes to have come out of the recent pandemic and new ways of working is the recognition that every part of the system is equally important.

“Moving from ‘you/me’ to ‘we’ was a huge step.”

Within the Sheffield Primary Care and Mental Health Transformation (PCMHT) programme, joint ownership and distributed leadership are vital. “Moving from ‘you/me’ to ‘we’ was a huge step,” explains James Sutherland, head of commissioning for Sheffield CCG. “The commitment to ensuring each partner is an equal stakeholder who has an essential role to play, regardless of size, structure, or traditional power dynamics, has been a core principle of collaboration.” 

The primary leadership team has worked to a shared purpose, set of values and has not been defined by organisational boundaries. The team has worked in a matrix style, simultaneously supporting all partners to draw upon the collaborative skills, knowledge and experience of the team. Each partner had its own bespoke support developed, which recognised that each partner is an essential piece of the jigsaw puzzle of complex change.

In the Southwest, the PERIPrem (Perinatal Excellence to Reduce Injury in Premature Birth) project created and embedded a culture where all pre-term babies are seen as ‘our’ Southwest babies, rather than belonging to the local maternity unit. Working together as a PERIPrem clinical community across 12 trusts with two academic health science networks, ensured as many pre-term babies as possible had access to the most clinically appropriate care, at the right time and in the right place. 

“Everything that was outlined in the (PERIPrem) bundle just helped show how closely all of these different members of the team are working together to do everything they can to help your babies and I think that’s just absolutely incredible,’’ shares service user Amy. 

Flexibility

“The system needs to try to minimise requirements and leave more flexibility at a local level to allow people to get on and do things rather than stop them,” according to Sir Richard Leese. He is not alone is his view. Several leaders flagged the need for flexibility and the understanding that rigid structures and contracts restrict innovation and collaboration. 

Sheffield’s PCMHT programme took proactive steps to prevent this, recognising that mental healthcare had been fragmented for too long. Rather than being driven by a board or committee, a clear set of objectives and requirements were established at the outset. A small core team of executive leads, clinical leads and management were empowered and trusted to undertake the work with only minimal board oversight. 

James Sutherland, head of commissioning, attributes this flexibility to enabling them to focus on need, and to adapt and change the programme where required. This resulted in amending some of the tendering processes so they could work with smaller local charities, more aligned to the needs of the population, when previously they may not have had the chance due to rigid NHS processes. James comments that “rather than being on the periphery, they became a core delivery partner towards mental health care support and treatments.”

In Selby Town PCN, allowing roles such as a dietician from the community team to sit in primary care, but be funded by trusts, has caused an administrative burden. It often requires service-level agreements between organisations, complicated financial flows, procurement rules and information governance hurdles. 

“There is often not the time for the additional administration as there is already lots to do in the day job,” says Steve Read, head of community services at York and Scarborough Teaching Hospitals NHS Foundation Trust. Often only those who are really invested in making the change will take the time to try new ways of working. However, by building on the relationships formed between the head of community services and the clinical director for Selby Town PCN, they have been able to work closely and adapt models to focus on improving outcomes for vulnerable care home residents. 

A focus on the population

In Sheffield, by working with local charities, some very specific to the population such as Sheffield African Caribbean Mental Health Association, they reached into communities to reduce the stigma around mental health and help residents access the care they needed.
In the BSW system, keeping the team focused on reducing the time children had to wait for surgery meant that teams worked together much more closely to share and reduce patient lists. It quickly became apparent that patients and their parents were happy to travel further than their local hospital for surgery if it meant they would be seen sooner. 

There were over 1,200 children on the BSW day surgery lists, with more than 200 patients waiting over 52 weeks for oral surgery and ears nose (ENT) and throat surgery as of November 2020. At the time of writing, there had been a total reduction of the 52-week waiters by 79 per cent for ENT and 40 per cent for oral surgery.

Carers now feel more empowered to look after residents with more confidence to identify those at risk of malnutrition

A focus on population health in the Selby patch identified a need to support those giving care to the most frail and vulnerable population residing in care homes. Historically, if a resident in a care home was beginning to lose weight, the care home would arrange an appointment with the GP, who would then refer to the dietetics service. Due to the referral process and the availability of clinics, this could take as long as three-to-four weeks to get the intervention. In the meantime, the patient was deteriorating. 

By working with the staff within care homes, and educating them in food and nutrition, the carers now feel more empowered to look after residents with more confidence to identify those at risk of malnutrition. “One home reported that their residents now gain weight much quicker after hospital admissions than before. This is due to the dietetic training, which highlights the detrimental effect a hospital admission can have on nutritional status,” explains Nicola Sumpter, who has been working as a community dietician in the Selby Town PCN. 

System oversight

Having a helicopter view through system oversight has helped to alleviate workforce issues. In Sheffield, by working together with a view of the whole system, the collaborative was able to exploit opportunities to look at where the workforce was needed and best placed. 

Dr Fiona Goudie explains that there was always the risk that building up their mental health workforce would be “robbing Peter to pay Paul and taking from secondary care”. But by taking advantage of the opportunity to work with the voluntary sector, apprenticeships and additional roles, they avoided depleting areas of the system. It allowed the collaborative to work with the voluntary sector to enhance the mental health offer and employ community connectors and health coaches. 

As a group of partners signed up to the transformation programme, they used the apprentice scheme to fund ten places on the new clinical associate psychologist programme (graduate psychologists who are trained to masters’ level) increasing capacity to deliver psychological therapies. In addition, they brought in specialist mental health pharmacists to support primary care and focus on medication reviews and deprescribing. This would not have been possible without the system view and a commitment to share resource between the partners rather than competing for staff. 

In the Southwest, there was a shortage of senior paediatric nursing staff at Salisbury in particular, making it difficult to increase activity as a way of shortening times children waited for surgery. The trusts shared a self-selected group of staff and specific equipment from across the three hospitals, sending them to Salisbury – which provided the estate resource – as the host trust. Having oversight across the three trusts helped them to operate in a more joined-up way, increasing surgery capacity and ultimately reducing waiting times for children. 

Sustainability

When speaking to system leaders, sustainability and futureproofing were identified as key challenges to overcome. Sheffield’s local charities were unable to bid for tenders to provide the health connector workforce as part of the city’s project working with the voluntary sector. Commissioners were only offering short-term contracts. The sector highlighted the need for longer-term investment to offset the admin and set-up time, attract the right personnel and support the posts in a sustainable way. 

“Why are we not treating the voluntary sector as we would any other health organisation?” James Sutherland questions. “We would never dream of only offering a one-year contract for a service, why should we expect the voluntary sector to accept anything less?” As a result, the collaboration agreed to offer a two-year contract for the mental health connectors with a one-year extension. 

Working differently and taking a risk requires more input

In comparison, in Selby placing dieticians in primary care is only at the start of the journey. The PCN has had to illustrate proof of concept before the post is made a permanent fixture. The head of community services explains that it is not surprising that pilots fail to get to the next level, as often it is easier to keep doing things in the same way, as “you never need to prove that works.”

Working differently and taking a risk requires more input. Unless people are really invested in the change, new ways of working often fall by the wayside as there isn’t the time on top of the day job to continue. In Selby, it took the initiative of the clinical and service leads to work out a mutual agreement and host the community dietician post in primary care. As part of the pilot in Selby, the dietician is fully evaluating the impact on residents and staff.

Co-design, co-production and bringing people with you

Co-design and co-production are “absolutely crucial to collaboration,” says Sir Richard Leese. “And when it comes to comes to clinical decisions, people with lived experience need to be part of this.” From a system perspective, Sir Richard Leese emphasises the importance of case-making when delivering projects as part of the provider collaboratives in his patch. When looking at the provision of specialist services, “we cannot practically provide them all over the patch”.

He explains that if the reconfiguration of vascular services onto one site had been made five years ago, there would have been uproar. But by “building the case and bringing people with us on the journey” they secured buy-in for the changes. Involving people, communities, clinicians and politicians as part of the decision-making, and ensuring that it was done with rather than to them, was critical.

"Absolutely central to the project was the need to collaborate with parent partners; we bought them into our project team so that their voices could help shape the project from the outset"

In the Sheffield system, the collaborative defined the problem through co-production and engagement with people and communities. This resulted in the focus for the improvements to be in some of the most deprived PCN areas in the borough with the highest health inequalities: those where mental health care was in the greatest need but had low uptake and were difficult to access. 

The bundle of care for babies born pre-term was co-created by maternity and neonatal teams and parents. Ellie Wetz explains that “absolutely central to the project was the need to collaborate with parent partners, and we bought them into our project team so that their voices could absolutely help shape the project from the outset.” Quality improvement and coaching were used to implement this approach across organisational and professional barriers. 

This meant that clinicians from obstetrics, midwifery and neonatal teams worked together with patients to change how care was delivered for pre-term babies. The benefits of the partnership working and including patients as part of the process are clearly articulated by service user Lauren: “‘I truly believe that this package saved my boys’ lives. Without it I’m not quite sure where we’d be now. But because of PERIPrem I have two (17-week-old) beautiful little boys who are just starting to smile, and that is down to PERIPrem.”

Don’t think about funding

When broaching the topic of funding, those system leaders who were on their way to collaboration saw it as less of an issue. “Funding is only a barrier if you are of the mindset that funding is a barrier,” shares Dr Nick Jackson. “If you take the view that what is more important is building relationships, then that costs nothing. When you have got good relationships it is easier to talk about funding.”

The relationship in the Selby area that has grown between the community trust and the PCN director is an example of this. Through focusing on the partnership and how they could better support the population they both serve, the agreement to work collaboratively and host a dietician in primary care fell out of that discussion.

Working on the Sheffield PCMHT programme, Dr Fiona Goudie remarks that “financial allocations have always come secondary to the purpose of the partnership. The collaboration has focused on what is needed to achieve the transformation aims to benefit patients in Sheffield.” This has been achieved through the leadership culture and the ethos of the partnership. Rather than discussing and potentially creating tension over ‘who could or who has’ hosted roles, the maturity of discussions has led to a focus on ‘what is the function of a role?’ and ‘who is best placed to host the role?’

Common language and clear communication

“Being seen and available really helped me share the benefits of the dietetics role and helped me to work closer with primary care staff and the care home workforce,” explains dietician Nicola Sumpter. “I even sat in the staff rooms and kitchen so that staff could come and talk to me about any concerns they had about frail and vulnerable patients.”

At the Southwest ASHN PERIPrem collaboration, the team created a common language across organisations and professions, with patients and parents. “This has helped a better understanding and supported staff to have clinically based discussions with patients about various treatment and their benefits,” she explains. Clinical and parent passports were created in a variety of languages to advise and reassure parents and families while their children were given treatment.

In the BSW paediatric day surgery example, the team used a patient group to test ideas and provide input into the process. There are 75-to-120-minute journey times between the three hospitals across a mostly rural geography. They wanted to understand if it was safe and reasonable for children to travel up to two hours to have day surgery and how their parents would feel about this. Patients were generally willing to travel relatively long distances for quicker access to surgery, as long as they had a minimum of three weeks’ notice for the surgery.

Supporting provider collaboration

About Integration and Innovation in Action

Integration and Innovation in Action is a new series that showcases how local services are working in partnership to address the biggest challenges facing health and care. Head to the web section to find out more, register for events and join the conversation on social #IntegrationInAction