How should acute care collaborations best be progressed? And what is the evidence about the characteristics of the different models? Gareth Fitzgerald explores
The Integrating care: Next steps paper and the subsequent white paper recently published by NHS England and Improvement both include acute care collaboration as a key pillar in progress towards Integrated Care Systems (ICSs). Every ICS will need to create a Provider Collaborative Board, which is a very positive step forward; however, we have seen versions of that in every STP and there are lessons to be learnt from the past successes and frustrations.
Some systems are in the advanced stages of acute collaboration and have already delivered significant benefits, including the Northern Care Alliance in Manchester and the Royal Free London Group. They have demonstrated both quality and efficiency benefits from deployment of acute care collaboration models. Whereas others have made little or no real progress on this journey – and later in this article we will unpick some of the reasons for this. We believe that all systems can partake in the benefits of acute care collaboration. But the scale and scope of benefits will depend on the clarity of objectives and the depth of the collaboration model that is agreed.
PA Consulting has assimilated the evidence from acute care collaborations nationally and worked hand in hand with some of the most advanced acute collaborations to progress their transformations. These models can achieve many of the benefits typically planned for mergers without incurring the level of costs associated with a transaction. We see four key recurring lessons.
The characteristics of different collaboration models and their benefits
There are a range of different acute care collaboration models which involve various degrees and forms of integration of governance, leadership, and operating models. There is an emerging evidence base for their characteristics and benefits.
We have found that tighter collaborations typically involve fewer organisations and looser alliances involve a greater number. Our experience, and drawing from publicly available information, indicates that these tighter collaborations typically involve two to three trusts in the sharing of a chair and chief executive, a group leadership team and significant devolved decision-making. By contrast, alliances typically involve five or more providers with a nominated chair, with no shared executive leadership or delegated authority. This can lead to a situation where there are multiple tiers of acute collaboration that emerge in one ICS. For example, there may be a provider alliance and a group model or merger within this, as may soon exist in South West London, with a tighter collaboration in place between St. George’s University Hospital and Epsom and St. Helier Teaching Hospitals.
There are enhanced benefits from tighter collaboration models. There is a noticeable step change in pace, scale and complexity of benefits as more integrated 'tight link chain' or 'group' models are adopted. These models have shared leadership, resources and decision-making which can be deployed in the interests of the population without recourse to multiple statutory boards.
The scale and scope of benefits also typically broadens from tactical efficiency and support services, to clinical transformation benefits, as hospitals move beyond looser forms of collaboration. The looser models tend to focus more around clinical support and corporate services which are not as central to the way that the clinical specialties are organised and have less direct impact on clinical and population health outcomes. For example, looser alliances have had success in reducing agency costs and collaborative procurement. Groups appear to move beyond this and create more focus on addressing fundamental clinical quality and workforce sustainability issues. This focus and progress on clinical governance and standardisation has been evident at both the Northern Care Alliance and the Royal Free.
Once a shared chair or chief executive is in place there is typically rapid progress from loose chains towards a tighter 'Group' model or merger
There is a direction of travel from looser to tighter collaboration over time. There are key differences between 'Loose Link Chains' which share a chair or CEO, but no executive leadership or committees in common, and 'Groups', which are more formally integrated.
The evidence we have seen suggests that few systems stop at only the Loose Link model. As confidence grows in the collaboration, the lack of shared resources and decision-making processes in a loose collaboration becomes a frustration. To deliver the underlying case for change, most Loose Link Chains move towards a Group (or merge in some cases) over time. The Mid and South Essex system is a good example of rapid deepening of the collaboration model over the period 2017 – 2020 as a strong leadership team and transformation plan developed.
Achieving the new models often requires brave decisions from senior leadership and providing clarity to wider leadership teams about the future opportunities for them as individuals
Creating a clear vision and career opportunities for leadership teams is an important enabler for acute care collaboration. There is a clear record of individual senior leaders who have made bold decisions to support acute care collaboration. However, there is also an understandable level of concern from leaders that their roles could be diminished in a group structure.
Our review of the models suggests that the level of transformation required internally and externally with system partners, especially in the early years, means that the requirement for senior transformation leadership is greater, not lesser. Effective messaging early on can reduce the risk of attrition during the collaboration journey.
There is no conflict or tension between acute care collaborations and place-based models of care. You can make both work together and they enable each other.
Finally – and perhaps most importantly, the role of place can be effectively supported alongside acute collaboration models. There is no dilution of place-based care models inherent in acute care collaboration models. In fact, the enhanced governance and support models in acute care collaborations enable local acute leadership at site level to be a focal point for place-based development and make integrated care models a top strategic priority.
The most advanced and integrated acute care collaborations have enabled their hospitals to develop some of the most diverse and localised place-based models of integrated care around the hospitals. The Northern Care Alliance and the Local Care Organisations that work in partnership with each of the hospital sites are an excellent example of this. The view that acute care collaborations undermine place-based integration efforts is not supported by the evidence. The potential conflict that does arise is not in the models, but in the available leadership time and transformational resources to deliver both concurrently.
In summary, we believe that there is increasing evidence to demonstrate that, if adequately managed, acute collaboration models are a very effective lever to deliver scale economies, clinical standardisation, and sustainability benefits. Deeper collaboration has demonstrable organisational and system benefits and can often achieve this without commitment to the significant costs historically associated with mergers and acquisitions.
Each system needs to find the model that can work in their local context, but the role of place needs to be front and centre of an integrated plan which the acute collaboration should enable. Tighter collaboration will deliver further and faster benefits and will require strong leadership, focused on the significant organisational and system wide benefits for the local population and its workforce.
Gareth Fitzgerald is a healthcare expert at PA Consulting.
