No hospital is an island: new models of acute collaboration in the NHS

Encouraged in recent years through the NHS Five Year Forward View, the Dalton and Carter reviews and now Sustainability and Transformation Plans (STPs), hospitals are looking for creative solutions to clinical and financial challenges that they can’t solve on their own.

We recently brought together the 13 acute care collaboration vanguards, who are exploring this issue as part of the new care models programme, in a ‘community of practice’ hosted by the Nuffield Trust and The King’s Fund.

These 13 are a diverse bunch at first glance. Certainly the scope of their collaboration appears different. The four emerging foundation groups, Royal Free London, Salford, Northumbria and Guy’s and St Thomas’, are looking at bringing together full hospitals. Other models focus on single service lines, like EMRAD’s radiology consortium or Moorfield’s network of eye services. But at closer inspection, it looks more like a continuum of collaboration across acute services. The hospital groups are all considering tiered membership options, in which other hospitals could gain some of the group benefits through more limited collaboration options. Meanwhile, other partnerships such as Working Together and Developing One NHS in Dorset are specifically looking at collaborating on a defined cluster of clinical and back office services.

The potential benefits of new collaborative models include: the ability to standardise clinical and operational practice; to share resources (including clinical rotas as well as managerial talent); to invest in central functions (that single institutions might struggle to); to generate scale efficiencies (in particular in back office and clinical support functions); and to leverage brand (including to attract staff).

So what’s new about this? After all, hospitals have always found ways of working with each other in some form or another.

Three things we think.

First, the old collaborations have tended to be informal. Ties between secondary and tertiary providers, in particular, have often relied on relationships between clinicians who may have trained together. That means it can be fragile if there is a change of personnel or relationships sour. Guy’s and St Thomas’ and Dartford and Gravesham’s collaboration is looking to formalise some of these pathways, starting in paediatrics, cardiology and vascular services, where there were longstanding clinical relationships between the two trusts. The Neuro Network (which is led by The Walton Centre) is similarly looking to formalise and build on its 12 satellite neurology services in the North West.

Second, they have often been at limited scale. The Royal Free is looking to build a chain of perhaps ten to 15 hospitals. Working Together, for example, brings together seven acute hospitals in the north east. EMRAD’s seven acute trusts provide radiology services for 6.5 million people in the Midlands – that’s about 10% of the country. In many places STPs are helping galvanise discussions about acute collaboration across a geography.

Third, in the past where these collaborations have been formalised, merger or acquisition has been the prevailing option. But this may be changing. We heard from Sharon Lamb about the range of intermediate options that trusts and foundation trusts across the NHS are exploring, including:

  • Shared directors and support services: Birmingham Children’s and Women’s hospitals successfully operate a model of this kind;
  • Prime contract and contractual joint ventures: clinical services such as pathology and elective surgery may be particularly suited to this model, such as the Elective Orthopaedic Centre in south west London and north Surrey;
  • Committees in common: a model being tested in South Essex;
  • Corporate joint ventures: which have the benefit of being able to generate and retain their own funds.

Of course, structural mechanisms cannot substitute for good relationships. They can only build on them. Michael West reminded us of some of the key success factors for systems leadership of this kind, including a shared vision across organisations, long term stability and continuity, and frequent face to face contact.

So where next for this agenda? The key tasks of the new care models programme over the next year, supported by The King’s Fund and Nuffield Trust, will be three-fold.

First, codify the different collaborative models emerging from the vanguards and elsewhere.

Second, support the vanguards to deliver these models and to identify when and why these arrangements are most effective. This work will be brought together in a framework document in the next few months (as have been published for the first three types of vanguards).

Third, work with NHS Improvement, the Care Quality Commission and the other national bodies to remove barriers in the system that prevent collaborations of this kind emerging.

Nigel Edwards

Nigel Edwards is Chief Executive at the Nuffield Trust. Prior to becoming Chief Executive in 2014, Nigel was an expert advisor with KPMG’s Global Centre of Excellence for Health and Life Sciences and a Senior Fellow at The King’s Fund.

Nigel was Policy Director of the NHS Confederation for 11 years and has a wealth of experience in health and social care. He joined the organisation from his former role as Director of the London Health Economics Consortium at the London School of Hygiene and Tropical Medicine, where he remains an honorary visiting professor.

Nigel has a strong interest in new models of service delivery and a practical focus on what is happening at the front line as well as a wealth of experience in wider health care policy in the UK and internationally.

Nigel is a well-known media commentator, often in the spotlight debating key policy issues.

Nigel is currently working with the WHO Regional Office for Europe and the European Observatory on Health Systems and Policies on developments in health care provision in Europe.

Jacob West

Jacob West is a national lead for NHS England’s New Care Models team. Jacob’s background is in public policy and health management. Prior to joining NHS England, he was strategy director at King’s College Hospital. From 2003 to 2010 Jacob worked in a number of roles at the Prime Minister’s Strategy Unit, ultimately as acting director. He advised two Prime Ministers on public policy in a range of areas including health, criminal justice, and education. He has also worked as a senior policy advisor to the Premier in Queensland, Australia. Jacob was 2014-15 Harkness Fellow in Health Care Policy and Practice at the Harvard School of Public Health and remains an advisor to the Harvard Global Health Institute.