David Harrison - Chairman, Anglian Community Enterprise
My gaff, my rules
There are some very high expectations, in some very high places, about how “collaboration” will transform the fortunes of the NHS. Those working at the “worm’s eye” level appear to have considerable license to collaborate. How’s collaboration working out for you? In recent months, my organisation has spent huge amounts of senior executive time, working alongside colleagues in partner agencies, in an effort to design and landscape our local health system so that collaboration becomes the new black. Amongst other things, we’ve been involved in:
- Setting up and participating in one of three place-based health and well-being Alliances for our 2nd wave ICS
- Creating a partnership service delivery model for a whole-county learning disability service, working with two other NHS Trusts
- Developing a new co-venture by bringing together incumbents delivering urgent treatment services, under NHS England’s Alliance Agreement arrangements
- Creating and mobilising a GP collaborative that operates across nine GP practices, of which we run four
In the last 12 months or so spent trying to develop “new models”, I’ve come across a range of collaborative behaviours. All of them are effortful and time-consuming, some of them are wasteful and repetitive, and a few of them are petty and spiteful.
Three types of “collaborative” behaviour stand out as follows:
Type 1: “my road or the high road” collaboration
This happens where co-venturing is seen by one partner as a necessary inconvenience, usually to secure new or ongoing business. In such collaborations, “partnering” features prominently in any narrative, but fails dismally to guide behaviour.
Typically, one partner identifies itself as primus inter pares within the co-venture. This “partner” then focuses its time and effort on discharging the “primus” role, whilst neglecting the “pares” role.
Prime contracting arrangements reinforce this hierarchical approach to co-venturing. Worryingly, NHS England’s recently consulted-upon Integrated Care Provider contracting arrangements look set to “hard-wire” prime contracting into NHS integrated care, at the expense of alliance-type approaches. The former is an exercise in efficiency, achieved by allocating risks and responsibilities to partners; the latter is an exercise in effectiveness, achieved by pooling them amongst partners.
Type 2: “to me to you” collaboration
Typically, this happens when partners encounter novelty or uncertainty, which is then spiked further by complexity. It is fuelled by nervousness, lack of confidence and a deep-rooted fear of making, or taking, offence, in fragile arrangements where co-dependencies are rife.
By and large, real-life service transformation is led by those clinical and non-clinical staff one or two steps down from the Board. We know that effective groups typically go through a “forming, storming, norming, performing” cycle if they’re to tackle problems, find solutions and deliver results.
Despite this, partners can and do act with undue reticence and unnecessary politeness. Somehow, we’re failing to give our change leaders the license to press through the performance cycle so they quickly come out the other side. We’re left with behaviours that collude to slow pace, dilute purpose and stifle innovation.
Type 3: “lipstick on a pig” collaboration
The outward signs of this type of collaboration are all positive. Leadership teams enthuse about collaboration, they ring-fence time to spend together, and they invest energy in designing and developing mechanisms they believe will aid future collaboration.
However, months of joint endeavour seem to pass, but result in:
- No observable benefits to those working on the front-line; or
- Collaboration deliberately skirting around the really wicked issues where “losers” as well as “winners” are likely; or
- Even if wicked issues are attacked, collaboration falling apart following the onset of “hostilities”.
Where next for collaboration?
The pace at which collaboration is progressing locally is neither unexpected, nor terminal to the direction of travel for the NHS. It does though, have consequences for ambition and pace.
Type 1 and Type 2 behaviours merely reflect immaturity and are fixable simply by more and more practice – but this fix won’t take root overnight.
However, eliminating Type 3 behaviour may be trickier. It betrays a lack of courage, and of collective organisational will, to deal firmly, but effectively, with organisational “loss”, when pursuing system-wide gains.
It is not helped by the absence, despite the promises, of any tried and tested mechanisms that mitigate the impact of “loss” as it presents at the organisational level. This is a shame because only once we succeed in creating such mechanisms will we see partners stepping up to take a bullet for the team.
Jacque Mallender - President, EMEA, Optimity Advisors
Thank you David for a thought provoking perspective on the very real challenges of collaboration in the NHS. Sadly, these challenges are not new. One of my first projects, over 30 years ago concerned the difficulties of professional collaboration across the boundaries of hospital, community, primary and social care – and that was even before we introduced the payer provider split!. Nor are these challenges unique to the NHS; throughout the world, patient outcomes and payer value is compromised by barriers between professionals and/or organisations in what is a hugely complex industry. Efforts to collaborate are mitigated by competition, professional rivalries, and systemic barriers such as misaligned payment systems and inadequate technology investment. Interestingly, wherever you are in the world, if you speak to patients, families, carers, and health and care professionals they know exactly what collaboration needs to look like to deliver efficient and effective services. There is much hope amongst health system economists like me that ICS adoption at scale has the potential to make a big difference. But as you rightly imply, David, we need to design an ICS model for the NHS which rewards collective success to avoid putting yet more “lipstick on a pig”.
David has worked extensively in the public and private sectors. He is a qualified chartered accountant and spent some years in investment banking before joining the public sector in the 1990s. Here he became a senior civil servant (Dept of Health and HM Treasury) and, for 11 years from 1999, led the health practice of Partnerships UK.
David has worked at the policy level in government and as part of the regulatory apparatus in the public sector. He has also undertaken and led detailed, complex and prolonged commercial negotiations on behalf of government and public bodies, managing multi-disciplinary teams, comprising both public and private sector personnel, in strategic change programmes, in PPPs in public service outsourcing and in public:public and public:private co-venturing arrangements.
In recent years, David has provided market design and development advice to NHS England in respect of commissioning management (and informatics) support. David has also provided programme direction and integration advice to one of England’s 1st wave ICSs.
Jacqueline is a Senior Advisor (Economics) to Optimity. She is a respected international economist and health systems transformation specialist. Having started her career as a UK government economist, she went on to work with a "big-five" consultancy before founding an independent consultancy in 1988 which evolved to become Matrix Knowledge. Matrix Knowledge became part of Optimity Advisors in 2014. Jacqueline initially led our Health and Public Policy work in Europe and was the lead Partner for our successful entry into the Middle East. She subsequently served as President of our EMEA practice until May 2019.
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Niamh has 25 years of experience at senior levels in health provision, commissioning, policy making and research internationally and is the firm’s lead advisor for NHS and local government transformation. Niamh specializes in strategic delivery of innovative models of care across organisational boundaries and real-world implementation of public sector policies using rapid evaluation and learning cycle methods to inform implementation and provide real time feedback to decision-makers, frontline staff and service users.
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