In a second I’ll ask you to shut your eyes. To think about the best working collaboration you’ve had with someone from outside your organisation. To think about why the relationship worked when others didn’t. Ready? Ok, go.
Welcome back. What did you come up with? If you’re anything like me, words such as trust, respect, fun, and honesty might be swimming around your brain. The ability to pick up the phone and ask a silly question, or a favour, or just rant.
Ok, next one. Don’t need to shut your eyes for this. Think about words you’d associate with a couple of the most prominent NHS versions of collaboration: mergers between providers, or the beloved sustainability and transformation plans. Of the printable terms, I’m guessing governance, due-diligence, and synergies, might be there or thereabouts.
How is there such disconnect between how we think of collaboration on an individual level, and collaboration between NHS organisations? Between the personal and the mechanistic? Looking at the evidence doesn’t help, but rather just deepens the confusion.
Take provider mergers. Most are sold on the collaborative benefits they’ll bring - yet they don’t really seem to work. Between 1997 and 2006 around half of hospitals in England were in some way involved in a merger. Impact? Very little, said Martin Gaynor and colleagues in their 2012 study. A host of other papers from the UK and beyond have found a similar story: over-claimed impact on financial savings, and negligible impact on quality, if at all, or worse. Even the most positive studies agree that squeezing value out of mergers is far from easy, and takes far longer than expected.
We get too obsessed on whether to ‘do’ a particular model of collaboration – be that merger, STP, ACO, or more – rather than the practical learning as to how to make such a model work.
But looking at non-structural collaboration can give a different story. Let’s take the ‘clinical communities’ approach developed by the Health Foundation – a relatively simple way of supporting and securing improvement across multiple sites, trialled in the UK and now particularly taken up by Johns Hopkins in the US. Impact? Three projects were independently evaluated; all made notable progress and recorded significant achievements.
Don’t get me wrong – this isn’t an argument that structural forms of collaboration are bound to fail, or that non-structural will always succeed. But it does highlight an interesting quirk in our thinking that we get too obsessed on whether to ‘do’ a particular model of collaboration – be that merger, STP, ACO, or more – rather than the practical learning as to how to make such a model work.
Sir David Dalton’s 2014 review into options for NHS providers made a refreshing change by stating “what matters is what works” – in other words, choose the right option for your circumstance, not what the fad of the day dictates. Two and a half years on we now have a plethora of different models of provider collaboration popping up – from acute care collaboration Vanguards, to primary care federations, to chief executives manning (or more commonly wo-manning) the helm of multiple trusts.
Successful provider collaboration isn’t the result of a handful of macro shifts, but the end-product of hundreds of micro inter-personal changes.
However we’re still barely scratching the surface as to the strategies, tactics and day-to-day plans which can make collaboration across providers fly. Here’s three ideas as to what needs to happen to move our thinking forward.
First is to shift the terms of debate from deadly boring dogma (is this model awesome or awful?) to one of pragmatic learning (what needs to happen to make this model work?). This requires ending our NHS penchant for magic bullets bound to succeed; the ACOs of today will more than likely become the PFIs of tomorrow.
Second is to absorb learning from every avenue. What can acute group models learn from primary care federations? What can both learn from school academy trusts? How can very different organisations bridge cultural differences to work together? Bringing people together to improve health and care is our mission at Kaleidoscope Health & Care. It’s these opportunities for cross-sector learning we’re going to get into at Collaboration: Know-How?, a learning event on 13th June for all those working on provider collaboration across the NHS (you’re welcome to join).
Third is to return to where we started. Health care is unescapably a human endeavour. Successful provider collaboration isn’t the result of a handful of macro shifts, but the end-product of hundreds of micro inter-personal changes. The role of organisational strategy is to increase the odds that colleagues across organisational boundaries will be able to form relationships of trust and psychological safety which will best support mutual learning.
There’s one further ingredient. For any of these ideas to work requires humility, particularly from leaders. Humility to say that no option comes with guaranteed success, you don’t have all the answers, and need to ask others for help. But also humility that no leader can command and control their way to cultivating relationships of respect, fun, and honesty. Knowing how to collaborate is about supporting people as people, not organisations as machines.