Emerging challenges for collaboration: holding onto what works in a changing NHS

Over the past few years, provider collaboration has delivered real and tangible benefits for patients, staff and systems. In the Black Country, as in many areas, working together at scale has helped us to reduce variation, improve access and strengthen relationships across organisations. The shift from a more competitive environment toward collaboration has taken time, sustained effort and a deliberate focus on building trust where it was not always strong.

However, the environment in which collaboration operates is now changing.

As the NHS moves into the next phase of reform, there is a clear and welcome focus on integration, neighbourhood working and population health. At the same time, there is a renewed emphasis on organisational performance, financial discipline and provider autonomy. Alongside tightening financial constraints and reduced resource for collaborative programmes, these changes are beginning to shape behaviour in ways that are not always aligned with collaboration.

What is becoming more evident in practice is that some elements of the emerging operating model, particularly the emphasis on individual provider performance and accountability, can act as drivers away from the collaborative approach that many systems have been building. As organisations are increasingly seen as the primary unit of measurement for quality and performance, there is a natural pull back toward sovereign behaviours – and this creates a real tension.

Systems are being asked to collaborate more deeply, particularly to deliver the three shifts and work across neighbourhoods, while at the same time operating within a framework that can encourage more organisationally focused decision-making. Financial pressure only amplifies this, as attention is drawn back to internal priorities and resilience.

The risk is not always immediate or visible. But over time, there is the potential for the gradual wearing down of the collaborative ethos that has been hard won.

In the Black Country Provider Collaborative, building that ethos has been a significant achievement in itself, given historical challenges in relationships across organisations. The progress made has relied heavily on:

• trust and relationship building
• shared ownership of system challenges
• consistent leadership focus on collective priorities.

It would be a step backwards if the system were to move back toward a predominantly competitive environment, where that focus is weakened and the benefits of collaboration are slowly and unintentionally lost.

Looking ahead, there is still a significant opportunity in the future operating model, particularly through neighbourhood working, integrated pathways and potential models such as integrated healthcare organisations, which could provide a renewed basis for collaboration, albeit with a broader and more integrated focus than the original, trust-led approach.

However, with key elements of the future architecture, including regional and integrated care board roles still evolving, it remains uncertain how collaboration will be consistently enabled and supported in practice.

The challenge now is to ensure that as the system evolves, it does not lose what has already been built. Collaboration has delivered so far and will be even more important in the next phase, but it will not sustain itself without alignment between policy, incentives and behaviour. Maintaining that alignment, and protecting the relationships and trust that underpin it, will be critical to ensuring that progress is not only continued, but built upon.

Sohaib Khalid is managing director of Black Country Provider Collaborative.