Collaboration can bring improvements in the quality and productivity of care
Barbara Green examines the barriers to improving quality and productivity in the NHS through collaboration.
There are many commentators who suggest that increased cooperation across the NHS is urgently needed to deliver sustainable improvements in the quality of care and the use of NHS resources. It is argued that greater collaboration will ensure care is more integrated, coordinated and affordable.
The paradox is that competition is already well established and rewarded and will continue to be promoted within the NHS, but a rebalancing of the system dynamics is needed to allow competition and collaboration to co-exist.
Conversations with senior NHS leaders in the North West have highlighted their views that strategic collaboration and the leadership of collaborative action within and across organisational boundaries are essential to delivering sustainable change at pace and scale, while reducing costs.
But it is recognised that this requires fundamentally different ways of thinking and behaving. Leaders need to unlearn the “certainties” that are often taken for granted, and to appreciate the perspectives of others.
For many successful clinicians and managers, the mindset and behaviours that have been n urtured for a competitive environment may be at odds with the requirements to purposefully share knowledge, power and risk for collaboration. As one chief executive commented: “The capacity for self-awareness, to know how the culture that shapes you determines how you see the world, is key to collaboration.”
Within the “clinically led NHS”, there may be an assumption that clinicians will readily collaborate in improving quality and reducing costs. Chairs of clinical commissioning groups, trust medical directors, PCT cluster medical directors, and public health doctors across the North West were asked to share their views of medical leadership and collaboration in delivering improvements in the quality and productivity of NHS care.
Either via a questionnaire or participation in a half day deliberative workshop, 80 senior medical leaders contributed. All support closer working between primary care and hospital doctors to improve the quality and value of services, but 67 per cent reported that collaborative relationships are limited, with only 4 per cent reporting that they currently have strong relationships that are delivering improvements. One participant said: “There is a limited forum for discussion and meeting, a sense of rivalry rather than collaboration. Personal interactions have eroded over the years”.
The collective view is that medical leaders should work together to design services (98 per cent), commission services (81 per cent) and deliver services (77 per cent). But the overwhelming majority report that they do not do this. There is agreement on the key behaviours that can sustain clinical collaboration including: a common purpose; shared and demonstrated values; open dialogue and information sharing; appreciation of the reality of others; and disciplined action for delivery. “Honesty and trust are critical and will only develop by actually demonstrating these traits repeatedly and consistently,” commented one leader.
Commissioners, trusts and individual clinicians all share a collective responsibility for delivering high quality and affordable care, and there is a strong consensus on the factors that help and hinder collaboration (see table).
Medical leaders believe they should collaborate, appreciate the behaviours that can enable and sustain cooperative action, and hold common views of what currently helps and hinders their joint working. They can identify significant quality improvements and productivity gains that could be made within their health economies. However, they are cautious that even if collaborative conversations can begin, there is a long history of talking, but with little action or consequence.
The strategic capability to effectively deliver collaborative change is a core leadership skill for clinicians and managers in clinical commissioning groups and provider trusts in the reformed NHS. This will need to be purposefully developed and fostered to secure collaborative commitment to difficult decisions and the timely delivery of complex and essential change.
|What helps collaboration?||What hinders collaboration?|
|Keeping the patient at the centre of care.||Steady erosion of the public service ethos.|
|Acceptance that the status quo of service delivery is not viable.||Denial, fear, nimbyism.|
|Removal of perverse incentives within and between providers.||PbR, competition, internal market.|
|New organisational forms or service delivery models that encourage clinical integration.||Clinicians working in silos.|
|Better information that allows peer review.||Vested interests, distrust.|
|Courage for joint ventures and long-term risk sharing.||Lack of genuine support for engaged and empowered clinicians at all levels.|
|Primary care speaking as a single voice.||Insecurities of Trusts – threats financially and to sustainability.|
|Shared primary/secondary care accountability for outcomes.||Lack of control over the practice of what individual GPs.|
|Wider commissioning board membership and clinical engagement.||Tensions between the clinical change agenda and organisational interests.|
|Clinicians skilled in team working with good rapport across primary, secondary, tertiary and social care.||Large consortia inhibiting conversations for change at ‘grass-root’ level between GPs and other clinicians.|
|QIPP as a golden thread running through everything.||Lack of ownership of QIPP by medical leaders.|