The Integrator: NHSE split over direction of provider collaboratives

“The least formed policy idea that has ever had this level of prominence,” is how the provider collaborative proposals in the government’s NHS white paper were described to me this week.

It is a description members of NHS England/Improvement may find more accurate than they would care to admit.

While providers still remain largely enthusiastic about the idea of provider collaboratives, which are seen as mechanisms to ensure more joint decision making within integrated care systems, I’ve been told their “enthusiasm is matched by their confusion”. With just a year to go until ICSs are expected to be made legal entities, there remains no clear agreement on what a provider collaborative should be, how it should be governed or how wide the collaboration vision extends.

I understand opinion on the direction of these collaboratives in NHSE/I is split into two camps, with regional directors also at odds on how best to proceed. One side is keen for provider collaboratives to become as formalised as possible, with tight governance, a budget-holding accountable officer and delegated responsibilities. The second camp wish to go no further than offering a menu of options on how these collaborations can be set up, and allowing local systems to decide what works best for them.

Given the tight timetable, it is likely the latter option will win out, as it gives the Treasury what it has wanted all along — accountability over the money going into ICSs without creating additional scrutiny over more complex arrangements.

However, it may not meet the expectation from NHS systems that “place” will be given the primacy it needs. As one source told me, “If ICS becomes the only thing that matters [in terms of quality and financial accountability], why bother with place if that might mean losing control over the money?”

One solution would be for the ICS to act as the budget holder, and the place-based partnerships to be the implementers of operational strategy through contracting (one financial option that Richard Barker, NHSE regional director for the North East and Yorkshire, suggested this month). Yet very few if any provider collaboratives are yet capable — or indeed willing — to take on long-term, patient outcome focused contracts that would give real subsidiarity to place-based decision making.

For example, the latest board paper from Herts and West Essex ICS shows two out of the three emerging integrated care partnerships on the patch are developing memorandums of understanding. These suggest that collaborations will be mostly limited to realising back-office efficiencies, as well to reviewing digital and clinical pathways that are unsustainable if provided at all three acutes in the ICS, (on a side note, I am presuming, although no one seems able to tell me for sure, that ICPs are examples of provider collaboratives).

On the other end of the scale, I understand one tertiary centre thinks the white paper proposals will mean it will be involved in six provider collaboratives. For all the talk of freeing up management time on contractual issues, involvement in that many collaborations would involve agreeing and managing six blended payment models. Marcel Levi, outgoing chief executive for University College London Hospital Foundation Trust, spoke for many when he said work could come to a “grinding halt” if there are too many meetings and layers of bureaucracy in the new ICSs.

Little thought appears to have been given to how commissioning for the local needs of a primary care network population will be managed. Indeed, the recent NHS planning guidance said each acute trust must be involved in at least one provider collaborative yet failed to include community trusts in this demand. This is a surprising absence given the increased reliance on community care during the pandemic to maintain capacity at acute level.

With all these differing views, it seems the final nirvana of system-level commissioning for ICSs may be a vision that may take a decade to develop, as it has with mental health provider collaboratives — if it does at all.

Financial directors remain unclear about what would be expected of an ICS and the providers within it. For example, while there are clear instructions that a system’s financial envelope must balance, it is unclear who has responsibility for sorting out any large, financially unstable trust on the patch. It may be that a system could agree to not falling below a certain level of individual trust deficit but demand it becomes a national issue if a single organisation continues to financially deteriorate despite system efforts.

How these financial problems will impact on any MOUs or other longer term contracts between provider collaboratives has not been thought through. It wouldn’t be surprising if the current finance recovery fund is retained as a national risk pool to bail out failing trusts and systems.

Sir Simon Stevens told HSJ last week that the new governance around ICSs and provider collaboratives should be kept “as simple as possible and as flexible as possible locally”, describing the process as an “evolutionary” one.

With so many questions unanswered — and without any current agreement within Skipton Towers on how best to proceed — it is hard to disagree with one view I have heard that provider collaboratives could see a return to the “old [sustainability and transformation partnership] approach” in which variations are allowed to flourish until a clear, preferred model is found in three or four years’ time.

If a similar process is followed, NHSE must make clear from the start that provider collaboratives are here to stay for the long-term. Otherwise, confusion could quickly shift to cynicism.