Is together always better?

How good are NHS organisations and the wider system at achieving the potential benefits of partnering? The opportunity to move away from current frustrations may seem attractive but there’s no guarantee that a new model will prove any better. The landscape of health and other public services is littered with good ideas and worthy intentions that made little or no difference. The evidence for previous NHS partnering can be summed up as ‘unlikely to achieve expected savings in the short term with little measurable impact on quality’.

So what are the ingredients for successful partnerships? Our new report Partnerships for improvement: ingredients for success explores the realities of partnering in five current examples in the NHS.

The case studies reflect the varying types of partnerships with a range of starting points, scale and maturity.

We found that working across organisational boundaries is markedly different to taking forward initiatives in a single organisation with a particular set of collaborative leadership and management skills. That partnering needs distinct skill sets is often overlooked, meaning people involved at the coal face often aren't explicitly supported to work in these different ways. Gathering meaningful data is a major problem.  Without it insights teams struggle to understand impact and identify how to further improve quality. Even finding the right partner can be challenging. This choice was obvious for some of our case studies, but others only found the right skills, capacity and resources by thinking laterally and looking beyond the usual suspects of other NHS organisations.

Partnership is not always voluntary. The last few years have seen many examples of mandatory partnerships or organisational takeovers at the behest of regulators. In such cases, a successful outcome often depends on transferring ways of working and standards from the stronger organisation rather than co-producing something as partners. However, it’s important to make sure good practice in the less strong organisation isn’t lost, as well as emphasising its potential to improve.

Our research comes at a time when enthusiasm for choice and competition between health care providers as a means of improving care quality appears to be wavering. The Five year forward view talks about new models of care working across traditional organisational boundaries to address the challenges facing the English NHS, but doesn’t mention the word ‘competition’ once.

Recent rulings by the Competition and Markets Authority (CMA) – including approval of the merger of Birmingham’s two biggest providers – have acknowledged that the patient benefits of cooperation between organisations may far outweigh the reduction in patient choice. Assumptions about the benefits of cooperation over competition also underpin sustainability and transformational plans, accountable care systems, acute group models, and general practice confederations. 

Perhaps, as the current thinking goes, locking providers in battle may not be the best way to improve quality, productivity and efficiency in the current financial climate. Instead, do we stand a better chance of driving sustainable improvement by unleashing their innate commitments to people, communities and achieving the highest possible standards?

It isn’t hard to see why supporting organisations to collaborate rather than compete is attractive. It suggests organisations, and the professionals and managers that work within them, are not just focussed on self-advancement and market preservation, but rather on collaborative values, a cornerstone of the NHS constitution. Such partnering approaches are also being deployed in other parts of the UK and indeed within many international health and care systems.

Partnering may avoid at least some of the heavy transactional costs and protracted timescales contained in large scale tendering exercises. It could also limit the uncertainty for patients and staff as they wait to hear if a lost tender will mean being forcibly transferred to an unknown employer. Moves away from competition may even help address concerns that continue to play on the minds of many that the NHS is creeping ever nearer towards increased privatised provision of services.

There is an oft quoted African proverb that ‘if you want to travel fast, go alone. If you want to go far go together’. The NHS is hoping that partnering will provide a means to go both ‘faster and farther’ in our search for solutions to the health care challenges of the 21^st century.  But we must be wary though of seeing collaboration as a cure for all our ills, and failing to recognise that sometimes it is more effective to work solo or indeed in competition. Otherwise, the organisations involved in partnering could well find themselves going slower, shorter, and perhaps in the wrong direction entirely.

Robin Miller (@RobinHSMC) is a researcher at the Health Services Management Centre (HSMC)

This blog has also received contributions from Ross Millar (HSMC), Tim Gardner (Health Foundation), and Will Warburton (Health Foundation)