When not to collaborate

Unfashionable things to say in health policy in 2023: things were better when Andrew Lansley was health secretary, those Vanguards projects were a good thing, maybe Strategic Health Authorities were the winning NHS three-letter acronym after all.

All debatable. All quite possibly true. But let’s add another to the list: collaboration isn’t all it’s cracked up to be.

This might strike you as a funny thing to say – particularly from us.

At Kaleidoscope, we specialise in the art and science of collaboration. We exist in part because of a firm belief that, whichever way you look at it, collaboration is the future of health and care.

Increasing multimorbidity? Requires better joined up care. Increasing personalisation? Needs better partnerships with patients and citizens. Increasing awareness of social determinants of health? Depends on alignment between health and other services.

So why isn’t collaboration always the answer?

Over the last six and a bit years we’ve studied what makes the difference between those partnerships that fly, and those that flop. Spoiler alert: there’s no magic. There are no hidden illuminati passing down a secret working-together-recipe from generation to generation.

Study those collaborations that have seriously managed to generate significant benefit from joint working, and instead, what you see is almost beautiful in its apparent mundanity.

Any organisation’s capacity to collaborate effectively with partners will be finite.

We talk about eight characteristics of effective collaborations:

• Starting with a clear purpose driven strategy, with defined, realistic goals and a relentless focus on what the partnership was set up to achieve, without distraction.
• Having the right culture: with partners committed to purpose, empowered to act and operating within an environment where trust and generosity are deliberately cultivated. Leaders actively seek to span boundaries, and there’s a myriad of ways to communicate, connect and convene across members.
• And using just enough structure to keep it all moving: a keen focus on measurement and learning, with governance processes that enable not suffocate, and the skills and capabilities to make the whole thing work.

This may seem a tall order to do it all at once, but we see it done: from the incredible ImproveCareNow network linking hospitals internationally to support children with Crohn’s disease, through to the clinical communities approach used at Johns Hopkins Medicine in the US, through to examples way outside health such as tactics used by the US military, or even Wikipedia.

They’ve done this not by accident, but with concerted effort, focus and hard work.

Learning from this, it’s clear any organisation’s capacity to collaborate effectively with partners will be finite. There will always come a point when the overall value an organisation can get from working in partnership will start to decrease.

Risks of not adding value

Let’s take a step back, and for sake of brevity (if not plain English), restrict ourselves to acronyms. Currently, NHS trusts are being asked to collaborate with their local ICP, and ICB, as part of the wider ICS. They’re required to be part of an ACP, or CCP, or both, as well as working closely with their PCNs.

They’re also working with the NHSE regional team, probably part of an AHSN, a Cancer Alliance, maybe a hospital group, maybe a University. Oh, and if you could also work separately with your LA, VCS, LMC, LEP, that would be great.

The point here isn’t revolutionary. Thinking the NHS might have overdone the competition bit and needs to collaborate more, is one thing. Flooding NHS organisations with requirements to collaborate with everyone, is quite another. Doing so, risks no collaboration properly adding value, and the whole name of partnership working being put back quite significantly.

How to avoid such a fate?

Three actions for any NHS organisation:

1. Be ruthless with priorities. Collaboration is about creating value together. Work out which of your partnerships are adding most value and give them the time and resources to help them succeed.
2. Just say no (kindly). Be prepared to say that you are not going to prioritise some partnerships at this time. Part of building a reputation as a good collaborator is being shown to be worthy of trust; saying no to a partnership is a better outcome than saying yes, but not being able to deliver on your promise.
3. Build your collaboration capacity. The amount of partnerships an organisation can take on effectively isn’t fixed. You can increase it through concerted skills development, or the removal of practices that get in the way. Have a deliberate plan to become a consistently better partner (the eight characteristics provide a good framework), and get feedback as to how you’re progressing.

The fashionable stance for any NHS strategy at the moment is to set out the highest number of partnerships possible to get involved in. Nice intent, bad idea. It’s time to change the focus from collaboration quantity to quality.

This blog first appeared in the Health Service Journal in February 2023.