Professor Sir David Fish: driving improvement through partnership working

Since 2009, Sir David has been working with health and care leaders to drive improvement through collaboration in his role as Managing Director of UCLPartners. The former medical director spoke to us about his experience as Chair of the Mid and South Essex Success Regime and building partnerships.

UCLPartners was set up in 2009 for the fundamental reason of getting people to work together in partnership. The founding partners recognised that we were losing efficiency, and losing potential population and patient benefits, by overly focusing on competition rather than competition and collaboration. The requirement for this flexibility of mind-set is common to many modern industries.

Sir David explains why trust is so important when working with partners across a local health and care economy.

Tell us about your experience in driving improvement through partnership as chair of the Mid and South Essex Success Regime?

When I went to chair the Mid and South Essex Success Regime, I went to the first meeting and thought ‘what’s being asked of us is to get an agreed plan in eight weeks that would transform this challenged health economy into a sustainable service, ie close the projected gap of £216 million, and support the health and care needs of the 1.2 million population’.

What I learnt, the thing we had to do most, was to focus on this superordinate goal and provide coaching to support partnership skills in the leaders across the regime - rather than top down instruction - such as how they approached conversations and planning to get things to work in partnership.

A plan on a page can be produced in a day but it wouldn’t be enacted without the understanding, co-ownership, commitment and trust that enables future delivery.

At the outset, often questions surrounded ‘what does this mean for my organisation?’ and ‘what does this mean for my budget?’. As the process continued, and local leaders role modelled effective partnership working, these questions evolved into ‘how can we support the wider population objectives?’. These were really inspiring people, working in a hard place, who were motivated to meet the challenge.

What advice would you give those working collaboratively across a local health and care economy?

After observing meetings in my time as Chair of the Mid and South Essex Success Regime, I would say in trying to do something in partnership, it’s often helpful to frame a question such as ‘this is what I can contribute, what would you most like me to contribute from this menu’ rather than ‘what does this mean for me and my organisation’. We risk developing a mind-set of non-partnership working if we keep going down the latter route. The former moves us away from the traditional institutional conversations and mind-sets. 

Everything I have witnessed underlines that the transition to a partnership approach is the sine qua non of effective place-based systems of care.

How can trusts balance their own objectives while working collaboratively across a local health and care economy?

Understanding you can do both is okay. You still need to do what you can to ensure the individual operational efficiency, like ‘what’s happening on ward 32 with the number of nurses on a shift?’. But then you would take a different approach when looking at, for example, how we’ll organise end of life care or chronic long-term conditions. In these examples, you would start with the patient populations not the institution. It is helpful if regulators openly acknowledge this challenge.

So there will be some things where you start with the institution (or trust) but in any place-based approach, you will so often start with whole patient population.

You would then work through how you would produce the most cost effective set up for your local health and care economy. We should be as, or more, excited for the things we can do together compared to the things we can do on our own and get into the mind-set of ‘of course we should share our expertise to deliver the real objectives the people want’. This is where the most impact can be made, when many of the traditional intra-institutional savings have already been driven.

Whether as a commissioner or provider, we should also recognise we might not have the best skills to lead on some things, and be willing to act in partnership with others who have more capacity/capability in a particular domain to work on behalf of the wider system ie sometimes leading and sometimes following according to skills and resources. Delivery can then build further trust. 

The advantage in healthcare is that so many people will naturally have collaborative skills; it is about allowing them to surface and celebrate it in a safe space

Why is trust so important when it comes to partnership working?

There can sometimes be a mind-set that says ‘I can only deliver what I’m individually accountable for’; it’s harder to get into the mind-set of the more complex governance of a partnership model, which has to start with a willingness to develop trust and recognise the skills of other. You can’t work in partnership if you don’t agree the goal and develop trust for delivery.

For the Mid and South Essex Success Regime the goal was: we’re going to deliver a sustainable health and social care system that improves the wellbeing of the population within a confined financial envelope. You have to believe that common goal will draw people together.

You then build the trust further by doing things together that show it was better for the local population and, here’s the complexity, it was either neutral or a win for your institution.

If you see win/lose all the time, then you’re not adding any net value.

We’re starting to see the benefits of partnership working in Mid and South Essex with progress on many fronts, including the acute group model for the three trusts, and innovative approaches to out of hospital care. It was a privilege to work with such committed teams.

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