A collaborative operation

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Charities and the NHS should work together to best deliver the joined-up care that patients deserve, writes David Shaw.

Everyone agrees partnership working is a good thing, but below the surface there is a great deal of ambivalence. Collaboration is held out as the ideal, but at the same time competition is becoming more prevalent. Could charities help the NHS get round this contradiction?

The benefits of collaboration are clear enough - joining up services around the patient, and optimising pathways to ensure care is delivered by the right people in the right setting. The need for coherent interagency working, with joined-up case management, has long been recognised in health as in other sectors.

Each NHS restructure has included elements to promote collaboration. Under the last government, the Cabinet Office and its satellites made various attempts to nudge charities towards a more collaborative approach. As a result - or maybe coincidentally - there have been many successes.

Yet even if we all like the motherhood, the apple pie is not to everyone’s taste. Collaboration is parallelled by increasing competition. NHS providers and charities often adopt positions that militate against joint working as they find their feet in the new healthcare market. In a challenging economic climate, voluntary organisations need to ensure any combined service provision does not result in an overall reduction in donations.

For NHS commissioners, it is a tricky balance to gather the inputs of those who understand local services - often NHS and charitable providers - without affecting potential competition. There are concerns that real provider collaboration will inhibit the development of a market within which individual bodies can compete.

The alternative is that commissioners specify more comprehensive and integrated services that consortia can bid for. But such competition “for”, rather than “within”, the market could be high risk, especially in areas where measurement of patient outcomes is still elusive.

False starts

Underlying these perceptions, there is sometimes a feeling that collaboration may be more trouble than it is worth. There is concern about the effort required to build the necessary trust, about inevitable false starts, and about introducing new structures into an already volatile environment.

It is not easy for charities and NHS bodies to invest in speculative relationships that may never bear fruit. So providers juggle the desirability of collaboration with the inevitability of competition. Commissioners struggle to reconcile a comprehensive, composite service model with the ceaseless market restructuring that has long characterised the NHS.

Charities may be able to help the NHS keep focused on the prize of partnerships working. Independent charitable income - and strong local accountability through fundraising and volunteering - mean that charities can discharge functions complementary to both NHS commissioners and providers.

Additionally, through focusing on a specific area of need, charities can complement the resources and support offered by national bodies such as the Department of Health or National Institute for Health and Clinical Excellence.

For almost a decade, Marie Curie Cancer Care and partners have developed a collaborative approach to end-of-life care. Since 2004, we have been developing a series of integrated service models, plus tools to support implementation. These initiatives make up successive stages of our Delivering Choice Programme, which aims to double the numbers of people who are able to spend their final days at home if they wish, and push palliative care up the political agenda. The models have been independently evaluated by the King’s Fund and other bodies, and show demonstrable benefits.

These projects involve both commissioners and providers. They produce a service blueprint and supporting specifications, which commissioners can take to the market as they think best. The resulting service delivery partnerships typically involve NHS provision, independent hospices, other charities and Marie Curie.

We believe such partnerships are often the best way of delivering the joined-up care patients need at the end of life. We are committed to establishing them, but have no agenda to become prime contractors, or indeed to increase our market share. Our aim is to form partnerships that collectively provide the best care with the resources available. Our experience is that our partners - commissioners and providers - share this overriding objective.

One example is the pilot Greenwich Care Partnership, which aims to reduce inappropriate hospital admissions and enable more patients to be cared for in their place of choice.

The prime contractor is Greenwich and Bexley Community Hospice, with Greenwich Community Health Services - now part of Oxleas Foundation Trust - and Marie Curie acting as sub-contractors.

Another example can be found in Lincolnshire, where Marie Curie’s rapid response service is located within St Barnabas Hospice. It runs alongside the St Barnabas-run Palliative Care Co-ordination Centre but is separately commissioned.

In east London, we worked with St Joseph’s Hospice and other stakeholders on the Delivering Choice Programme. Partners identified co-ordination of care as a priority and the Tower Hamlets Palliative Care Centre was opened as a result. It is based at Mile End Hospital and operated by the NHS provider. Marie Curie and St Joseph’s are now working on supporting co-ordination across east London, and a range of other initiatives to improve patient choice and quality of care. These include locating a Marie Curie Helper befriending service at St Joseph’s, and working with St Joseph’s and children’s hospice Richard House on care for terminally ill young adults as they make the transition into adulthood.

More recently, we have been working with acute providers, for example Royal Liverpool and Broadgreen Hospitals Trust. The goal has been to establish focused services that enable and support discharge, with the right mix of inpatient, hospice and community services working as a coherent whole. This service is jointly funded by the trust and Marie Curie.

To date, benefits have centred on enabling more patients to die in their preferred place of care, often meaning a move from acute to community and hospice settings. The goal is a substantial quality gain that is at worst cost-neutral. However, reductions in acute activity mean that potential savings are still emerging.

We have learned that our expertise has limited value if we do not find ways of effectively disseminating it. We are working hard to make our contribution more accessible to those facing many competing priorities in a turbulent and stressful environment.

For example, we have recently produced materials that unpack the economic impact of such a shift to community and hospice settings, and support the pragmatic application of NICE and other quality standards in end-of-life care.

Most importantly, we think that initiatives such as these will have the greatest impact if they involve both commissioners and providers. The risk of conflict of interest can be managed by having transparent objectives, and a clear handover to formal tendering or commissioning where appropriate.

We have seen with our own eyes that by working together, charities and NHS bodies can substantially improve end-of-life care. Here at Marie Curie Cancer Care, we are no longer ambivalent about partnership working.

David Shaw is head of service development at Marie Curie Cancer Care.