Background

The purpose of this chapter is to start the process of gaining a better understanding of IOCs. Given the large, multifaceted and complex nature of IOCs, the aim here is to provide an essential first step of theory-building in articulating ‘what the programme is’, ‘who is the supposed target’ and ‘what is the supposed outcome’.55,56 To this end, we combine a review of grey literature (e.g. policy and organisational strategy documents within the NHS) and narrative and systematic reviews of evidence to capture key definitions, typologies, ingredients and outcomes associated with IOCs (see Appendix 1 for methods). Excerpts of this chapter have been reproduced with permission from Aunger et al.61 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.

Definitions and terminology

A variety of terms have been used to describe joint working, including integration, collaboration, partnering and partnership working. Partnership working is a widely used to describe the joint development of organisational structures or working across boundaries by the sharing of resources, authority and accountability. The following definitions capture these arrangements:

. . . a mutually beneficial process by which stakeholders or organizations work together towards a common goal.57

. . . a negotiation between people from different organisations with a commitment to working together over more than the short term to secure improvements which could not have been achieved by acting alone.17

. . . a series of events in the history of a system, leading to the evolution of new structures of interaction and new shared meanings.54

‘Partnering’ is another term that is commonly used in the literature. Miller and Millar13 suggest that partnering is useful term for understanding various joint working arrangements. Crowley and Karim58 define partnering as:

. . . a cooperative strategy [that an organization implements] by modifying and supplementing the traditional boundaries that separate organizations in a competitive climate. In this way, partnering can be used to create a cohesive atmosphere [in which] all project team members openly interact and perform.58

Interorganisational collaboration is a similar term and has been defined as follows:

. . . interorganizational collaboration is the set of communicative processes in which individuals representing multiple organizations or stakeholders engage when working interdependently to address problems outside the spheres of individuals or organizations working in isolation. The outcomes of these processes have the potential to benefit or harm the parties to the collaboration, as well as others.59

[Interorganizational collaboration] the belief that more valuable knowledge can be created than if each organization were to work alone as complementary resources and competencies from partners can create interorganizational synergies.60

Although defined differently by different authors, common to many definitions of partnership working, partnering and collaborating is the notion of working together to achieve benefits that would otherwise not be attainable by working alone. The core notion of ‘working together’ is a commonality across these terms. We will primarily be using the term IOC in this report, but the terms partnership working and partnering may also be used in particular instances of joint working.

Types of partnering

A range of scales and types of partnership working can be identified, and these different types of partnering have been presented as existing along a continuum by various authors.8,61,62 Glasby et al.,8 for example, distinguish between ‘depth and breadth’ of partnership arrangements. Similarly, Sullivan and Skelcher62 categorise several different collaborative relationships, ranging from networks (i.e. informal ad hoc relationships) through to formal partnerships, federations and mergers (see Table 1).

With a particular focus on NHS providers, Miller and Millar13 identify a variety of partnering practices linking NHS providers, ranging from structural partnering, such as organisational mergers and acquisitions, through to individual partnering arrangements, such as buddying between executives and clinicians across provider organisations to provide mentoring support and guidance.13 Miller and Millar13 also suggest that partnering can sit along a continuum, from a voluntary intrinsic act to work together through to partnerships that are mandated by government regulators (see Figure 1).

FIGURE 1 Depiction of axes of collaboration by Miller and Millar.13 (Figure not reproduced here; see the original article.)

The 2014 Dalton review4 outlined a range of provider models of care. The Dalton review distinguished between different interorganisational forms, including collaborative arrangements (i.e. a voluntary pooling of resources, which involves two parties creating a third to provide a particular service to both initiators), contractual arrangements (i.e. more formalised agreements) and consolidatory arrangements (i.e. a change of ownership, encompassing mergers and acquisitions)4 (see Figure 2).

FIGURE 2 Typology of provider collaborative models proposed by the Dalton review.4 (Figure not reproduced here; see the original article.)

The NHS England publication ‘No Hospital is an Island’64 built on the Dalton review typology by developing a framework for acute care collaboration models. The NHS England publication64 depicted organisational forms by their degree of organisational integration, as well as by the scope of services they intend to deliver (see Figure 3).

FIGURE 3 A framework of acute care collaboration models, depicting organisational forms by their degree of organisational integration, as well as the scope of services they intend to deliver (contains public sector information licensed under the Open Government Licence v3.0).64 (Figure not reproduced here; see the original article.)

Another example comes from the Northern Ireland Audit Office (Belfast, UK).65 The Northern Ireland Audit Office arranges different partnering arrangements by their degree of integration, from networks characterised by low commitment at the bottom of the spectrum, through cooperation, coordination and collaboration, to fully fledged partnerships, which require formal agreements and detailed joint planning (see Figure 4).65

FIGURE 4 Depiction of typology by Northern Ireland Audit Office.65 (Figure not reproduced here; see the original article.)

Across these various typologies, the key characteristics at play are the degrees of integration, whether a collaboration is mandated or voluntary, and whether the collaboration is cross-sector or within specific services. Although the terminologies used to describe such arrangements (i.e. alliances vs. hospital groups) can be fluid and are not universally agreed on,61 the typologies use a range of partnering types (see Table 2).

What are collaborations intending to achieve?

Despite emphasis being placed on collaboration and integration across health-care systems, questions continue to be raised about the lack of robust evidence regarding whether or not such relationships lead to desired outcomes.48 This has largely been explained by the ‘wicked problems’ collaboration is often looking to solve and the resulting challenges and dilemmas regarding how to measure collaborative effectiveness and success.53,66 Guarneros-Meza et al.53 review a range of measures and frameworks to demonstrate how collaborative performance can include several measures, comprising the quantity and quality of service outputs, consumer satisfaction, service objectives, expenditure data, equity in the allocation of resources and service outcomes.67 The measures and frameworks can encompass common models of assessing performance, relating to goal attainment (outcomes), performance targets (outputs) and cultural efficacy-measuring factors, such as changes in rhetoric, emotions and symbols.48 Silvia,51 drawing on Mandell and Keast,68 shows how effectiveness can be measured at three inter-related levels of network operations:

1. The operating level: the extent to which participants have developed a better understanding of each other, and whether or not they have developed a shared language and culture, new ways of communication and the ability to find common ground.
2. The organisational level: activating, framing, mobilising and synthesising activities, as measured by the creation of a shared vision, the establishment of member commitment to the network’s mission and the inclusion of all network members in the collaborative process.
3. The environmental level: the ability to successfully meet the needs of external stakeholders and constituencies (e.g. citizen awareness and the outcome proxies).

A review of partnering outcomes by Aunger et al.61 found that evidence from NHS policy documents, such as the Dalton review4 and NHS Five Year Forward View,3 advocates different collaborative arrangements to provide a range of potential benefits to population health by improving care, quality and efficiency. A review of NHS provider mergers by NHS Improvement (2017b) claims that merged organisations have the potential to help the local health economy by standardising care and quality, increasing market share in clinical services, improving financial sustainability, avoiding market share erosion and improving reputation to aid in staff recruitment (see also Aldwych Partners30). Aunger’s et al.’s review of strategic plans from 26 NHS providers demonstrated how intended outcomes can be arranged into the four broad categories of ‘delivering consistent high quality care’, ‘developing our people’, ‘leveraging scarce resources’ and ‘embracing innovation’.69 Within these larger categories, long-term and multiple medium-term objectives can also be identified. For example, within delivering consistent high-quality care, an objective is to ‘provide members (i.e. clinicians) with access to world-leading specialists from within the Healthcare Alliance’, by ‘enabling clinician-to-clinician relationships, facilitating knowledge share and access to specialist opinion’.69

Drivers for interorganisational collaboration

Alongside outcomes, a range of perspectives and empirical research has been put forward to understand the stated and unstated drivers for IOCs. Table 3 summarises the results of the systematic search, which identified the following domains and organisation theories associated with the formation of IOCs in health care.

These dynamics can be summarised as follows.

Expansion

Drivers for IOC draw attention to the organisational expansion within market environments where collaboration is sought for competitive advantage and strategic position.70 Forming an IOC for market expansion can be linked with strategic choice theory, which proposes that an organisation will enter into a collaboration if the benefits exceed the costs and if the collaboration will increase the ability of the firm to deliver superior products, improve service efficiency or increase market power.71

The perspective of expansion is captured by Postma and Roos,78 who draw attention to how the formation of health-care mergers can represent a strategic attempt by organisations to gain market power by merging with a competitor.72–75 Angeli and Maarse76 investigate the evolution of mergers and acquisitions across Western European health-care providers. Angeli and Maarse76 chart the rise of financial service organisations acting as acquirers in mergers and acquisitions, which have been driven by the introduction of market elements in health-care financing and provision, the broadening of private practice and for-profit medicine, the retrenchment of public financing arrangements and the closure of public hospitals or the conversion of public hospitals into more private-like entities. Expansion of market power can also be attributed to the self-interests and personal ambition of managers as a potential motive for collaboration.77,78 Such a perspective resonates with agency theory, which suggests that managers act as utility maximisers,79 where the architects of IOCs may seek to have their organisations partner with others to increase their reputation in the marketplace or to increase their benefits by managing a larger organisation.78

Consolidation

The formation of IOCs is driven by the need to consolidate services within a market environment. Connections are made here with transaction cost economics and theories of interfirm collaboration,80,81 which focus on how organisations organise their boundary-spanning activities to minimise production and transaction costs.

Various collaborative efforts37,70 highlight the economic drivers for overall and unit cost savings through improved economies of scale. Much of the coverage related to transaction cost economics underpins the rationale for mergers.76,82,83 A literature review and secondary data analysis by Gaynor et al.84 traced the hospital ‘merger mania’ in England between 1997 and 2006. The review84 highlights how the drivers for these mergers included facilitating hospital or service closures to release capacity in the short term, secure financial viability of smaller organisations and enlarge the hospital to provide better services for the buyers of services. Fulop et al.85,86 outline similar economic drivers for trust mergers as an opportunity to take advantage of economies of scale and scope (especially regarding management costs) to rationalise the provision of services by reducing excess capacity to treat patients. Resulting efficiencies can lead to improved clinical quality, as usage of specialised unit increases, quality of medical training increases, and staff recruitment and staff retention become more effective.

Participation

Drivers for IOC draw attention to how such forms can increase participation of stakeholders to reduce environmental uncertainty. Such assumptions connect with a stakeholder theory of organisations at the centre of an independent web of stakeholders with a responsibility to consider their needs with making decisions/transactions.87,88 In a health-care context, these stakeholders are typically patients, members of the public, staff, board members and government.78,89,90

Increased participation is aligned to multi-hospital arrangements that are better able to improve quality by ensuring community needs are identified, assessed and assigned priority for service, with comprehensive services reaching those most in need.70 Greater alignment with patients and public interests is connected to the ethos of integrated care in ‘meeting the needs of people with chronic diseases’91 and the drivers for joint commissioning as a way to overcome fragmentation by achieving ‘a seamless service’ where ‘assessment of need is unhindered by organisational boundaries’.302 Reflecting on partnership working in mental health, Glasby and Lester92 and others have identified the importance of a service with a single point of contact as beneficial for service users and their carers who can often experience fragmented services, a lack of continuity and conflicting information in situations where local agencies fail to collaborate effectively.92,93 Smith et al.37 document how improvements to patient care and service provision featured as reasons to form collaborations in primary care. Collaborating between practices can help fill gaps in service provision where single practices are not able to provide all services, where patients need better coordinated care and where improved planning and provision of services at a population level is needed. Hunter and Perkins’ study94,95 of local strategic partnerships and local area agreements found that providing a coordinated approach to tackling public health issues was a prerequisite of effectively resolving such issues.

Learning

Drivers for IOCs often arise from a desire for greater organisational learning and to improve the ability of organisations to absorb knowledge from partners.96,97 Absorptive capacity is central to such an approach, with a firm’s ability to recognise the value of new knowledge, assimilate it and apply it in a business setting.98 A rationale for IOC formation is that firms form partnerships to capitalise on opportunities to learn or enhance their competitive position through superior knowledge.99

Within IOCs, such conditions for learning have the potential to increase capability and innovation through education and skills development.70 Studies of mergers of health-care providers identified organisational learning and shared practice as stated drivers for merging.86 Sharing of knowledge fosters coordination of care, as best practices become shared between organisations,90 including learning from different perspectives.92,94,95,100 Van Raak et al.,90 in their study of integrated care in the Netherlands, finds motivations to collaborate based on opportunities for learning about other providers whom they had never encountered before, and generating new concepts for care delivery to improve performance. Westra et al.101 examine how health-care organisations balance competition and cooperation in a situation of ‘coopetition’, where knowledge-sharing and interorganisational learning are considered the primary motives to cooperate with competitors. Leach et al.102 present a case study of a buddying agreement to help teams undertake change and develop a medical pathway where ‘improved learning’ underpins the aim to promote close working partnerships, compassionate leadership and improve quality and safety.

Sustenance

Drivers for IOC resonate with the desire for sustainability and the need to fill a perceived resource need or to exert power or control over organisations that possess scarce resources. The sustainability of IOCs draws attention to systems and how organisations must engage in exchanges with their environment to obtain resources. Resource dependence theory posits that organisations require resources from their environment and, therefore, cooperative interorganisational relationships will be formed as a managerial response to the need for critical resources controlled by others in the environment.90,103,104

In their review of multi-hospital systems in the USA, Provan103 documents drivers to establish such forms as the need to access critical resources, with Markham and Thomas noting the development of ‘lateral’ or ‘service alliances’, in which similar types of organisations with similar needs and dependences come together to achieve benefits, such as economies of scale, enhanced access to scarce resources and increased collectives.78 Van Raak et al.90 also capture how access to resources was an important reason for becoming involved, where participants benefited from cooperation to exert power over organisations that possessed desired means. Smith et al.37 note how issues of sustainability, both in terms of finances and the primary care workforce, emerged as significant across their evaluation of PCNs, and were identified as key reasons to enter into collaborations in primary care.

Mimicry

Drivers for IOCs in health care draw attention to the institutional environments shaping how organisations collaborate to obtain legitimacy or to succumb to isomorphic pressures by mimicking or copying others. Such a viewpoint aligns with institutional theory, which posits that environments impose pressures on organisations to appear legitimate and to conform to prevailing social norms.71,105 Legitimacy can gain access to critical resources and expertise, as well as enhance reputation and gain visibility.

Dickinson and Glasby17 note that, through interorganisational partnerships, smaller organisations can gain legitimacy by increasing their recognisability, image and standing. Collaborations can also be perceived as socially desirable because of the positive outlook that partnership working inspires. Field and Peck77 outline how ‘the modus operandi of the perceived market leaders is likely to be copied by other organisations in the belief that this is the most effective way of operating’, with merger motives connected to examples of ‘mimicking’ (i.e. uncritically copying business practices from the private sector).78 In their study of joint commissioning, Dickinson and Glasby22 document how joint commissioning can be understood as producing efficiencies, empowerment and productivity, but also with other potential meanings as inherently a ‘good thing’. Connections to institutional theory can also be found in Dickinson and Glasby’s17 analysis of a mental health partnership. Dickinson and Glasby17 found that a large number of staff members found it hard to identify what their partnership had been set up to achieve. Although some previous internal policy documents set out process-based aspirations (e.g. a single point of access for service users), these process-based aspirations were often very unspecific and often focused on processes and outputs, rather than on outcomes.

Coercion

Contributions draw attention to the interlinkages between mimetic pressures to conform and wider institutional and systemic pressures mandating collaboration.78,86,90 What Works Scotland198 notes that many partnerships that claim to operate through collective governance are, in reality, also shaped by mandates from central government. The presence of such hierarchical mechanisms leads to less powerful partners feeling disenfranchised and lost within the partnership106 and, in turn, less likely to engage.107

Fulop et al.86 note that the unstated drivers for mergers include facilitating hospital or service closures and securing financial viability of smaller organisations.108 In the research by Fulop et al.,86 common to all mergers was the need to maintain quality and level of service in the context of external policy drivers, with reconfigurations informed by pressures for improvements to services and closer cooperation with local government and partnership agencies. Dickinson and Glasby17 also find that, although staff often claim that mental health partnerships provide better services for users, the majority of the potential benefits cited by staff are to do with responding to national and local politics to make more efficient use of scarce organisational resources. Central government produced coercive isomorphism by both explicit techniques (e.g. a legal duty for health and social care agencies to work together) and more subtle techniques (e.g. making partnership a necessary feature for some sources of funding).

Although the stated goals of PCNs in the United Kingdom (UK) are to improve population health, share staff and improve personalisation of care,109 Smith et al.37 also found that the reasons to enter PCNs appear to be more tightly focused on policy and financial incentives, with practices obligated to form PCNs and accept the financial incentives associated with networks for fear that they would be ‘left behind’.37 In their study of STPs, Sanderson et al.46 argue that, although the intention of STPs was to create conditions at a ‘system’ level for purchasers and providers to act as a self-governed common pool, local actors were not able to agree local rules, citing the conflict with the continued regulatory focus on the financial sustainability of individual organisations.

These various drivers draw attention to the often paradoxical and multifaceted nature of a collaborative endeavour (see Figure 5). The drivers also show how individual theories and perspectives are in themselves insufficient for capturing the complexities, norms and traditions involved in relationship formation.63,71

FIGURE 5 Depicting the drivers for IOC. (Figure not reproduced here; see the original article.)

Initial ‘ingredients’ for success

A range of ingredients for success have been outlined to determine the key shaping factors affecting collaboration. In an exploratory empirical study of mergers, buddying and contracting across NHS providers, Miller and Millar13 identified the ‘ingredients’ for successful partnering, which included effective senior and clinical leadership, the importance of trust between partners, acquiring meaningful data, and regulatory approaches that combine both quality improvement and assurance approaches. In addition, Hudson and Hardy110 depict how the determinants of a successful partnership include having an existing local history of partnership working, effective monitoring and reviewing of organisational learning, having a shared vision, and development and maintenance of trust through behaviours and attitudes, such as ‘fairness’, openness and honesty, sacrifice and accountability.

Likewise, a recent systematic review of reviews12 sought to determine ‘shaping factors’ of how cross-sector health-care collaborations work, and identified resources and capabilities (e.g. organisational capacity), motivation and purpose (e.g. shared vision, unrealistic aims, competing aims, national policies, commitment), relationships and cultures (e.g. trust, historic relationships, communication), governance and leadership (e.g. decision-making, accountability, leadership support) and external factors (e.g. geography, social/economic context) as key ‘shaping factors’.

In addition, Aunger et al.61 developed a typology of shaping factors for successful collaboration that incorporated a typology by the Advancing Quality Alliance111 (see Figure 6) and was supplemented with other emerging evidence from the review.17,65,112–114

FIGURE 6 Depiction of domains key to integrative efforts by the Advancing Quality Alliance.111 (Figure not reproduced here; see the original article.)

Aunger et al.61 argue that the examination of organisational perspectives and theories surrounding the integration of these elements leads to the understanding that different partnering types are likely to interact with some elements more than others (see Table 4). For example, a partnership synergy theory suggests that certain characteristics are intrinsic to partnerships, namely leadership, administration and management, governance and efficiency.115 As such, one could argue that partnering interventions largely exert their forces of change through changes to service and care model design, leadership, governance, and financial and contractual mechanisms, and that subsequent changes to information technology (IT) systems, culture and workforce occur as knock-on effects.

Stages of the collaboration life cycle

A variety of contributions have sought to capture how organisations may go through multiple collaborative arrangements throughout their lifetime. We conducted a systematic review and ‘best-fit’ framework synthesis116 to identify key literature regarding the life cycle of collaborations in a health-care setting, and this resulted in the formation of several key stages, including contemplating, connecting, planning, implementation and maintenance or dissolution (see Figure 7). The full methodology can be seen in Appendix 2.

FIGURE 7 A life cycle model of IOC conclusion. (Figure not reproduced here; see the original article.)

The contemplation aspect of collaborating incorporates behaviours analogous to ‘thinking about’ collaborating before it actually begins.117,118 For example, the paper by Hudson et al.119 puts forward behaviours such as ‘recognizing the need to collaborate’ and ‘identification of a legitimate basis for collaboration’. These behaviours and others have been integrated into the model as ‘defining the problem’, ‘identifying resources’, ‘identifying stakeholders’ and ‘considering solutions to problems, i.e. collaborative forms’.119

The connecting phase revolves around behaviours that establish the initial processes of relationship-building between actors. For example, Lowndes and Skelcher89 put forward ‘informality, trust and cooperation, willingness to work together’ as key features of connecting. Likewise, ourpartnership.org.uk121 establish that, in this stage, ‘partners get to know each other and plan future activities’ and undergo ‘realistic self-appraisal and appraisal of partners’.89,120,121

The planning phase includes behaviours such as ‘setting targets, establishing management teams’,122 ‘fostering partnership working values and engagement’123 and ‘developing basic agreement’.120

The implementation phase includes behaviours such as ‘managing inevitable conflict between partners’,121 ‘experience of difficulties in new relationship’120 and ‘evaluating and refining action plan’,122 and is characterised by the beginning and middle phases of putting the collaboration into action, undergoing problem-solving as conflicts arise.

The maintenance phase refers to ‘building mechanisms to overcome barriers’120 and ‘sustaining trust between members’.124,125 In this phase, the ultimate outcomes of partnerships are most likely to be achieved, as the focus moves from the functioning of the partnership to the achievement of goals.

Dissolution-type behaviours, such as ‘letting partnership die, or keeping certain aspects but not others’89 and ‘ending one or more partners’ involvements’121 can also feature at this phase due to either irreconcilable conflicts or the aims of the collaboration being achieved.

Figure 7 depicts the full life cycle model, which includes the behaviours and processes identified that are intrinsic to various stages of a collaborative life cycle.

The aim of this chapter has been to provide insights into the principles, characteristics and outcomes associated with health-care IOCs. Given the complex and multifaceted nature of IOCs, the next stage is to develop these findings with a methodological approach able to grasp these underlying contexts, dynamics and outcomes over time. In the next chapter, we outline how a realist synthesis approach is employed to better understand how IOCs work, why and for whom do they benefit.