This chapter draws together the key contributions made by the research. The chapter begins with an overview of our final refined theory and goes on to assess the theoretical, methodological and empirical implications of the study. The final section extends the discussion into the assessment of the different ways in which the research can support current policy and practice. The review findings are translated into actionable insights and practical tools to support those implementing health-care collaborations. In this regard, the chapter presents the results of a pilot of a practice-based diagnostic survey and a maturity matrix. Finally, we acknowledge the limitations of the study.
Developing a refined realist theory of interorganisational collaboration
Through analysis of theoretical, empirical and stakeholder evidence, this study has synthesised several MRTs and CMOCs to better understand how, why and in what circumstances IOCs are effective for NHS providers (see Figure 16).
FIGURE 16 Achieving IOC: a synthesis of causal links between collaborative functioning and performance. (Figure not reproduced here; see the original article.)
This research provides important insights into how the contexts and mechanisms of collaborative functioning may lead to successful collaborative behaviour. The research finds that the core mechanisms at play within collaborative functioning relate to the development of interorganisational relations linked to trust, faith and confidence. Crucially, the extent to which task success and task failure is achieved appear to be mediated by supporting mechanisms related to capacity, legitimacy, complexity, conflict and risk tolerance. The research breaks new ground in understanding the extent to which collaborative behaviours lead to performance improvement. The research finds that performance improvement can be achieved when the mechanisms of organisational efficiency, cultural efficacy and technological effectiveness are triggered, which, in turn, can drive improvements across a range of dimensions, including care quality, safety, efficiency and experience.
These findings have important implications regarding realist understandings of IOC. Our refined theory extends existing realist contributions to understanding collaborative synergy,132 with the development of CMOCs surrounding health-care IOCs.135 The further articulation of partnership functioning mechanisms as essential precursors to collaborative behaviour and the accomplishment of collaborative performance is able to provide new insights into the potential of IOCs in driving ‘purposeful collective action’.127
Theoretical implications
Our findings add to the small but growing evidence base regarding what works in relation to IOCs. The mechanisms identified by this research lends support to those identified in previous studies regarding the ‘shaping factors’ for IOCs and cross-sectoral collaborations. The factors include organisational factors, such as capacity, creating a shared vision, unrealistic aims, trust, communication, governance and leadership.12,13
In addition, through its use of realist methods our contribution is also able to articulate how, where and why such factors resonate and for whom. For instance, our synthesis of theoretical, empirical and stakeholder evidence highlights how building trust and faith, particularly in the early phases of IOCs, helps to buffer against potential conflicts, particularly during the later stages of implementation. Our findings support other research that suggests that trust is closely linked with the concept of collaborative synergy (framed here as ‘collaborative behaviour’) and mutual successes.54 The findings introduce new insights regarding the relationship between trust and risk tolerance to explain how trust is a necessary factor for engaging in collaborative behaviour. The concept of faith, although relatively intuitive, has often been under-represented in existing theories of IOC.44 Our findings, therefore, provide new insights into how the ‘motivation to engage’ in the collaborative process.127
Where realist evaluations have focused predominantly on collaborative functioning within the dynamics of IOCs,54,127,219,220 our extension of understanding collaborative performance48 provides an additional insight to realist contributions. Studies of IOC note the role of performance, highlighting the importance of alignment or ‘things coming together’ across involved organisations in the potential for generating synergy.127 Our review findings explain why benefits are attained and also how they are achieved, with the articulation of casual links identified between collaborative functioning and performance.
Our research provides important insights into whom some of these changes benefit. For example, although consolidation of services may benefit patients with more mobility and transport access, stakeholder accounts also draw attention to how changes might also disadvantage patients who already struggle to access services. Those leading collaborations provide rich accounts of the challenges, conflict and energy required for joint working to function. The benefits and drivers for doing so were reflected in their desire to support population health, generate efficiencies and economies of scale, and promote shared learning and knowledge transfer, and also in furthering reputations and generating competitive advantage.
As this analysis is qualitative and realist in nature, it is not possible to identify to what degree performance improvements were realised within the case study examples. However, the research provides further valuable contribution in emphasising the importance of non-traditional outcomes outside conventional measures of efficiency and effectiveness, when evaluating collaborative relationships.48,221 The articulation of the mechanisms of collaborative performance highlighted in this study lays the foundations for future development of a realist framework for assessing relationships between high-functioning IOCs and their performance against long-term outcomes.
Empirical implications
Our research has synthesised a range of evidence and, in doing so, provides a valuable contribution to the ongoing study of collaboration and integration of health services. Against the background of the current ICS policy agenda, the empirical findings of our research raise important implications for the prospects of a shift towards place-based collaboration. Defined as ‘the geographical level below an ICS at which most of the work to join up budgets, planning and service delivery for routine health and care services (particularly community-based services) will happen’,222 the implementation of place-based collaborations are likely to be essential for the overall functioning of ICSs. The King’s Fund have provided several principles to guide these efforts, including starting with a shared local vision, building a new relationship with communities, investing in multiagency partnerships, building up from what already exists locally, embedding effective place-based leadership and nurturing joined-up resource management.222 There is potential for the theory arising from this project to feed into current discussions around place-based relationship-building and the role of anchor institutions. The role of faith, trust and other mechanisms signpost what is required in the development of place-based partnerships.
The issue of organisational failure and turnaround is central to both function and performance of IOCs. Failure and turnaround in health-care organisations has been the subject of a number of evidence reviews,223–225 but significant knowledge gaps have remained in relation to identifying the effective methods for turning around and achieving performance improvement in NHS provider organisations. Our findings assemble a range of insights into the mechanisms and outcomes of turnaround approaches. In doing so, the findings disentangle what Jas and Skelcher226 refer to as the ‘excellence theory’ underpinning the features associated with high-performing organisations.
The findings in relation to collaborative performance and cultural efficacy supports the suggestion that ‘absorptive capacity’ theory can provide useful insights into the causes and facilitators of organisational failure and turnaround.224,227 The implications of our research suggest that the success of IOC can be explained, in part, by organisational learning and the extent to which internal knowledge processes are realigned with changing external environmental conditions.
Our empirical contributions also provide insights into alternative perspectives for understanding IOC, including the role of reputation and impression management in the establishment of collaborative functioning (i.e. building trust) and performance measurement (i.e. cultural efficiency). The contributions also identify how quality improvement and organisational development approaches give focus and method to collaborative functioning and shape the long-term outcomes of improved quality, safety and experience. The implications further capture how ‘techno bureaucratic’ approaches to collaborative performance loom large over the proceedings, with efficiency savings and economies of scale being sought after, and the role of consultancy and other third-party evidence informing such decision-making processes.
Policy implications
A central theme running throughout the empirical and stakeholder evidence identified by our review is the care needed when introducing mandated forms of collaboration. Mandated forms of collaboration are typically used with ICSs, provider collaboratives and PCNs now operating across England.33 Yet, mandated collaboration is open to criticism regarding the extent to which this approach is able to foster the collaborative mechanisms required for performance improvement.12,228–230
Our evidence, therefore, raises important concerns regarding the potential for the newly mandated ICS arrangements to impact negatively on existing collaborations that have already been built in well-established ICSs.231 Our findings suggest that mandating collaboration is likely to make some of the central mechanisms, such as building trust and faith, more difficult, particularly within severe resource-constrained contexts and limited workforce capacity. However, these findings also draw attention to how the current agenda has the potential to kick start collaboration in many local systems where there previously was little relationship-building. A range of practical implications arise from the findings to support the translation of policy proposals, including the importance of focused activities, the implementation of improvement methodologies, the need for shared purpose and having clarity of vision. Attending to these mechanisms provide a crucial platform for any IOC and require consideration when embarking on or sustaining any collaborative venture.
These findings also raise important implications for policy regarding the types of regulation required to support collaborative working. The balance between individual and system accountability remains a contentious issue, and our findings suggest that accountabilities weighted towards the former are likely to limit the risk tolerance for collaborative behaviour to occur. The development of regulatory approaches to performance ratings and accountability is required to ensure that collaborative rather than competitive motivations prevail.
Translating context–mechanism–outcome configurations into practice
Figure 15 shows that to achieve a flourishing IOC requires attention to be paid to the connections between collaborative functioning and performance. For those wishing to develop an IOC, Table 10 sets out a range of practical steps that organisations and those in leadership positions can take in the development of IOCs.127 Building on other contributions that have sought to translate realist reviews into practical guidance, Table 10 presents a series of ‘if . . . then . . . because’ action statements that can act as a guide for those tasked with developing IOCs that can facilitate performance improvement.232,233
| IOC task | If (context) . . . then (outcome) . . . because (mechanism) ‘action’ statement |
|---|---|
| Leadership behaviours and attributes | If positive leadership traits and behaviours, including empathetic leadership, visibility, showing vulnerability, espousing local benefit, learning from others, persuasiveness, demonstrating commitment, generosity, consistency of approach and fostering a positive culture, are in place, then these can increase collaborative behaviour by enhancing trust and faithIf negative leadership traits and behaviours, such as being ‘missing in action’, not being held accountable and being overly resistant to change, are in place, then these can significantly decrease faith and willingness to collaborateIf a ‘culture of improvement’ for organisations is fostered through performing cultural due diligence and this can promote engagement in collaboration by improving faithIf the collaboration works towards sharing improvement programmes and strategies across organisations, then this can drive organisational performance improvements by improving collaborative behaviour |
| Enhancing trust and interpersonal ties | If organisations work on understanding the impact of negative prior experiences in collaborations, then they can improve initial trust which can reduce conflictIf organisations can foster a mutual understanding by formulating and instilling a shared vision, then they can reduce conflict through generating a cooperative atmosphereIf the collaboration can deliver ‘quick wins’ at the beginning of the life cycle, then they can improve trust and faith because they avoid inertia and maintain momentum and ‘energy’If collaborations can understand and mitigate the impact of the regulatory environment, then they can improve faith because it lowers the workforce’s perception of complexityIf the collaboration can prioritise interpersonal communication between organisational actors, via face to face where possible, then they can improve trust because this helps to build interpersonal relationshipsIf there is significant geographical distance between partners, then this can act as a barrier to trust formation because it can undermine the ability to have informal interactionsIf flexibility and a degree of autonomy within the IOC can occur, then it helps build trust because it avoids feelings of a loss of organisational autonomy (conflict) |
| Risk tolerance | If the collaboration implements an appropriate degree of formalisation, then it can enable the appropriate environment in which collaborative behaviour can occur, which improves trust and/or confidence |
| Faith and initial faith | If organisations include service users and front-line staff in its design, then this will improve faith because this helps keep the vision clearly focused on key outcomesIf a clear vision is maintained from the outset, with clear outcomes and a logical path for achievement, then this improves trust because it helps to avoid conflictIf the collaborations keep an appropriate level of ambition, then it improves faith because ambition prevents feelings of failure when ambitious goals are not achievedIf collaborations involve very large organisations, or many partners, then this can reduce faith because it causes an increase in the perception of complexityIf organisations can ensure that there is a perception of progress (i.e. forward momentum), then this will contribute to faith being maintained because there is ongoing evaluation and implementation of milestonesIf organisations implement ‘champions’ in the IOC, then this can help to spread the faith in the collaboration because ‘champions’ help share the vision within the workforceIf collaborations can prevent a high degree of staff turnover, then they can prevent a loss of faith because every staff member that leaves needs to re-learn the vision of the collaborationIf organisations can understand the reputation that the chosen IOC form has in the public (e.g. privatisation), then they can improve faith because they may be able to better understand the impact on the workforce |
| Managing mandated collaborations | If those involved can acknowledge that mandated IOCs usually manifest in unequal power structures, then they can reduce the negative impact of this on trust because they pre-emptively understand that additional conflicts may ariseIf mandated collaborations understand that building relationships and a truly cooperative environment cannot be forced, then this may aid collaborative behaviour in leveraging contractual and ‘confidence’ mechanisms to reduce perceptions of riskIf the collaboration is mandated, then efforts should still be undertaken to build working interpersonal relationships because this improves trust and, thereby, collaborative behaviour |
| Confidence and formalisation | If organisations can ensure an appropriate level of formalisation of contract is in place, then they can increase collaborative behaviour because, for more complex, integrative or mandated collaborations, greater formalisation mitigates risk between partners when engaging in collaborative partnersIf collaborators can perform due diligence around potential areas of disagreement, and enshrining accountability mechanisms in contract, then this can improve trust because it can help to amicably resolve conflicts later on |
| Managing and resolving conflict | If shared and clear accountability is in place, then IOC conflict can be avoided because of these improved conflict resolution mechanismsIf the IOC has clear dispute mechanisms in place, with adjudication by an unbiased third party, then trust can be improved because conflicts are more easily resolvedIf there is a clear and shared vision in place, then this improves trust because it helps to avoid conflicts occurring |
| Ensuring capacity for implementing the collaboration | If organisations recognise that implementing a collaboration requires significant time, effort and financial input, then they will have improved faith because their perception of progress will not be negatively affectedIf IOCs understand that initial performance drops may occur while resources are redirected towards the implementation of the collaboration, then collaborative behaviour will be enhanced because losses of faith will not take placeIf organisations begin a collaboration without first ensuring there is adequate capacity, then this can undermine faith and trust between partners because their perception of progress will be negatively affected. In addition, if funding to implement collaborations is sourced externally and it is not forthcoming, then faith and trust can be critically affected because capacity is no longer in place |
| Cultural integration | If a shared culture can be fostered between organisations, then trust can be improved because it helps to avoid cultural conflictsIf the IOC is cross-sector or cross-service, then it may have a greater cultural divide because of differing professional backgrounds, which makes cultural integration more difficultIf IOCs perform cultural due diligence prior to implementing the collaboration and implement a plan for cultural integration, then they can improve trust because it avoids unforeseen conflicts occurring later in the process |
A consideration of ‘if . . . then . . . because’ action statements can provide valuable support and guidance for anyone wishing to understand and develop an IOC.
Diagnosing the readiness and progress of a collaboration: a developmental survey
Based on the development of our action statements, our findings have enabled the creation of a survey to help organisations assess their readiness for collaboration or assess the progress being made by a particular collaboration.
The readiness for collaboration survey has been piloted with a mental health provider collaborative (see Appendix 4), with a subsequent workshop to discuss the findings taking place on 13 September 2021. For the 21 respondents who completed the survey, the results raised concerns about the time and resource capacity for implementing the collaboration, as well as a challenging landscape associated with significant history of competition with their partners (see Figure 17). That said, the respondents agreed that there was a shared vision for collaboration with their partners.
FIGURE 17 Example question response. (Figure not reproduced here; see the original article.)
Feedback from piloting of the survey indicated that the survey provided a valuable means for stimulating discussion regarding the perceived readiness for collaboration. However, feedback also suggested that refinements were required to enhance the clarity of specific question items. Given the potential range of organisations and individuals involved in the collaboration, a larger sample may be needed from each organisation to be able to compare answers from different perspectives or stratified sampling to gain more in-depth insights into particular groups.
Designing a maturity index for collaboration
Alongside an understanding of collaborative readiness and progression through a survey, our findings can also provide a range of insights into the ‘maturity’ of an IOC. Building on the notable contribution of Westrum234 in understanding maturity is the idea of creating a climate that provides ‘good information flow’ that is able to ‘support and encourage other kinds of cooperative and mission enhancing behaviour, such as problem solving, innovation, and interdepartmental bridging’.234 Westrum234 characterises different levels of maturity by different types of culture:
- A pathological culture characterised by low cooperation, shirking of responsibilities and not open to change.
- A bureaucratic culture characterised by modest cooperation and focused responsibilities.
- A generative culture characterised by high degrees of cooperation and sharing of risks.
Westrum’s234 development of a maturity matrix aims to translate such ideas into reflective tools for discussion and reflection. Table 11 outlines our translation of Westrum234 into a maturity matrix that depicts different cultures of collaboration. Further testing is needed to ensure applicability to different collaborative types. Nonetheless, the matrix presents a good starting point for adaptation by other practitioners and researchers alike.
| Key element | Level of maturity | ||
|---|---|---|---|
| Pathological for collaboration | Bureaucratic for collaboration | Generative for collaboration | |
| Trust (i.e. ‘a psychological state comprising the intention to accept vulnerability based upon positive expectations of the intentions or behaviour of another’) | There is a low level of perceived trust between partners, and this may be due to a history of competition with the partner, poor history of collaboration or conflicts. There may be an unequal sense of power structure where one partner may receive more benefits of the collaboration than the other | There is a medium level of perceived trust between partners. There may be a history of competition, but the reputation of the partner is strong, few conflicts have occurred and the conflicts have been resolved amicably. There may be an unequal perception of power structure, but the partner seems unlikely to take advantage of it | There is a high level of perceived trust between partners. Conflicts, when they seldom occur, are solved amicably. Any history of competition is forgotten. There is no perception of any risk when it comes to relying on the collaborator to act altruistically. Any issues with the power structure in the collaboration do not present any barrier and are not perceived to be likely to be taken advantage of |
| Faith (i.e. a motivation or ‘energy’ to work on the collaboration) | There is a low level of perceived faith in the collaboration, and this is likely because members of the workforce perceive it to be not worth working on or otherwise extremely difficult to achieve properly. This is because collaboration could be far too ambitious and overly complex. Likewise, there is a perception that there is not enough resource to implement the collaboration properly. There may also be little sense of progress towards achieving the aims of the collaboration. Leadership may also not be sufficiently supportive in a manner that enables implementing the collaboration | There is a medium level of perceived faith in the collaboration. The workforce may perceive the collaboration as tentatively worth working on, but progress overall may be slow. Workers may feel that the collaboration will be difficult to achieve, but not entirely impossible. Workers feel that there is adequate resource available to implement the collaboration, but that it will be an uphill battle. Leadership is on board with the collaboration, but may not be properly focused on implementing it | There is a high level of faith in your organisation. The workforce is enthusiastic to work on the collaboration and morale is high. Sense of progression towards the aims and objectives of the collaboration is strong |
| Confidence [i.e. the belief that your partner(s) will behave collaboratively because they are obligated to] | Your collaboration is mandated or is very integrative (i.e. a merger), but does not have appropriate legal frameworks in place to enable collaborative behaviour. Or, it is a voluntary or non-integrative type of partnership (i.e. an informal arrangement), but has an overabundance of legal frameworks in place that are undermining the ability to build trust. Both partners feel that it is too risky to engage in any kind of altruistic behaviour | There are mutually agreed-on legal frameworks in place, which enables both partner(s) to feel confident that they can behave altruistically without negative consequences. However, the existence of these contractual obligations are making it difficult to build trust outside of the contract | The legal frameworks are perfectly suitable for the type of collaboration that is in place. Neither partner feels that there is a risk to engaging in collaborative behaviour, and that the legal frameworks in place also do not undermine the ability to engage in altruistic behaviour to build trust |
| Ease of cultural integration | You perceive your chances of being able to culturally integrate with the partner(s) as low, or otherwise there is currently no perceived progress towards neither an integrated culture nor a mutual understanding of cultures | You perceive there being some chance of being able to culturally integrate with the partner(s), but it is/will be an uphill battle | The organisations already have very similar cultures, or there is significant progress towards either having an integrated culture or mutual understanding and way of working between cultures |
| Perceived legitimacy (i.e. whether or not the collaboration is perceived as being a legitimate means to the advertised end) | The collaboration is not perceived as a legitimate effort, and this may be due to it being undermined by mandated forms of collaboration or due to a lack of stakeholder and workforce involvement in the arrangement | The collaboration is perceived somewhat as a legitimate effort. The collaboration may be mandated, but it involves stakeholders and the workforce in the planning and implementation of the arrangement | The collaboration is largely perceived as a legitimate undertaking. There is strong ownership among the workforce and patients and the public are involved |
| Interpersonal communication | There is little communication ongoing between partners. When communication does take place, there is a sense of uncomfortableness. There is an unwillingness to share information across organisations | There is some communication between partners and sometimes it can be uncomfortable. Your organisation is opening up to the idea of sharing information with the partner(s) | You feel no reservations about communicating and sharing information with your partners. There is frequent communication between partners and it feels second nature to do so. Both partners are receptive and communicative in a way that facilitates the building of positive interpersonal relationships. Information required for delivering patient care is also moving smoothly between organisations where required |
| Clarity of vision (i.e. how clear the aims and objectives of the collaboration are, as well as how to get there) | What the collaboration is hoping to achieve is unclear. Everyone you ask has a different concept of what it is hoping to achieve, and the road to achieving those outcomes is equally unclear. Even senior management seems to be lacking agreement on what is hoping to be achieved | Many members of the organisation are largely in agreement on what the collaboration is seeking to achieve, particularly in senior management and those who are architects of the collaboration. Some members at a lower level of the workforce are still lacking agreement, however. There is some clarity on how collaboration is seeking to deliver performance improvements | Most people you talk to agree on what the collaboration is seeking to achieve, and this even is the case across partners. There is a clear logic with respect to how the collaboration is going to lead to the desired performance improvements. There is a clear timeline of milestones along the way |
| Sharedness of vision (i.e. the degree to which the aims, objectives and plan for the collaboration is shared across partners) | Neither your organisation nor the partners in the collaboration have agreement on what is hoping to be achieved. When discussed, there is active disagreement on even what you are hoping to accomplish | Partners agree on the ultimate outcomes for the collaboration, but perhaps not on the best route for how to get there. There are occasionally disagreements, but these are resolved amicably for the most part | There is total agreement on the aims and objectives of the collaboration and how to get there. Both partners have formally signed off on a plan for how to reach the desired outcomes of the collaboration, and this agreement extends to the way people interact, with few or no conflicts on even small details of the plan |
| Risk tolerance (i.e. to what extent an organisation is willing to engage in behaviour a partner could take advantage of) | Your organisation is not willing to engage in altruistic behaviour, as you feel that your partner might not reciprocate or may even take advantage of the situation in a competitive manner to your organisation’s disadvantage | Your organisation is willing to engage in altruistic behaviour in some areas, but not in others, as your level of trust and confidence in your partner is not high enough and you have concerns that your partner will not behave in a competitive manner in certain areas | There are no barriers to engaging in behaviour that your partner could take advantage of if they wanted to. The concern that this may happen no longer exists and there is sufficient trust and confidence to allow you to work on the aims of the collaboration with the partner. You experience the partner behaving altruistically to your organisation’s benefit, and vice versa |
Limitations of the project
Literature component
Although every effort was made to be as exhaustive as possible in our search of the literature, including multiple waves of systematic searching, as well as searching the grey literature sources, it is possible we inadvertently omitted literature that would have been informative to the present review. A particular challenge was covering all the partnership types because of the myriad of overlapping terms used to refer to collaborations. In addition, although some included papers did document cases of collaborations that in dissolution (e.g. Murray et al.100), these papers were under-represented. This is perhaps due to the biased under-reporting of failed collaborations arising from publication bias. Inclusion of more examples of unsuccessful collaborations would have provided further evidence to supplement our review. The study was predominantly focused on the UK; however, we did include several studies from abroad (e.g. Austria195 and the USA172) and we did not purposely remove any papers based on country-specific metrics. Indeed, additional information from other regulatory contexts would have been more informative. Nonetheless, owing to the scope of our project, it is likely that we missed important literature emanating from the experience of other countries and health systems.
Empirical component
Our sample was exclusively drawn from the English health system and it is not clear whether or not our findings would apply to other contexts. Our interview sample included senior staff members and executives. Such purposive sampling was driven by the need to gain a breadth of different arrangements we did not have the resource to identify a wide range of opinions and perspectives. Time and resource limitations were further hampered by the difficulties of carrying out fieldwork during the COVID-19 pandemic.
In addition, patient representatives were drawn from well-informed local Healthwatch volunteers, board members or employees, which meant the representatives could have had different perspectives from the general patient population. Furthermore, use of our prior theory in constructing the retroductive coding framework could have biased the analysis in favour of identifying excerpts that would support our theory. However, we attempted to mitigate this by being actively aware of this possibility during analysis.
Although the present research sought to generate insights into what is considered a collaborative ‘outcome’ in both a realist and pragmatic sense (i.e. what outcomes do stakeholders desire from collaborating), it was, nonetheless, difficult to draw out causal connections between what was happening in local health systems and national system long-term effects on patient safety, quality, etc. This is perhaps due to the inherent complexity present in health systems and the significant length of the causal chain.235 There is also significant overlap, which is difficult to overcome, in terms of what people expect from partnerships (i.e. drivers and motivators) and what actually results from them (i.e. outcomes), and it is not always clear to which patients or the literature are referring. We have attempted to mitigate this by analysing the mechanisms within ‘collaborative these often overlap, they are not necessarily the same.
Theoretical limitations
Finally, depending on the level of analysis, it is possible to criticise the theory for not providing sufficient in-depth analysis. As previously mentioned, the analysis required a relatively elevated level of abstraction to embrace multiple types of IOC. This level of abstraction was required to keep the analysis process manageable and in many cases we did not have evidence for the range of collaborative types at this level of depth. Although novel in its contribution, our development of a realist theory for collaborative performance also requires development with further application. Nonetheless, we have signposted what and where future research on this topic is needed. Furthermore, our refinement of existing realist theory in relation to IOCs provides researchers with further opportunities to interrogate different types of collaboration across different contexts.