Improving the collaboration and integration of services has become a mantra for health-care systems around the globe. The need to work across organisational boundaries is promoted as a solution for achieving the necessary innovation, coordination, efficiency and relationships to meet the financial, demographic, workforce and quality challenges currently being faced.1 The COVID-19 pandemic has sharpened the policy focus on interorganisational collaborations (IOCs) and partnership working as a response to the pressures brought on by the pandemic.2
Interorganisational collaboration includes the formation of alliances, groups, associations, networks and mergers.3–7 Such arrangements have been closely linked to policy contexts where governments have mandated collaboration or have sought to create conditions for ‘co-opetition’ between providers to expand the market position of high-performing organisations.1
A variety of factors have been attributed to achieving success within such initiatives, including the importance of organisational capacity, having a shared vision with realistic aims, building trust, the availability of robust governance structures and collaborative leadership.8–13 However, realising the advantages of collaboration is far from straightforward.14 Notable barriers to IOCs are include the geographical distance between partners, the influence of historical events, competitive behaviour, the regulatory environment, a lack of organisational resources and coordination, power imbalances, and incompatible organisational structures and cultures.8,15–17
Historical developments
England, UK, has seen no shortage of attempts to promote IOC. The apparent need for improved partnership working can be traced back at least as far as the introduction of ‘national planning systems’ in the 1960s. Subsequent policy developments include the 1974 NHS reorganisation and the National Health Service and Community Care Act 1990.300 Both policy developments encouraged improved collaboration between the NHS and local authorities.18 The New Labour government, during its early years of government, espoused a shift away from competition to collaboration with a raft of policy initiatives, including joint commissioning arrangements, pooled budgets, health improvement programmes, health action zones and a duty of partnership for NHS bodies and local authorities.8,19,20 Nevertheless, these initiatives struggled to achieve their desired goals and outcomes,19,21 with the ambiguity surrounding collaborative arrangements, such as joint commissioning, posing further practical and technical challenges to attributing any performance improvements being made.22 The challenging policy logics of hierarchical control and market competition that characterised New Labour’s term of office are also noted as challenges for developing collaboration across NHS providers.23,24
The Five Year Forward View
Although the Health and Social Care Act 2012301 promoted competition, the Five Year Forward View3 gave emphasis to developing and piloting new care models to encourage interorganisational and cross-sectoral partnership working.25,26 In response to significant variations in quality across the NHS provider sector, the Care Quality Commission (CQC)27 also promoted a range of partnership options for ‘challenged’ organisations and organisations assessed as requiring ‘special measures’.6 The options included options for mandated support, with the appointment of one or more partner (or ‘buddy’) organisations to provide support, with-longer term options including merger and acquisition. To improve coordination and standardisation of services across the provider sector, the 2014 Dalton review4 outlined a menu of collaborative approaches, including the voluntary pooling of resources by multiple organisations (e.g. joint ventures and federations) and consolidation arrangements (e.g. integrated care organisations and mergers), as well as buddying arrangements between lower- and better-performing organisations to facilitate the sharing of best practices.
A stream of research has sought to evaluate the collaborative approaches introduced by the Five Year Forward View.10,12,25,28 Studies provide evidence of how new care models have helped to stimulate organisational innovation and promote system-wide collaboration.25 Billings et al.10 note a set of facilitative factors, including the development of relationships and alliances, effective local and national leadership, the availability of expert knowledge and skills, and additional tranches of funding. Challenges have also been highlighted with regard to overly ambitious policy expectations and the collection and use of performance information, as well as difficulties in developing ongoing relationships with regulators. Furthermore, questions remain about whether or not the agenda has had sufficient time and support to develop approaches responsive to population need.26 In addition, questions remain about the limited effect of the vanguard programme on reducing hospital activity.29
Mergers and acquisitions between under- and well-performing providers have received much attention, with concerns raised regarding the time, cost and complexity for stakeholders involved, and the variable financial and clinical quality improvements being achieved.30 The impact of ‘buddy’ hospitals providing support to struggling organisations or those in special measures appears to have aided organisational improvement and turnaround, as measured by the CQC performance ratings.6,31 Despite the Health and Social Care Act 2012301 promoting competition, Allen et al.32 note how commissioners chose mainly to use collaborative strategies to affect major service reconfigurations, and this was also endorsed as a suitable approach by providers.
The NHS Long Term Plan and beyond
The policy focus on collaboration continued with the publication of the NHS Long Term Plan.33,34 Building on Sustainability and Transformation Partnerships (STPs), integrated care systems (ICSs) have been introduced, which bring together mental health, social and acute care, specialist services, primary care and local government, with the aim of promoting greater regional coordination and more of a population health focus.33,35 Primary care networks (PCNs) hold shared budgets, with the aim of developing new services to enhance integration, improve sustainability, secure additional funding and improve economies of scale.36,37 NHS provider collaboratives also contribute towards the ICS agenda with the development of specialist mental health-care pathways.38
Within the current context of the pandemic,39 new Health and Care Bill aims to accelerate the shift towards greater collaboration with the accompanying legislation to accomplish much of what was put forward in the NHS Long Term Plan.40 Proposals include a duty for the NHS and local authorities to collaborate with ICSs, which are now statutory bodies, comprising ICS Health and Care Partnerships (bringing systems together to support integration) and an ICS NHS body (responsible for day-to-day running of the ICS), and include commissioning functions. The arrangements will allow NHS providers and Clinical Commissioning Groups (now ICS NHS bodies) to make joint decisions via joint committees and committees-in-common arrangements, as well as bring in other partners. Competition law [through the Competition and Markets Authority (London, UK)] and regulatory functions promoting competition are removed, along with the need for competitive tendering if not providing value. The introduction of provider collaboration reviews by the CQC to encourage learning about health and social care collaboration provides a further statement of intent with regard to how regulation can facilitate collaboration and partnership working in the delivery of services.41
The formation of a mandated ICS agenda raises questions about the potential of ICSs to undermine existing collaborative relationships and their susceptibility to enacting hierarchy-based governance and behaviours, rather than ‘place-based collaboration’.42 Emerging findings from ICS so far point to challenges ahead in developing the relationships, trust, accountability and authority for successful joint working.43 A similar picture is painted with regard to PCNs, with limited progress being reported.37 Concerns have also been raised about the regulatory implications of the policy proposals. For example, with the current inspection regime focused on individual organisations,44 it is not at all clear how ICSs will be scrutinised and performance rated.45 Sanderson et al.46 note that, although the intention of STPs was to create conditions for common pool resources at a ‘system’ level, local actors often struggle to agree local rules, citing conflicts with the continued regulatory focus on the financial sustainability of individual organisations.
Research rationale
Despite the burgeoning evidence base and increased policy emphasis on collaborative working, notable gaps in knowledge persist.17,47,48 Criticisms have been lodged at the limited number of actionable insights generated from integrated care policies,49 and the failure to demonstrate successful outcomes for staff, users, financial sponsors or other stakeholders.21 Collaboration often falls short of expectations, so much so that its continued appeal to policy-makers has been likened to ‘an expression of faith’, rather than driven by tangible evidence.50
The ambiguities and uncertainties surrounding the nature and effect of collaboration mean that achieving ex ante objectives is unlikely, given that ‘the act of collaborating with others often results in the interactive adaptation of perceptions and performance goals’ over time.51 The term collaboration is also deemed problematic in the way it potentially glosses over the diverse array of mechanisms that can be used to describe how organisations work together and the relative appropriateness of these mechanisms for different tasks and contexts.52
As a result, our understanding of the mechanisms and processes for spreading and sustaining evidence about successful relationships is limited. Many questions remain about how interorganisational arrangements, such as mergers, alliances, joint ventures and buddying collaborations, work, for whom and in what circumstances. Indeed, appeals have been made to further identify the elements of successful collaboration, particularly the assessment of effectiveness for horizontal collaborations between health-care providers.1 There is also a need for further empirical research to better understand the interplay of barriers and their context dependence, as well as their underlying causes and visible symptoms.15
The literature in this area calls for more robust theoretical frameworks and more sustained empirical research to explore which types of partnership approaches work (or not) in particular circumstances, why and for whom.13 Although general theories of how IOCs work have been proposed, establishing the causal links between issues such as culture, leadership and governance in strengthening or weakening collaborations requires further development. Auschra,15 for example, calls for greater understanding of the barriers to the integration of care in interorganisational settings, with the need for more attention devoted to using existing organisation and network theories that address such barriers. Auschra15 notes that ‘while reviewing existing literature, it became clear that the notion of “barriers” lacks theoretical underpinning’.15
Given the complexities of collaborative arrangements, Guarneros-Meza et al.53 advocate ‘theories of change’ approaches to assess how collaboration synergies and coordination are shaped by contexts, behaviours and structures, and this is achieved by asking ‘how’ and ‘why’ partnership practices are carried out in different contexts. Applications of realist methodology in relation to partnership working are also advocated as an approach well suited for studying multiple interventions implemented in diverse contexts with a range of stakeholders.54 However, applications of realist approaches to understanding IOCs within health-care settings has hitherto remained an underdeveloped area.
Research aims and objectives
The aim of our research is to provide useful intelligence regarding how, why and in what circumstances different approaches to IOC are effective in improving the performance of NHS provider organisations. To do this, a realist synthesis of evidence was carried out with the following inter-related supporting objectives:
- To explore the main strands of the literature about IOC and identify the main theoretical and conceptual frameworks that can be used to shed light on the conditions and antecedents for effective partnering across sectors and stakeholders.
- To assess the empirical evidence with regard to how different interorganisational practices may (or may not) lead to improved performance and outcomes.
- To understand and learn from NHS evidence users and other stakeholders about how and where IOC can best be used as a mechanism to support turnaround processes.
- To develop a typology of IOC that considers different types and scales of collaborative ventures that are appropriate for particular NHS provider contexts.
- To generate evidence-informed practical guidance for NHS providers, policy-makers and others with responsibility for implementing and assessing IOC arrangements in the NHS.
Our research provides practical guidance and learning to support NHS leaders with assessments of the different candidate partnering approaches available. Our research has important implications and learning, regarding the principles and methods that are required if collaborative approaches are to work successfully across boundaries and to engage the workforce and wider population within these collaborative efforts, for those engaged in leadership.
Chapter outline
This report is structured into eight chapters and arranged as follows. Chapter 2 provides the context for this work, with a review of typologies, drivers and dynamics associated with the life cycle of collaboration. Chapter 3 presents the methodology employed, providing an overview of the realist synthesis approach and our stakeholder analysis. Chapter 4 presents the results of the realist synthesis, drawing on 86 items of literature and analysing how, why and for whom do IOCs in health-care work in particular circumstances. Chapter 5 refines understanding of collaborative functioning with the presentation of findings based on primary data collected from a range of stakeholders, including policy-makers, practitioners and patient representatives. Chapter 6 presents findings from the stakeholder interviews and develops a novel theory of collaborative performance that aims to further explicate the mechanisms underlying collaboration that drive performance improvement. Chapter 7 assesses the implication of the findings, with an outline of the final version of our realist theory of how and why IOC works. Chapter 7 also presents options for the translation of our research into practice, with the development and piloting of tools designed to assess the readiness for collaboration. The report concludes (see Chapter 8) with a summary of how the project has fulfilled its objectives and with recommendations for developing future research, policy and practice in this important area of policy and practice.