This chapter concludes the report with an overview of how the project has accomplished its objectives. This chapter also sets out recommendations for future research to support the development of IOCs between health-care providers.
Achieving the research objectives
Objective 1: to explore the main strands of the literature about interorganisational collaboration and to 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
This project has incorporated key conceptual frameworks and theoretical perspectives that can be used to structure understanding and empirical investigation of IOC. Partnership synergy theory115 and collaborative performance48 informed the development of the MRTs used in the realist synthesis of evidence. The development of the initial rough theory identified a range of theoretical frameworks for understanding the formation and dynamics of IOCs over time, as detailed in Chapter 2. Our realist review and refined theory has gathered some of the foremost literature on IOCs in shedding light on the barriers, facilitators and other contextual elements affecting the process of collaboration.
Objective 2: to assess the empirical evidence with regard to how different interorganisational collaboration practices may (or may not) lead to improved performance and outcomes
Taken together, the review of the literature and empirical work in this area has helped to answer this question by providing valuable insights into the ‘black box’ of health-care IOCs. Through an iterative process of gleaning and refining the causal chain IOCs, we have been able to generate novel insights into how day-to-day operations translate into more causal elements, which, in turn, influence how performance improvements area realised. These insights included the core mechanisms driving collaborative behaviour, such as trust and confidence, and their link to risk tolerance, as well as faith, and the contextual factors and occurrences that can undermine success. Likewise, our analysis of the collaborative behaviour to collaborative performance component of the causal chain gives rise to new insights into how performance benefits are achieved.
Objective 3: to understand and learn from NHS evidence users and other stakeholders about how and where interorganisational collaboration can best be used as a mechanism to support turnaround processes
Our stakeholder analysis incorporated a variety of perspectives, from those with responsibility for leading IOCs, patient representatives, policy-makers, regulators and professional bodies, about how and where IOCs can best be used as a mechanism to support performance improvement. The important role performed by our Advisory Group should also be noted in terms of contributing valuable insights throughout the project, including ‘sense-checking’ the results and ensuring that the theory was understandable to end users.
These contributions have further refined our understanding of what works, for whom and in what circumstances in relation to IOC. The contributions draw attention to the various leadership qualities required, the capacity constraints and challenges being faced by NHS providers, the role of improvement methodologies and the importance of legitimacy and task complexity, as well as the significance of building confidence through contractual and compact ways of working.
Objective 4: develop a typology of interorganisational collaboration that considers different types and scales of collaborative ventures that are appropriate for particular NHS provider contexts
Our research identified how typologies of collaboration, and the extent to which the conditions and antecedents for effective partnering are influenced, can be shaped by the degree of integration associated with the collaborative endeavour. Other factors were equally important in terms of whether the IOC entered into was voluntary or mandated. These key characteristics informed the rest of our theoretical development and the key mechanisms we identified, such as the conception of the confidence versus trust spectrum, the degree of integration associated with different types of collaboration and whether or not the collaboration is mandated.
Given the shifting policy agenda during the lifetime of the project, as well as the onset of COVID-19, our stakeholder analysis made sense of these different types and scales of collaboration within the context of the ICS landscape and the role of IOCs in improving population health.
Objective 5: to develop evidence-informed practical guidance for NHS providers, policy-makers and others with responsibility for implementing and assessing interorganisational collaboration arrangements in the NHS
Our review has sought to translate our findings into practical guidance. This included the development of ‘if . . . then . . . because’ statements, the development of a collaboration maturity matrix and a diagnostic survey to understand collaboration readiness and progression. These tools translate our review findings into applications in practice. The initial pilot of our collaboration diagnostic survey with a mental health provider collaborative provided valuable results and is informing how this collaborative is being developed. Further testing and refining of the survey are needed to ensure applicability across a variety of interorganisational collaborative settings and to improve internal validity.
Future research directions
A range of theoretical, empirical and policy implications arise from this research. Specific issues that warrant further consideration and investigation include the following:
- We call for a more inclusive sampling strategy to further refine our theory and better articulate what is working ‘for whom’ in relation to IOCs. Where much of the analysis of IOCs has captured the experiences, processes and outcomes from the perspective of those leading programmes and initiatives, further research is needed to gather workforce perspectives regarding how new processes are understood and operationalised, and how IOCs shape patient and user interactions.
- Our research breaks new ground with the inclusion of patient representatives. Yet, further research is required to better grasp how IOCs can engage and improve population health, drawing on principles of co-design and co-production.
- The COVID-19 pandemic raises a number of implications for the future of IOCs. Our research identifies how the pandemic has been a driver for activity where a central feature has been the use of digital platforms for communication. These digital communication methods have proved invaluable, yet clear limits to ‘interpersonal communication’ can be identified. Learning from our review suggested that contexts are likely to have a negative affect on the ability to build trust and generate the informal relationships and, therefore, further research is needed into digital platforms and their role in facilitating collaboration.
- Further research is needed to investigate the applicability and adaptability of several elements raised by this project, such as the roles of faith, trust and other mechanisms in the formation and maintenance of place-based partnerships. Learning from other national contexts could facilitate such efforts, with further comparative studies of IOCs from across the UK and beyond.
- Building on our realist theory of collaborative performance, further research is needed to disentangle the motivators and drivers from the ‘outcomes’ associated with IOCs. Such research resonates with a policy landscape placing greater emphasis on measuring the outcomes and social value generated from collaborative working.
- Where our review has focused on the perspectives and implications of IOCs for NHS providers in England, further research is needed to critically engage with alternative partnership activities taking place within current policy agendas. Greater attention to the role of public/private partnerships is called for, and more analysis of the role of the private sector more specifically, within collaboration and integration initiatives. The place and positioning of social care within the IOC agenda also require further development, as does the role of the third sector and how these organisations intersect within the IOC landscape.
- The role of regulation is crucial to developing different types and scales of IOCs. Yet, our understanding of regulatory functions and levers is relatively underdeveloped. A review of regulatory models and perspectives is, therefore, needed for overseeing and promoting collaborative ventures. Learning from other sectors and health-care contexts can provide a valuable contribution to supporting the IOC agenda.
These issues, along with many others, represent key lines of inquiry for any future research in this area. Given the significance and importance of IOCs to policy-makers, practitioners, patients and communities, our review has the potential to support the development of knowledge, skills and behaviours across a range of stakeholder groups. Following the recent government announcement of a leadership review to ‘improve processes and strengthen the leadership of health and social care in England’, our research can provide valuable insights into the leadership actions and behaviours that enable high-performing collaboration and integration across organisational boundaries.236