How do interorganisational collaborations drive performance improvements?

The purpose of this chapter is to generate new insights into the nature of collaborative performance. Few contributions, to date, have delved deeply into how the benefits of collaboration are realised. To do so, the chapter analyses stakeholder interview and focus group data to better understand collaborative performance mechanisms as they occur, and their outcomes. A theory gleaning approach is employed where the collaborative performance framework put forward by Dickinson and Sullivan48 is combined with a realist methodology. The chapter concludes by arguing that, through the analysis and application of collaborative performance, a series of interlinked, testable mechanisms can be identified, with the potential for further refinement by future research.

Background

The literature on collaboration and networks highlights notable ambiguities and uncertainties about what collaborative arrangements achieve. Guarneros-Meza et al.,53 for example, note how interpretations of what constitutes a desirable public service outcome, and the dimensions that make up its performance, is likely to be shaped by pragmatic, political and social factors that can differ between contexts and among actors. The performance of collaboration can involve contextual, functional and behavioural variables, including:

• a focus on management styles and their relationship with outputs and process outcomes
• a focus on how structure and context encompass resource opportunities and constraints [i.e. the external environment (climate and turbulence) and previous legacies of hierarchical governmental arrangements]
• the role of cultural efficacy within the external environment and context, defined as the overarching discourses and rituals.

Given the multifactorial nature of any collaborative endeavour, Salignac et al.66 note that caution is, therefore, needed in making claims about performance improvement. The development standards and goals ‘may not reflect what the collaborative ultimately intends to or actually does achieve’.51 A more realistic view of collaboration is required that better depicts ‘the interactive adaptation of perceptions and performance goals’ over time.51

This chapter argues that through adopting a realist understanding of collaborative performance we may help to address some of these challenges. A realist understanding of mechanisms helps us to break down the various elements that generate improved performance. By mechanisms, we mean changes to people’s attitudes and behaviours, and/or changes to availability or allocation of resources introduced by collaboration, that can drive benefits to more long-term outcomes, such as improvements in care quality, safety, productivity and experience.131

Up to now, our approach has been to incorporate partnership synergy theory as a high-level MRT to help us understand how collaborative behaviour (or ‘synergy’) links in to the ‘black box’ of collaborative performance. To further understand and generate a greater depth of understanding in relation to collaborative performance, the chapter will draw on a framework by Dickinson and Sullivan48 to act as a MRT to better understand the dimensions of collaborative performance mechanisms. Dickinson and Sullivan48 argue that much of how we understand collaborative performance in health and social care has been couched in ‘techno-bureaucratic’ understandings of collaboration, where a focus on efficiency and effectiveness arising from collaboration has been at the expense of analysing the performative and sociocultural dimensions that guide collaborative efforts.

Dickinson and Sullivan48 adapt McKenzie’s216 dimensions of performance into the domains of organisational efficiency, technological effectiveness and cultural efficacy (see Table 8), which are defined in the following ways:

• Cultural efficacy refers to ‘an expression of staged or ritualized representations or enactments of particular social and cultural traditions’.
• Technological effectiveness relates to how ‘technological advancements can enhance the performance of everyday objects’.
• Organisational efficiency focuses on common understandings of organisational performance, ‘achieving more for less by employing tools of performance improvement’.

The following sections will present how the domains of cultural efficacy, technological effectiveness and organisational efficiency were reflected in the accounts of the stakeholders involved in our research. Although Dickinson and Sullivan48 outline several areas within their framework (see Table 9), our particular interest here is in those characteristics that could most suitably align with mechanisms that are realist in nature. In our reframing, cultural efficacy becomes ‘an understanding of how actors’ cultural efficacy (i.e. behaviours, attitudes, symbols, practices, identity and emotions) may change in a manner that could feasibly drive improvements in safety and quality of care further down the causal chain. Cultural efficacy also refers to changes in ‘values, ideas, and practices that may become challenged by collaboration’, as well as signposting that ‘how [actors] feel about collaboration in general, or collaboration with different institutions, has implications for what we do in practice and how we might go about this’.

Our understanding of organisational efficiency draws particularly on the question ‘If collaboration does improve services and outcomes, which features of these collaborations produce these impacts?’. For technological effectiveness, we add to the concept by Dickinson and Sullivan48 by drawing on the definition of technology by the Oxford Dictionary as ‘the application of scientific knowledge for practical purposes’. This expands the notion of technology from machines and IT to include aspects, such as the sharing of knowledge, experience, evidence or expertise, that were previously unbeknownst from one organisation to another, and this relates directly to knowledge mobilisation across boundaries attained from research and development efforts.217,218

Analysing intermediate performance mechanisms and outcomes

Cultural efficacy

The mechanisms identified within the collaborative performance domain of cultural efficacy included improved communication, improved coordination, the translation of improvement strategies, the improvement of organisational reputation and the ability to work across sectors.

Enhanced communication channels within local systems were identified in focus group discussions. Patient representatives captured how improved communication had the ability to improve patient flow and enable sharing of knowledge between organisations:

On one occasion my X-ray results were not available at [provider] because the communication between where I had the scan done and the main hospital didn’t exist. So, it is about communication and that’s the nub I think of partnerships.

Those leading collaborations described how improved communication enabled the translation and diffusion of improvement approaches between collaborative partners. Some key benefits of collaboration were based on ability to create the conditions to learn from other organisations and professions about how to improve services. Collaboration created conditions ‘to get to know each other and work together’, with the sharing of results and learning from each other creating conditions conducive to ‘quality improvement for everyone’:

. . . collaboration as opposed to like shaming everybody into improving . . . has been about if you all sit down and look at what you’re doing with patients of certain conditions on a regular basis you’ll level up, because you’ll start to learn from each other.

Collaborating across boundaries made it possible to leverage new connections to drive greater delivery of services. For example, collaboration in response to COVID-19 was attributed with facilitating the vaccine rollout within localities:

. . . we have been hugely successful in getting to the marginalised communities. It’s been because of the relationships that we’ve had with those social value organisations, you know, CVS as the umbrella organisation, we’ve been able to vaccinate people who, you know, who many other localities have found it really, really difficult.

The knowledge translation underpinning approaches to the turnaround of challenged organisations was also raised. Interviews reflected on the ability of collaboration to support the translation of best practice:

. . . [if it was possible] to codify what the good organisations were able to achieve, then it ought to be possible to move that into an organisation that was struggling and show them the sort of ingredients that could be mixed to make things better.

Established methods and learning from academia were connected to having a wide range of benefits in relation to better care and financial sustainability, and improvements in staff well-being, morale and engagement. Leaders described the improvement strategy that they were sharing through their collaboration as rooted in organisational development:

So, we use in our trust the Athena team journey approach of Professor Michael West . . . one of the things that he’s promoted was these Athena team journeys . . . which is basically understanding the basics of what are people’s roles, what’s the vision of the team, how do you work together, how do you debate together, and how do you continue changing, and establishing a team within a team.

Other leaders turned to different sources for their improvement strategy. Therefore, private sector consultancies also featured in shaping the leadership approaches being undertaken to achieve organisational turnaround:

And it was about a £2.5M investment with [consultancy firm] and that launched what we call our patient first improvement programme and that’s been our absolute . . . our navigation tool since then and it’ has changed the way that we lead, manage, set our objectives.

A faith in quality improvement methodologies was highlighted as a case in point, where established tools and techniques could demonstrate and communicate improvements being made to different audiences, exemplifying how a change in cultural efficacy could take place through collaboration:

. . . we took . . . the breakthrough series model for improvement out into that organisation, and it is thriving, . . . And what we were saying was, ‘Tell us how you’d like to do this’, and then showing them the outcomes from that. So PDSAs [Plan-Do-Study-Act], tests of change, it’s just their language now, it’s just the way they do things.

Alongside the communication and translation of methods and information, interviewees connected collaborative performance with the competitive advantages for organisations involved. There were both reputational and financial advances for engaging with collaboration:

. . . two organisations . . . You know, they recognised that there was something in it for them as it were. So [provider] were, ‘Well, if we pull this off it’s good reputationally and we get a load of cash . . .’

Collaboration brought competitive advantages, with measures of esteem associated with the visibility and recognition gained from the wider health system, and this was particularly the case for mergers, where the increase organisational size could enhance the organisation’s status as measured by league tables:

. . . because I think we do have a particular view about, ‘What’s the size of your organisation? Are you in the top 10 or the top 15? Where are you ranking in this?’ We rank everything, don’t we? There’s a league table for everything.

Increases in organisational size enabled improved reputations and the potential to increase influence over the local health economy, and this was particularly reflected by interviewees from larger types of collaboration:

So, in the NHS we’ve got groups and they are big and a bit like us, and now we’ve developed an association of groups because actually, ‘we’re big and important and we want to influence’.

This mechanism of improved reputation had the potential to drive workforce improvements by attracting better staff. The reputation attached to being a poor-performing organisation was also considered as important in driving the need to collaborate within contexts of organisational turnaround:

. . . so they [the partner] recognised for themselves the fact that they’d normalised such poor standards, and that if they continued to do that, patients would suffer, and their reputation would suffer. And so they very quickly got on board with the improvement journey.

Demonstrable improvements in CQC ratings had a reputational impact on those leading collaboration in providing reassurances regarding their approach to performance improvement:

So you know, it’s . . . it just feels good to me that . . . by the time I left the organisation, for whatever you might judge the CQC for, it was able to report that services were now ‘Good’ across X. And you know, for me that was just a reassurance that we had done the right thing.

Collaborative performance also had symbolic qualities in delivering assurances that health and social care systems were working as intended. Seeking out IOCs provided a means of avoiding other forms of enforced collaboration that could undermine continuation of services from the organisation’s perspective:

. . . the consultation document says it’s going to be loads better for patients and staff that may or may not have been true or it may not be delivered. But, actually, the real outcome was to improve confidence in the child protection system in this struggling trust. And to carry on as a champion for children by making sure we don’t get merged in the specialist trust.

Organisational efficiency

Organisational efficiency was captured in a range of accounts recounting cost savings and resource constraints driving collaborative behaviour. Stabilising financial performance enabled cost savings and workforce changes, and were deemed to improve outcomes by concentrating services in different places. Achieving economies of scale across a geographical area, as well as standardisation occurring across boundaries to a specification and scale, with respect to human resources, clinical pathways and corporate functions, also featured as performance improvements.

Collaboration brought opportunities to improve workforce coordination and configuration of services through reducing duplication of effort and reallocating resources more appropriately:

. . . [it’s] much easier where we have a shared critical care service that gives opportunities for colleagues to work in different places and gives us the opportunity to use our assets differently.

. . . collaborating together makes it more possible for your patients to access that service at the specification it needs to be delivered even if it’s not necessarily in your unit, you know, down the road or whatever. And then that will open up obviously access to more specialised or better facilities for patients but also kind of help to sustain the quality at a higher level.

The ability to move staff around more easily when collaborating was also noted as enabling access to additional workforce capacity. Examples of ‘redirecting resources’ enabled by greater coordination were widely noted by those leadings IOCs:

. . . when we were trying to seek solutions to some of the thorny issues, so, workforce being one, we took a paper to boards across [local area] and said, ‘We can seed some medical leadership from [trust 1] for example into the emergency department at [trust 2] but we need others to work with us on actually where we can across the system get workforce support’, because the gap was too big for one organisation to suddenly dip in its back pocket and, hey presto, fill some of those gaps.

The reduction in duplication of effort was extended to reduced costs, as centralisation and process redesign efforts were connected to demonstrable savings. Achieving economies of scale across a geographical area, as well as standardisation occurring across boundaries with respect to human resources, clinical pathways and corporate functions, all featured in driving collaborative performance:

We have one recruitment team. We have one medical staffing team . . . when the two trusts came together, a number of those functions were centralised, which does give you some economies of scale. So from a cost point of view, it has some benefits.

. . . the procurement work stream saves the trusts I presume £1M and £2M a year based on the joint procurements that they do that reduce the costs of things, which broadly pays for the cost of running [the collaboration].

Wider perspectives regarding improved economies of scale were noted in relation to talent management of the workforce:

. . . we believe that the NHS in particular in this country is suffering from fragmentation that leads to a reduction in the opportunity to grab economies of scale. So, whether that’s the traditional economies of scale, you know, that would be procurement, but just as importantly, it’s really about talent, it’s clinical talent as well as technical talent, and being able to grab as much of that as possible.

This ability for organisations in a collaboration to pool resources also enabled spending on projects that were not previously possible when operating alone, as a director of an alliance stated:

. . . we’ve brought in about £35M of capital funding through collaborative proposals for radiology systems, single laboratory information management system in pathology which will underpin all the pathology services working together.

The pooled resources that enabled purchasing of more expensive equipment or contracts had the ability to further enhance care quality. Collaborating enabled services to be contracted out to partners who were able to deliver those services better. Likewise, interviewees reported that working cross-sector in their collaboration enabled resources to be redirected to enable improved service coverage for patients:

And that is the partnering if you like, because we have got the third sector which allows us to reach people who find it difficult to engage with services. And that means we might actually make things better.

However, although collaboration enabled expanding outwards, collaboration also allowed for consolidating services to a smaller number of providers where patients could be more easily referred within the collaboration. Service consolidation was connected with improved sustainability of service delivery:

. . . it’s a big town, had a district general hospital that at one stage provided the full range of treatments as you’d expect from something in the 1970s, 1980s. Yet now has been repurposed specifically around acute medicine.

However, in contrast, the interviews with patients also identified that consolidation of services had, in some cases, led to them having to travel further, which could have potential to reduce access for some. A patient representative recounted their experience as follows:

. . . instead of sending people to [hospital 1] to have their scan and then having them transferred to [hospital 2], it was better to actually take them straight to [hospital 2] which is another 15-minute drive in an ambulance.

Those involved in implementing collaborations also reflected such experiences:

Over time, it could mean that patients potentially have to go further for their treatment, rather than getting it locally. And, you know, sometimes regardless of how well their local hospital is rated, people want to go to their local hospital.

However, it was also apparent that caution was needed when considering the potential of organisational efficiency to simultaneously improve care and save money. Some scenarios were recalled of integration increasing costs as community services ran alongside acute services, and this may be the case when collaborative functioning is not optimised and also for particularly complex collaborations:

Most projects have struggled to do both, to improve care and to save money . . . the classic example was [trust] that seemed to be doing quite a good job early on at keeping people – more people in the community and then reducing admissions to hospital. But we never got to the stage of actually closing the beds that were we were previously admitting people to. We just filled them with somebody else . . . So, the people that were paying for care were paying for all this community service over here and they were still paying for the previous acute beds that are now just filled with other people.

Technological effectiveness

Technological effectiveness featured in interview accounts where the learning had been accumulated across organisations about how to re-design care pathways:

. . . we frequently will have visits from other hospitals and we will share where we are with our stroke service and share anything . . . why reinvent stuff that someone has already done?

Connections with organisational efficiencies were also made, with technological effectiveness also connected to reduced duplication of effort:

. . . the big programmes like the radiology, which was obviously very, very successful in terms of having joint reporting and having some joint policies, joint guidance, to us doing some joint clinical leadership training. And that’s all been really, again, that’s successful that we could do that.

Within these arrangements, the enhanced communication fostered by collaboration allowed for the delivery of more integrated cross-organisational clinical pathways by enhancing data-sharing. Implementation of such pathways was found to give patients a more seamless experience when moving between providers both within and between sectors:

. . . so can we try and take out some of that cost and improve patient experience by joining some of that up? And that doesn’t necessarily mean a sort of integrated provider but it certainly does mean that all those different parts need to be working much more closely and effectively together.

Technological effectiveness also encompassed enhancing access to technology, with the sharing of clinical innovations that organisations previously could not use:

. . . you know, if you look at [provider 1] and [provider 2] for example, you know, they’ve got robotic surgery in [provider 1] that [provider 2] patients can access more easily now.

The overall expansion of research and development was also enabled by enhanced access to resources:

. . . since we’ve become a group, research has exploded because we now have a footprint of 1.2 million patients and the electronic patient record in [locale] moving forward with a pace and purpose to get that in our North West sector care organisations.

Enhanced research and development could, in the longer term, further improve the kind of clinical quality that could be delivered in the providers involved in the collaboration.

Depicting the relationships between collaborative performance mechanisms

Figure 15 depicts how, within each of the collaborative performance domains, a range of mechanisms can be identified with associated performance improvements. Figure 15 shows that cultural efficacy can encompass mechanisms that underlie improvements to efficiency. For example, an enhanced awareness of the local system brought about by cultural efficacy can enable improved coordination, which thereby enables several other improvements, including redirection of resources and consolidation of services to more efficient or effective providers. Figure 15 also shows how increasing communication between providers within the local health system can enable many other mechanisms further down the causal chain, including the sharing of clinical practices in the technological effectiveness category.

FIGURE 15 Depiction of mechanisms underlying collaborative performance. (Figure not reproduced here; see the original article.)

We have also connected the performance mechanisms to what we define as ‘long-term outcomes’, denoting the outer areas affected by collaborative activity. Some of these long-term outcomes will be explored in the following section. However, it is important to note that these links between mechanisms and outcomes require further research, and, accordingly, provide an important basis for further inquiry rather than definitive evidence. Table 9 outlines the intermediate mechanisms identified and how the mechanisms relate to performance improvements.

Long-term outcomes

Connections were made by the interviewees between the mechanisms underlying collaborative performance and the end points of improvements sought from collaborations. Outcomes arising from collaboration were particularly important:

. . . so for me the outcomes that are important are patient related outcomes, staff related outcomes, and what I would call efficiency related outcomes.

A focus on improving population health as a desired outcome was particularly pronounced within accounts regarding the drivers of current collaborative activity. A range of contributions set out visions and goals to ‘bring together partners with a focus on health inequalities, deprivation, economic improvement and promote health and wellbeing as a shared purpose . . . ’ (17; chief executive officer; alliance 2). The focus on population health and reducing health inequalities was connected to the current ICS agenda as a driver for collaborative performance:

. . . if you look at what affects people’s health, it is have they got somewhere to live, have they got something to do, have they got someone to love? And, the economic recovery plans are going to be driven by city regions, getting to the heart of some of that issue, so who is going to have jobs, which sector has got jobs? We have, the care sector. Who is going to have jobs? We are. What about our supply chain? Well, the fact we can’t get PPE [personal protective equipment] reliably means we should make it ourselves locally . . . So, let’s put that together. And, then at the innovative end of the scale, this city region has 22% health-maintained jobs anyway, which has gone through a digital revolution. We have got the conditions locally to make that a reality, so let’s make it a reality. So, there is a really – and, then the other bit for us is the green agenda.

The leadership challenge was framed as one of enabling collaboration towards a greater recognition of social outcomes and social value. The challenge translated into identifying the most vulnerable communities using broader measures (e.g. educational attainment of children, the uptake of free school meals or employment levels). Collaborating with the third sector and faith groups was also identified within such efforts:

. . . so we’ve been doing hypertension clinics in the mosque so working with the faith sectors, starting conversations about going and doing things at the foodbanks.

Leaders attributed economic benefits to the place-based approaches already under way. One ICS leader illustrated the high level of cost savings they had achieved from collaborating:

So in 4 years, we had a £400M deficit gap in 2016. We’re breakeven now as a system. We had four organisations in requires improvement or special measures, now they’re all good or outstanding. We had the lowest investment profile into primary care 4 years ago in the country, we’re now in the in the in the mid-range. We’ve still got further work to do.

The focus from ICS-based interviewees was on how they were able to do more to engage with communities, run employment programmes and employ a large number of staff from that, including some of the most deprived communities:

The last 2 years, you know, we’ve moved £20M-worth of procurement out of national procurement into local SMEs [small and medium-sized enterprises], local companies within [local area] alone, that’s where we’ve tried it first, and we’ve got some good success in [locale]. So that’s an ambition of recruiting 1000 people every year into pre-employment programmes, with an expectation that 85% of them will lead to permanent, good-quality jobs in health and care, and that we’re targeting those wards that are the most deprived or have the most challenges.

To achieve the population health agenda required further development in creating a shift in understanding regarding provider collaboration. It was evident from the interviews that different systems were at different stages of development towards the ICS agenda:

. . . people might be at very different points in their journey so it’s not certain that you’re all terrible or you’re all good, it’s just about really trying to help them so that the outcomes we want around improving population health get there.

Wider challenges regarding outcomes were connected to ‘fundamental issues’ associated with the historical separation of health and social care systems ‘where integrated services have not been in policy-makers thinking’. Collaboration also surfaced contractual issues surrounding workforce development. Deeper considerations were needed regarding existing salary structures and funding arrangements:

. . . social care has come right up the agenda especially since COVID-19 and the integration across health and social care but we still have a different funding system which causes huge problems for people that want to collaborate across the two and so there is a sort of environmental point that I’d obviously apply across the country but there’ll be some that just apply locally as well.

Patient perspectives on outcomes

Patient representatives were also able to shed light on outcomes they had seen from collaborative efforts in their local areas. Overall, these reflections presented diverse reactions to collaboration. Patient representatives raised concerns regarding the translation of collaborative intentions into practice. Scepticism was associated of the aspirations for implementing large-scale change:

. . . it seems generally that across the STPs in the three areas that there’s still lots of planning but nothing concrete is happening in terms of improvements or changes for patients and the public.

. . . one of my ex-colleagues who was a chief exec[utive] in an acute trust said, trying to get a trust to change is like trying to get dinosaurs to dance.

However, with respect to PCNs, patient representatives had seen improvements, with experiences of joined-up care:

They’ve rolled [PCNs] all out now so we’re in the final stages of it really and it has been successful. If you can’t get treatment in one of the GP [general practitioner] surgeries, as long as it’s within the cluster, they’ll refer you to another. Patient transport had been an issue but they’ve done a lot of consultation around that too.

Joined-up care had a positive impact on outcomes, with one patient representative highlighting the improvement to ‘technological effectiveness’ they had enjoyed:

. . . our local primary care network pharmacist contacted me and through that discussion with her she changed my medication. That was brilliant, that really worked. Because prior to that our [local general practice] did not have a resident pharmacist.

Several longer-term outcomes had also been noted, with one notable example in the staff-related outcomes:

[NHS trust] were having massive problems with recruitment of radiologists and consultant medical staff at [trust]. Since they’ve become part of a large university hospitals teaching trust they have succeeded in recruiting to the areas that [they’ve] had problems with.

Another patient representative also had very positive experiences in their local system after a large merger took place:

I had to go in and have a little op[eration] and you couldn’t fault it, I got there at 7 o’clock in the morning, they gave me a side room to myself, I had it all day until I went home at 5 o’clock, it was brilliant and I’m excited for [the hospital] for the developments that they’re going to have.

Conclusion

This chapter presents the first comprehensive realist evaluation of how well-functioning IOCs can drive performance improvements. The chapter finds that cultural efficacy mechanisms prove to be particularly important for driving performance improvements from collaboration in other areas through improved communication, better coordination, shared improvement strategies and the enhancement of reputation. Organisational efficiency mechanisms are also identified, with the causal links between collaboration and improving financial and workforce resource allocation, and an increasing responsiveness and reduced duplication in service delivery. Technological effectiveness also connects with such areas and sheds light on the benefits collaboration can bring for research and development and working across clinical pathways. The full CMOC configurations identified in this chapter are depicted in Box 2.