The purpose of this chapter is to present the findings from interviews undertaken with a range of policy, practitioner and patient representative perspectives regarding how they understand and experience the mechanisms of collaborative functioning. The chapter organises these findings around the mechanisms central in the realist review (i.e. trust, faith, risk tolerance and confidence). Other supporting mechanisms are also captured along with the contexts influencing these interactions.
Building and sustaining trust in collaboration
Interviews provided a range of insights into how building trust was deemed essential to maintaining and building collaborative efforts. To nurture trusting relationships, leaders described the need for experience, with a demonstrable track record of involvement in collaboration and delivery in improvement. Authenticity was also connected to leaders’ understanding and visibility within local systems:
I think clinical leaders don’t move around as much as career managers, so I think that also means it is personal and because I know, you know, I know all of the GPs [general practitioners] . . . I’ve come across an awful lot of people and when you can just pick up the phone to people it’s a different conversation than if you’ve got to carefully craft a three page email isn’t it?
If you have been around for as long as I have, you can draw on that work because the work I was doing in world-class commissioning 15 years ago was about how do you reduce health and equality as a managed care variation and use your resources to deliver the best outcomes that you can? . . . And, then I could point to the vanguards following the publication of the NHS plan, which was about the same sort of stuff. So, by harnessing all of that work, what I did straightaway was deposit this as a continuation of existing work, and what we really were about was by working together, how do we add value to that landscape? And, really setting out some firm principles which are the founding stones of what we do every day, really.
Recognition that collaborative leadership differed from ‘traditional NHS leadership learned behaviour’ was depicted as an approach that transcended boundaries, with a focus on people and place. Interviewees described the approaches used to build trust, with empathetic leadership characterised by enabling people to be supported to enter into a collaborative mindset. Alliance 2, for example, reflected on the challenges associated with the configuration of vascular services from three sites to two. A lengthy process of engaging with clinicians ‘to give it up’ without being forced to was depicted. Other examples also featured within interview accounts:
I think it’s to do with the strength of relationships, but also the skill of the facilitation and the use of the data and the evidence, and the involvement of all of the clinicians, who ultimately see the value for patients in adopting that approach. And that’s what came out. So I think if you take those sorts of approaches, you usually do get to the right outcome. The ones where you don’t do that, and I’ve experienced this before, is the ones where you’ve got just a very strong kind of political agenda running with one or two high profile leaders that just want your railroad stuff through, and it’s bad news when you’re in those situations.
The importance of leadership in setting the tone and culture translated into demonstrating authenticity, visibility, empathy and openness:
I did become much more visible, spending time, with the rest of the executive team, visiting wards and departments, working alongside people, not just visiting and say hello, but actually acting in the role, whether that was as a porter or a nursing assistant or working in pathology, or whatever it might have been, and understanding, in a very small way, you know, what it was like to look through their lens.
Project management and boundary-spanning governance arrangements provided an important role in ensuring collaborations made progress and promoted consensus through understanding different organisational viewpoints, and this facilitated trusting relationships:
. . . a lot of what I do is understanding what each of the different organisations are thinking and what the people in it are thinking or what their concerns and worries are, and trying to sort of unpick those and find that consensus, find that area where everybody can agree and sort of . . . A lot of it is a bit of shuttle diplomacy in a way; you sort of go between people persuading these people to move this way and them to move a bit that way so you get them all into a place where they’re close enough together that they can work together.
Interpersonal communication
The ability to listen attentively and engage people in identifying areas for improvement was connected to building trust. In setting up alliance 2, interviewees described responding to cynicism to the proposed collaboration through getting a better understanding and appreciation of different perspectives. The power of informal interactions to build relationships was deemed a key mechanism for improving trust relationships:
[It] came from not waking up one morning and saying, ‘We’ve got to have an association and all get together’; it came from just going out for dinner and getting to know each other better, because there’s a group of colleagues that actually, I wanted to get to know, and they were really important to us.
Creating conditions where people felt open to talk about their experiences was important for creating an environment to facilitate trust-building:
Alongside that are the issues about openness and transparency, where I think you can’t just say something; people have to see it and feel it, and they have to know that you’re interested in the good, the bad, the indifferent, and that you will report it, that you’re creating a culture whereby you want people to talk about the things that they struggle with as well as the things that they do exceptionally well.
The challenge of communicating across larger-scale groups required greater attention being paid to governance. Focused programmes of work were required within such contexts to bring people together to share common issues and develop common approaches:
. . . we’re running about 9 or 10 programmes of work across different parts of hospital and hospital services. We bring together all the different functional directors groups, so the finance directors meet, the medical directors, the nurses, the estates people; so, they all meet to sort of . . . they sort of share common issues and try and come up with common approaches to things.
Cultural integration
A range of interview responses stressed the importance of cultural integration in building trust and faith in collaboration. Developing cultures of improvement was seen as essential, particularly in the translation of learning from higher-performing organisations to more challenging contexts. Underlying a culture of improvement was recognition of ‘toxic’ cultures exemplified by bullying and imposing management. Organisations finding themselves in positions of ‘learned helplessness’ unable to reflect on progress and generate improvements also featured, along with silo thinking of organisations fixing their ‘own problems’ rather than proactively seeking help from partners:
I do think that there is a kind of mindset issue about institutions . . . [that] becomes a barrier to collaboration because actually people like to think they can fix their own problems, can’t they? Or seeking help for whatever reason is not done proactively.
Cultures of ‘telling and doing to’ needed to be replaced with empowering, listening and enabling cultures. To do so, an honest and reflexive approach to problem-solving and progression was called for, where successful cultures of improvement were those able to reflect and understand achievements but also be open about difficulties:
So I think that, you know, that there is the risk that you can come at it in a sort of nicey, nicey way, and pretending everything’s okay, when actually you don’t either don’t believe or don’t trust or don’t agree with what someone else is saying. And I think having a safe environment where you’ve got relationships to a stage where you can challenge and be upfront about that, you know, and speak truth about it. But then move on, and, you know, and carry on doing the work together.
Challenges were met when trying to work across different professional backgrounds and ways of working. Cultural divides were encountered with those working in hospitals, across systems, and those in primary care. Difficulties were encountered with the associated power dynamics of organisations leading innovative models being associated with the ‘the big players’ at the expense of innovations being done in smaller scale providers:
It’s kind of, ‘size matters’, isn’t it? We get to this thing of actually, ‘How big is my organisation?’ So, it becomes inquisitory doesn’t it? Sometimes it perhaps gets in the way of collaboration so, ‘How do we view success?’ . . . we set up these kinds of quasi-groups that are a bit self-serving in some ways that are about themselves and their own importance. And, yeah, if you go to some smaller organisations and think, ‘Actually I’m doing some really brilliant stuff in my population’ . . . it’s kind of punching above its weight, really punching above its weight, and I think that’s amazing. So, it has nothing to do with size. It won’t ever sit in the [local] group. It certainly will never feature as a big integrated care system.
Challenges of generating a cultural of collaboration was raised in relation to ICSs. To support such efforts, having an awareness of local issues and ‘the geography of place’ was needed with regard to interacting with local area issues. Regulators also had a potential role in supporting cultural integration, with the ability of CQC to work across boundaries and feedback to organisations and the public about what worked well and what needed to be different was mentioned in this regard:
. . . how decisions get made as the ICS becomes a statutory body. All of that will have to change how we work. And it might need all providers to rethink what it is they’re doing and how they’re doing it, to make sure that ultimately, we’re doing the right thing for patients across [locale].
The limits of trust and risk tolerance
Building trust was synonymous with the risk tolerance required to support collaborative behaviour:
. . . let’s take the risk, let’s work on it together, and let’s share the risk . . . It’s about sharing it, and not letting it come down to the money, because if you put money into everything, it either goes really political, or you just don’t get anywhere.
An NHS context historically poor at exchanging information was raised as a barrier to such dynamics, with a lack of openness about failure and limited risk-taking being raised. Reluctance to share people and expertise across boundaries was also connected to a workforce institutionally focused in ‘wearing the organisation’s badge’. Such risk intolerance meant that the NHS often turned to management consultants to fill the information gaps:
We bring in management consultants who try and deliver something, they’re not really bought into it, they don’t have any prior experience in the NHS normally, it’s a weird thing to do. If they do have other experience in the NHS they then use that jack up the prices, which is absolutely preposterous, and we never have that round conversation.
Risk tolerance was also connected to the importance of organisational sovereignty and striking a balance that ensured workforce had some security and autonomy preserved:
. . . the way things are run within [the group], we attempt to give autonomy to each of the care organisations that constitute our group. Yeah, that has a standard oversight framework if matters are not being delivered to the appropriate standard or where there may be some concern about performance or trajectories . . . Yet generally the preference being each of the places to an autonomy yet working to the principles of big group.
Well-documented challenges of integrating professional groups with different risk appetites featured within the interviews. The context of COVID-19 was cited as ‘instrumental’ in galvanising clinical engagement in collaboration, but there was work to be done to engage clinicians outside ‘the COVID-19 agenda’. The context of COVID-19 was also attributed with creating conditions of diminished trust where there was less ability to have face-to-face connections and build genuine relationships. Working virtually across boundaries was fragmenting communication, although others did raise the equalising qualities:
. . . since the COVID-19 interruption, no, I think there is less ability to have that connection with people and that authenticity of what the reason you’re making the changes are.
Risk tolerance was connected to patient interactions and local service provision. Although those leading IOCs expressed receiving patient support for proposed changes in recognition that increased travel times would be accepted for higher-quality care, concerns about meeting the needs of communities within designated systems was also raised.
Building and sustaining faith in collaboration
Leaders of collaborations provided a range of insights into their approaches for instilling faith in collaboration. To work through any complexities and challenges required a delicate balancing act to ensure that the collaboration was feasible and realistic. Overpromising and overambition had the potential to reduce faith. Therefore, strategies to enhance faith needed to be focused on deliverables to maintain engagement and momentum. To generate focus and priorities, strategies included the use of diagnostics to assess whether or not to progress with an idea. In addition, due diligence work was carried out by consultancies to look at the benefits of collaboration in terms of reducing unwarranted variation, increasing quality and increasing efficiency to identify particular projects to bring services closer together. The following quote outlines the importance of building and keeping faith in the collaboration:
. . . you’ve got to pick some bits within [the collaboration] that you can actually deliver on because that’s the sort of thing which is too big, too contentious, is going to take you too long, and you’re going to be 5 or 6 years into this not really feeling like it’s actually delivered anything and that’s when people are going to go, ‘Why are we . . .? We’ve not seen any outcome from this so what are we doing?’.
Consistency of approach in leadership improved faith where stability, consistency of message, priorities and approach were attributed with success. For example, to break down the complexity of ICSs, hospital group 3 described the need to carry out a ‘True North’ exercise, focusing on breakthrough objectives and corporate projects that could be shared across organisations. Increasing faith was also characterised by the leadership behaviours of visibility, communication of benefits, and listening and reacting appropriately:
[It’s] leadership that listens because very often what you see is the kind of knight in shining armour vision of leadership which is one organisation is swooping in to help the other and everything’s going to be fantastic afterwards, well, if that person who’s coming in doesn’t listen to what’s good in the other organisation as well as what needs to be put right . . . that’s not going to work because people will resent it.
To build faith, leaders described how developing collaborative endeavours required going ‘where the energy is’ to establish momentum. Focused efforts with engaged stakeholders had the potential to reduce anxieties about task complexity as well as build trust:
Myron’s Maxims? . . . you start where the energy is and build out from that, that you have to do real work to make these things happen, talking about theoretical things doesn’t really work, you have to actually identify some real things because real change happens in real work.
Involving appropriate stakeholders within the collaborative process was supported. For example, if the goal of the collaboration was population health, then the governance and messaging needed to reflect this by involving councils, public health, police, fire services, the third sector and the NHS. Embedding such approaches needed to engage a mixture of provider and commissioner leaders to facilitate efforts in extolling the benefits of system working. The role of an ICS was cited as a case in point, with leaders needing to frame the ICS agenda landscape as being part of the organisational fabric as opposed to ‘an administrative construct or bureaucratic burden’:
I do think we have to continue to push those boundaries about, ‘What is it in our hospital institutions?’ – because that’s really what we’re talking about . . . I think that the more that we can really think about what can we shift out of the hospital institutions and place as care in our localities that for me is where we need to put our efforts and attention. And I include in that some of the big diagnostic pieces . . . Shift it out and put it as an interface between the hospital institutions and primary care.
The perils of maintaining faith in collaboration were raised where the energy needed for collaboration and the requirement of leaders to ‘go the extra mile’ created conditions of fatigue and burnout:
. . . we have tried to protect the organisation from the transaction as best we can, and just keep running great services for our populations, while we’ve dealt with burning the midnight oil on trying to get the business case and the transaction going as fast as possible.
Wider questions about the rhetoric and reality of system working also needed to be addressed. Well-publicised examples of system-wide collaboration approaches that had not achieved the demonstrable impact it aspired to at the outset were mentioned:
I already arrive at the table with a degree of cynicism, 30 years, ‘God, I’ve been here before’, and, ‘We’ll play this game; we can play this game, it’s easy, we know the rules’. So, I don’t think people have a lot of faith actually at a big system level that it can work. I’m trying to think of at a really big STP level what . . . So, there are examples, aren’t there? We shifted the dial in X on some things around some population health metrics, which was kind of the core purpose of the 5-year plan. Actually did we do as much as we should’ve done and we could’ve done? I think that’s a different question. And actually did that happen because we collaborated at a system level or was it because actually everybody in their local bit was just doing a bit and when you add it all up it looks good? I don’t know.
Capacity constraints
Faith in the collaboration was connected to the capacity available to support collaboration. Maintaining motivation and commitment for collaboration required the navigation of resource constraints and limited finances that could potentially weaken the resilience and energy to change. Chronic issues in parts of the country required structural responses rather than partnerships to generate improvement in recognition of the problems facing some of the worst-performing organisations:
. . . they will improve by just being given special treatment rather than partnering with another organisation because nothing’s going to overcome that, they actually just need more injection of cash to help them because it’s more expensive to run their services. And I think that policy, central policy is slightly allergic to making special cases even though special cases need to be made.
Similar points were raised about workforce shortages where the skill mix required for vertical integration and specialist care interdependences was not currently available. Organisational development teams, identified as crucial in collaboration efforts, were described as ‘bursting at the seams’ with demand in supporting existing change processes. The functions, such as analytical capability and project management capability, needed to maintain and improve services had been ‘stripped out’. The ‘partnership bandwidth’ for organisations to sustain multiple types of partnerships on different fronts simultaneously was brought into question:
I remember talking to someone from [trust], actually, so that I think they’re, you know, seen as an ICS, that has made particularly good progress. But they spent 18 months building relationships and didn’t do anything other than spend time together, talking about the challenges their organisations face, getting to know each other. And they spent 18 months doing that before they even tried to change anything about how they were running as an ICS. And that investment in time in building relationships, building trust, is hugely important. I think the challenge the NHS has got at the moment is it hasn’t got that luxury. So, you know, they’re going to have to do it, like as a mid-air refuel.
Within current capacity constraints, the development of ICS relationships was raised both as a challenge but also as an opportunity to have system-wide discussions about priority-setting and sustainability:
. . . through COVID, I think what we found is, a lot of providers have realised that it’s just not worth the risk of trying to pretend that you can deliver certain services, if you can’t. And actually saying, ‘Look, it’s fine. You do, you know, you deliver that because you’ve got the skills and ability to mobilise it now, we haven’t’. Whether they would have done that otherwise, when contracts are at stake . . . I don’t know”
Limits to faith and capacity were encapsulated in hospital group 4’s experience of the vanguard initiative. Hospital group 4 developed three clinical programmes across an alliance as ‘fully funded, focused and structured’. Yet, following the completion of the vanguard, hospital group 4’s funding, energy and passion to go develop and co-fund initiatives was lost, as the clarity and impetus needed for sustainability was removed:
We kind of had a lot of momentum coming out but I think we didn’t recognise the difficulty that would happen when we no longer had that. And it’s not just the money, it’s also the focus that comes with it, it’s the political cover. When you don’t have that suddenly people are a lot more cautious, also they’re a lot less focused on it and they think about other things.
Task complexity
Our interviews identified how instilling faith in collaboration was connected to the perception of task complexity. The scale of the collaboration was raised, where increasing the number of organisations involved increased participants’ perception of task complexity. Challenges were singled out in relation to vertical integration of functions along a care continuum, where collaborations involving the relinquishment of specialist services were susceptible to being a ‘battleground for money or kudos’:
I sometimes wonder if some of the kind of vertical integration and cross sector integration has been a bit more challenged because the challenges aren’t always the same or the incentives aren’t always the same and the finance works differently, the contracts are different and I think, you know, where trusts can kind of come together in a slightly more streamlined kind of way sometimes so reflecting on that workforce piece I think there’s quite a range of different initiatives that we covered but a lot of them are trust to trust.
Horizontal collaboration was facilitated when collaborations were located within coterminous boundaries (16). Such contexts proved problematic for alliance 1, where challenges were raised in connection with working across multiple local government and political constituency boundaries:
. . . the politics locally have been incredibly difficult, incredibly difficult, because the local politicians were adamant that X was to go into X, and not X. And that’s why it’s become so complex, that we’re disaggregating, we’re not just acquiring an organisation, we’re disaggregating it whilst acquiring it.
Integrated care system success was attributed to their maturity in terms of how far such contexts had progressed with vertical integration. Where alliance 1 cited continuing conflicts working within the ICS landscape where those with ‘the greatest powerbase’ continued to prevail (10), power dynamics were also connected to the formation of ICSs where the depleted resources of primary care, local government and social care meant that a greater need for acute sector experience was required:
So a lot of the capability to make the change happen to make the ICS successful, I think, sits in the acutes because they’re very good at mobilising things. Very good at making savings in efficiencies and have those hierarchies in infrastructure in that they can almost just ignore some elements, because it will happen by default, and should be putting energy into other things.
Getting the ‘right geographical footprint’ to meet the population size featured as an enduring issue across the interviews. Collaborations considered over a larger footprint were both supported in gaining a more strategic focus in relation to population health; however, these collaboration were also limited in the ability to build faith and trust in collaborative endeavours. The nature of local population characteristics would also influence efforts, where having a smaller population or a more affluent and well-educated sociodemographic could lower task complexity in terms of issues the collaboration needed to tackle. Conversely, having a larger geographical distance between providers had the potential to increase complexity and make it harder to build trust because of difficulties in forming personal relationships.
Legitimacy
Connections between faith and the legitimacy of collaboration were made by a number of interviewees. The perceived legitimacy of a collaboration was connected to different types of partnership working. The drive for a ‘system-wide’ agenda underpinned by ICSs was supported in recognition that collaboration required a more strategic focus to improve population health and sustainable services. The ICS agenda provided a vehicle for achieving such endeavours:
. . . we’ve had quite a bit of feedback around the kind of helpful role that an ICS could play in facilitating or convening partners rather than kind of seeking to be a unit of delivery.
Although still emerging across health economies, concerns were also raised about the legitimacy of the ICS agenda in draining energy and momentum out of other collaborative activities. The mandating of ICS structures had the potential to stifle existing efforts:
. . . you spend so much time developing something and then halfway through ICSs come in and you’re kind of cut off at the knees.
. . . it’s almost like the bit about working in a system that we need to do but we don’t want to squash those that have gone first . . . we just want to help them along that way and get them to sort of get to local agreement.
Other risks were raised in relation to ICSs ‘recreating a SHA [Strategic Health Authority] provider structure’ in resorting to a centralised, hierarchical approach rather than acting as a ‘servant of the organisations in the system’. Provider collaboratives were raised in a similar vein as having potential as a facilitator for instilling collaboration, but potentially problematic in being defined by organisational structure rather than relationships:
As soon as you create an organisation which has responsibilities and accountabilities and holds budgets and people work for that particular organisation behaviours and things . . . there’s a risk that behaviours and things change understandably because of those responsibilities and accountabilities and things, and we’ve got to try and find a way of taking the good bits – that will bring some benefits that new organisation for us – but not losing the sense of being a real partnership and not recreating a sort of SHA [Strategic Health Authority] provider structure.
Group models were deemed attractive for the running and delivery of secondary care based on their ability to provide a mix of options to accommodate different needs and interests. For example, alliance 2 described how such an approach was preferable based on its ability to retain identity and sovereignty as an organisation, as opposed to being ‘thrown into merger’. Group models had the advantage of being able to demonstrate benefits without having to spend ‘2 years on a disruptive merger process’ (17). Alliance and group ways of working were, therefore, conducive to building faith and trust, as, often, organisational sovereignty for money, buildings and infrastructure or workforce would be retained:
Group models seem like an attractive model for the running and delivery of secondary care certainly services and I think that’s partly because it does have a reasonable mix but it’s reasonably loosely defined by me . . . so it probably means different things to different people but it also allows within it because of the sort of hierarchy it actually is making some of those decisions.
Buddying, also referred to as a ‘management support agreement’ or ‘mutual aid’, was associated with a recognition that lighter-touch, time-limited collaborations to improve poor-performing organisations had benefits in sharing expertise and learning. However, in contrast with the mandated nature of special measures buddying arrangements, care was needed in having an appropriate cultural and organisational fit to create the conditions for collaboration. Financial support for the mentor within the buddy arrangements was also connected to facilitating collaboration:
So and I think it ended up being actually a relatively successful arrangement in terms of impact at [trust]. And I think from [trust’s] perspective it was pretty successful in terms of delivering a significant amount of cash into their organisation . . . but it was always viewed as a kind of time limited kind of fairly focused collaboration of doing some things which I think it did.
Mergers were deemed a legitimate option in contexts that required building economies of scale and reducing the number of providers and consolidation as far as possible. Yet, such forms of mergers required being treated with caution in taking ‘people’s eye off the main ball’, as valuable time and energy was lost to merger processes rather than focus on the improvement of workforce, structures and governance. To overcome issues, pre-merger activities were encouraged, with integration efforts focusing on clinical pathways and back office consolidation to start delivering benefits early.
Stakeholder involvement was identified as serving to increase legitimacy. Leaders often found it helpful to have service users involved to keep the focus of the collaboration on outcomes. Local system reviews led by CQC in 2017 were highlighted as an attempt to look at local systems ‘through the lens of a local citizen’ to encourage better joint working (7, 5). The reputation of specific forms of collaboration also influenced the willingness to engage in forms of collaboration. Fears were expressed by public representatives that greater collaboration would lead to privatisation, which undermined the legitimacy of collaboration. The label of privatisation was also present elsewhere, with leaders being driven to collaborate in ways that could manage public anxieties about privatisation:
. . . the public really feared privatisation I’ve got to say, and they really just wanted integrated services. The alliance with providers, our local providers, and their preferred option would be an alliance approach as well as a step towards.
Demonstrating progress
Our interviews provided a number of insights into how the perception of progress was important for ensuring that momentum was maintained. Evidence that progress was being made increased faith by serving as a motivator to continue with the collaboration. Getting feedback and ‘positive reinforcement’ was deemed important to ensure buy-in. To do so, focusing on practical ‘quick wins’ to expose organisations to the goal of the collaboration and ensure staff remain engaged was suggested:
I think part of the problems sometimes mergers in particular suffer from it’s almost they’re sort of too big and theoretical to achieve anything, whereas, get a couple of teams working together on a specific problem, like, ‘how do you redesign this service?’ and suddenly everyone sees the point of collaboration and what it really means. So I guess focusing on the practical and sort of some quick wins, probably the same sorts of things that are important for projects more generally.
That said, the promotion of quick wins was also susceptible to problems when tangible progress did not materialise in the longer term, which reduced faith and momentum:
I think that people are getting fatigued and wanting to see more outputs for it and if they don’t see that, if people don’t see things getting any different then it just becomes a talking shop and people start drifting away and I think that’s what we saw in some of the earlier integrated care models that people just thought we’ve just wasted a whole load of money like the Integrated Care Fund . . . 150 initiatives that all sound great but didn’t deliver very much and then it’s, well, should we put so much money into it next year or not because we can do a lot of the stuff ourselves.
A perception of peer pressure was also connected to driving progress where organisations or teams want to avoid the perception of ‘falling behind’ or looking bad in front of others. The use of assessment and accreditation systems was cited as an example of being open and transparent in showing good, bad or indifferent progress was being made:
. . . so we took the [assessment and accreditation system] over and showed it to them and said, ‘We really want to deploy this, but we want to deploy it in a way that you’re with us on it’ . . . so we brought them all together and we showed them the outcomes . . . so they 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.
Clarity of vision
Clarity of vision served to increase faith by reducing the possibility for miscommunication. Being able to articulate and construct a leadership narrative about the aims, goals and solutions that collaboration would achieve and the problems it would solve was connected to increased workforce engagement. Communicating a narrative of how the collaboration will be beneficial to staff through better alignment and ‘bringing parts together’ could also mitigate the potential exposure of collaboration being met with feelings of loss or being imposed on:
So it’s almost from a point of view of a member of staff is kind of what’s in it for me? Well, what’s in it for me as a member of staff, you know, what’s worked out? We’ve been able to make things better for patients but actually we’ve been able to grow our staff as well. And I think as a set of organisations in the NHS I think we’re for telling that story. And if we force ourselves to tell that story I think it would force us to change the reality of that in a more meaningful way as well . . .
To generate a clear sense of purpose, key actors used a methodology embedded within organisations to work through problems. As with the nurturing of interpersonal communication, leaders describe customising quality improvement approaches. Inspired by Virginia Mason, hospital group 3 described ‘a eureka moment’ in translating the Virginia Mason approach into a local improvement programme to lead, manage and set objectives to support staff:
. . . they’re all versions, you know, of basic improvement methodology, if you stripe them back, you will see that they share common components to them . . . I think the most important thing is that you select the one that feels right for you, and you stick to that methodology and it becomes the discipline, it becomes the rhythm, you know, the beating heart of the organisation, and that people get familiar with it, they get trained in it, you know, it is the only method that they then use, and it’s applied in all sorts of situations, and then just becomes the way of doing things.
Being ‘deliberate and visible’ about opportunities for partnership working was also connected to the need for inclusion of stakeholders. Involving patients and the public to help shape pathways and ‘cut out things not adding value’ was encouraged. To facilitate inclusion, having a communications strategy highlighting key issues and celebrating success was important. Dedicated programme leads also played a role in communicating the progress being through face-to-face relationships and meetings:
Having a communications strategy aligning with that vision to be delivered and supported by those leaders that is constant, reflected upon and respond to the different ways that people want to and need to hear those messages and that responds to their different concerns not to spoon feed because, you know; we’re all adults and we should be kind of empowered and enabled to operate as adults but in a way that actually relieves them of the anxiety that they might have about the situation that they are in.
Environmental influences on faith
Interviews supported our review findings that establishing ‘initial faith’ (i.e. if engaging in collaboration is feasible or, indeed, worth the risk and effort) was primarily shaped by factors related to the regulatory and policy environment. Owing to the timing of the fieldwork, it also identified the role of COVID-19 in shaping the perceived difficulty of the collaborative tasks at hand.
A shift in thinking was observed over recent years in the motivation and effort attributed to collaboration. The recent policy agenda in England emphasising collaboration was brought into view, where interviewees described a ‘movement’ from 2012 onwards as a reaction to the limits of competition within the Lansley reforms as a means to driving performance improvement. Mindsets around competition and ‘carving out a particular niche’ had increasingly changed, which had been driven by the Five Year Forward View3 agenda in incentivising people ‘to pay more interest in other parts of the system’:
. . . the realisation that you can’t necessarily specify and procure for healthcare became quite obvious so I think Simon Stevens came in he realised that and having come from a background of accountable care organisations internationally he’d got this view, the kind of blurring the edges a little bit about who was actually responsible for which bit of activity . . . But also thinking about quality at more macro level and also obviously some of the most powerful parts of the system with the ability to destabilise the NHS are the very large providers, so how do we rebalance that and bring those providers to the table with an incentive to population health long term?
The vanguard programme was cited as providing investment and energy to develop leadership ideas and initiatives, as well as enabling opportunities to learn from organisations elsewhere. The learning from new care models was also connected to current thinking regarding ‘systems transformation’ and the NHS Long Term Plan’s33 objectives for ICSs:
. . . the vanguard programme was the first way that we came together and started collaborating and I think that was great that there was a bit of investment to do that and there was real energy for trying to drive on with that.
The COVID-19 pandemic was significant at the time of doing fieldwork, and was identified as being important in driving shared purpose and the spirit of collaboration. The COVID-19 pandemic had facilitated collaboration where established ‘bureaucratic burdens’ and ‘discussions about money and capital’ had been removed from the agenda. The COVID-19 pandemic had brokered discussions that ‘dispelled myths’ about other stakeholders and enabled people ‘to get on and do other things and think longer term’. Patient representatives also documented the COVID-19 pandemic as driving a significant increase in collaboration between their providers (34, focus group):
. . . [during COVID-19] so many people have just been in favour of the removal of bureaucracy so removing a ton of barriers to partnership working and to relationships has just been so helpful so whether that’s DTOC [delayed transfer of care] fines or continuing health care. I haven’t heard anybody sort of raise any concern or any anxiety about all of those bureaucratic burdens which were lifted and seem to have really accelerated kind of partnership working.
The COVID-19 experience was attributed with driving the formalisation of the ICS agenda in ‘facilitating or convening partners’ with provider collaborative models interpreted as a way to deliver on the priorities of ICSs:
. . . with wave one COVID-19, we saw a lot of people saying, ‘We’ll work together to do something’. And then it didn’t quite get bad enough in our area to compel that. So things went very quickly back to the way they were. The second wave of COVID-19, things were much more extreme where we were. So we did manage to change the models of care. And then the legislation is trying to, I think, put walls around some of those things. They wouldn’t necessarily had been there in normal time. So there’ll be some difficulties in trying to mainstream that.
The formalisation of ICS structures created a recognition that contexts for collaboration were arguably now ‘stronger than ever’. However, the conversion of motivation and interest towards collaboration was by no means straightforward, with ongoing conflict with local partners stifling momentum. The move towards collaborative behaviour and away from competitive behaviour could be a turbulent one. Local competition ‘to be the best’ remained a challenge, as was the importance of organisational sovereignty and acknowledging existing boundaries. The power of professional status also featured where encroachment on professional standing could lead to resistance towards collaborative efforts:
. . . actually there is still very much that people want to hold onto their professional status, their standing, and where they’re at, and that it isn’t easy to maintain that vision of why you’re doing something because we’ve all got our own personal motivations for why we’re in work.
The present regulatory regimes promoting competition also featured, with documented challenges associated with working with regulators to support collaboration. Distrust of regulators built on experiences of broken promises about financial investment. The lasting effects and experiences of trying to collaborate within competitive environments was also raised, with the role of the Competition and Markets Authority ‘fresh in our minds’ as a detrimental impact on collaboration:
. . . the reward element, I believed then, and I still do now, could be, or could have been a sufficient element to reignite interest amongst organisations and to send the, you know, a huge signal that improvement is what the centre of the NHS attach importance to, and those organisations who step forward with competence and credibility would be rewarded to take on organisations that were in difficulty. That was the proposal that I put forward, and, in the end, we weren’t supported financially in the way that I was led to believe we were going to be . . .
Concerns were raised that as the COVID-19 pandemic recedes, the regulatory barriers that were previously lifted would be put back in place, stifling momentum:
. . . so the worry I suppose post COVID-19 is some of that coming back and those barriers going up again really.
Regulatory perspectives reflected on the role inspections had in helping organisations ‘keep focused’ and to provide a benchmark for progress in the turnaround of organisational performance. However, it remained unclear what the CQC role would be within the ICS landscape in holding organisations and systems to account for performance. Although moving to ‘system by default’ was being encouraged by the centre, concerns were raised about whether or not CQC had the systems and processes in place to oversee the agenda:
I think that’s an area where we would encourage regulators to kind of take a slightly different view of, you know, ‘what is performance in a system and how do you measure that?’ And then, there’s a wider question of, you know, ‘does CQC have their remit to performance manage a system, regulate a system?’ Not really, and does NHSEI [NHS England and NHS Improvement] have a framework in place to performance manage a system? Maybe not quite yet, so I think there’s quite a lot of work still to be done there.
One of the challenges for us is to be able to get enough information of good quality data upfront to try and make a targeted assessment. If we’re looking at a risk based assessment. you need good-quality data. At the moment the systems are not designed so that we can access that in a sort of real-time manner.
Improved collaboration between CQC and NHS England/NHS Improvement was called for:
I think COVID-19 has shown that actually lots of communities have benefitted from the systems that are in place and the mutual aid that’s happened. The provider collaborations that have actually sprung up from COVID-19 in particular have been legion and really interesting actually but at the moment there is a massive mismatch and I think, I think there has been a lack of desire from NHS England mainly and NHS Improvement and others to have a real conversation about what we want, they’ve just wanted to push through an approach and basically without, you know, we’ve got real incremental policy change without understanding the cumulative impact of all of these changes.
That said, positives regarding collaboration were mentioned within the trajectories for performance improvement. The removal of contracting mechanisms across NHS contracts could lead to more innovative models of care, with an increased focus on social value, as could the moves to global budgeting. Recent changes to performance risk ratings, with a move away from waiting time performance standards to prioritising equal needs, also presented opportunities for more creative solutions to engage the workforce across boundaries.
The presence of conflict
Conflict had the potential to reduce trust and faith by sapping the energy and momentum needed for collaboration:
. . . everybody sits around a table in partnership, you don’t recognise the conflict in the room if you’re not familiar with the players in the room. But the conflict then gets played outside of the room, in corridor conversations and email conversations, etc.
The formation of ICSs and its enforced changes to existing ways of working were predicted to lead to conflict. Although early formations of ICSs were locally generated, the latest ICS incarnations moving to greater formalisation raised concerns as a centralised approach. Conflicts in the potential for ICS structures to be NHS hospital provider focused at the expense of other providers also featured:
I think providers are kind of getting themselves in . . . I guess, aligned, to various degrees, to kind of deliver on these agendas, even in some of the most difficult places . . . I think in terms of the more fragmented providers – mental health, primary care, that’s going to be a more difficult journey in terms of jockeying for position and influence, because the table is still not big enough for everybody. That’s where the tensions arise.
Conflicts were raised in response to the demands placed on providers as a result of COVID-19. The role of the private sector was described as being helpful during the initial COVID-19 response, yet different interests and motivations between the public and private sector continued to be played out:
You have to work with the private sector in a completely different kind of financial system, and there’s no question that it would . . . I mean, why would it come in with the NHS on that? It can help the NHS kind of, I guess, deal with some of its backlog, but only through using our resource, what I would call NHS staff to do those procedures.
Building confidence
Formalisation and the fostering of collaborative behaviour through contracts and regulatory requirements was highlighted. Interviewees were largely sceptical of the notion of mandated collaboration. To avoid bureaucratic burden and to also maintain assurance processes, an alliance approach that encouraged compact ways of working with organising principles and supporting contracts was being encouraged. Memoranda of understanding were typically used to operationalise group and alliances as a means to support collaborative working. Memoranda of understanding set out decisions, approved business cases and created committees in common, where required, as an option to build in governance and give confidence that structures were in place for different eventualities:
. . . the way the MOU [memorandum of understanding] set it out is the decisions are still the preserve of the trust boards but I suppose what the committee in common does is it allows us to get to the point where you’ve got the chairs and chief executives all recommending the same course of action or the same decision to the [partnership] boards, and so in practice unless we make a real hash of it the committee in common recommends something then it tends to get agreed, so they sort of do make some decisions.
The formalisation and mandated nature of the current ICS agenda raised a number of implications regarding the confidence surrounding collaboration. At one level, the ICS agenda was seen as driving leader behaviours to ‘get real collaboration’ going. However, limits to the mandated nature of collaboration were also raised:
. . . we’re only really starting to see some of that changing now system regulation so the leaders probably weren’t strong enough to get real collaboration going until fairly recently I think and even in some cases people are doing that because they kind of have to and not necessarily because they want to . . .
Lack of clarity regarding the accountabilities associated with the ICS framework was creating ‘quite a bit of anxiety’ regarding what the eventual landscape would look like. Although the emphasis and energy was in place to promote collaboration and system working, the arrangements had no statutory underpinning, which lowered confidence between partners:
. . . we are asking organisations to works in systems, we’ve set the systems up and we’ve got ICSs and STPs across the country, they have no statutory underpinning whatsoever, they have office holders who have no formal role in law, they carry no liabilities.
Concluding summary
Our interviews provide a range of insights into how the stakeholders understand the functioning of IOC between NHS providers. To build and sustain trust was connected to the leadership skills and behaviours of authenticity, empathy, visibility and generosity. A commitment to place-based approaches also features, along with the importance of stakeholder engagement, data analysis and project management.
Our findings show how a delicate balance is required for building faith in any IOC. The presence of energising leadership that engages receptive groups and inspires and builds momentum is tempered by an awareness of the stark capacity issues facing current NHS contexts. To navigate challenging contexts, and a potentially overwhelming agenda, the findings draw attention to the importance of priority-setting, where perceptions of progress characterised by quick wins or the use of visual data can build faith; however, increasing task complexity is likely to reduce faith when multiple professional, financial, local government and political constituency boundaries are affected. The findings raise important implications for ICSs where place-based approaches to population health are supported but increasing formalisation has the potential to reduce faith, as energy and momentum is taken out of other collaborative activities and placed into potentially hierarchical performance management structures. Finally, our findings also show how a delicate balance is needed in relation conflicts arising within collaborations. In support of our review, interviews also stress the need for confidence, particularly measures that encourage compact ways of working and memoranda of understanding raising important implications about the mandated requirements of ICS arrangements.