When trust, confidence, and faith collide: refining a realist theory of how and why inter-organisational collaborations in healthcare work

Abstract

Background Health systems are facing unprecedented socioeconomic pressures as well as responding to the ongoing strains and surges brought about by the Covid-19 pandemic. In response, the reconfiguration of health systems to encourage greater collaboration and integration has been promoted with a variety of collaborative shapes and forms being encouraged and developed. Despite this continued interest, evidence for success of these various arrangements is lacking with the links between collaboration and improved performance often remaining uncertain. To date, many examinations of collaborations have been undertaken, but use of realist methodology may shed additional light on how and why collaboration works, and whom it benefits. Methods This paper seeks to test initial context-mechanism-outcome configurations (CMOCs) of interorganisational collaboration with the view to producing a refined realist theory. This phase of the review used case study and evaluation literature; combined with supplementary systematic searches. These searches were screened for rigour and relevance, after which CMOCs were extracted from included literature and compared against existing ones for refinement, refutation, or affirmation. We also identified demi-regularities to better explain how these CMOCs were interlinked.Results Fifty-one papers were included, from which 338 CMOCs were identified, where many were nonunique. This resulted in new mechanisms such as ‘risk threshold’ and refinement of many others, including trust, confidence, and faith, into more well-defined constructs. Refinement and addition of CMOCs enabled the creation of a ‘web of causality’ depicting how contextual factors form CMOC chains which generate outputs of collaborative behaviour. Core characteristics of collaborations, such as whether they were mandated or cross-sector, were explored for their proposed impact according to the theory.Conclusion The formulation of this refined realist theory allows for greater understanding of how and why collaborations work and can serve to inform both future work in this area and the implementation of these arrangements. Future work should delve deeper into collaborative subtypes and the underlying drivers of collaborative performance.Review registration This review is part of a larger realist synthesis, registered at PROSPERO with ID CRD42019149009.

Collaboration over competition? Regulatory reform and inter-organisational relations in the NHS amidst the COVID-19 pandemic: a qualitative study

“…Our findings suggest that rating collaborative systems requires a different approach than that currently taken with single providers, perhaps ensuring that collaborative behaviour itself is a component of what is assessed. Such a system could draw on findings from the present study and others relating to how functioning of inter-organisational and cross-sector collaborations can be optimised [27,49,50]. The concern, according to our interviewees, is that these new rating systems may unintentionally penalise collaboration, particularly in situations where partners may be 'dragged down' by poorly performing collaborators.…”

“…In addition, questions have been raised as to why the White Paper only briefly mentions the key underlying issues facing the NHS, including the need to address chronic staff shortages and widening health inequalities [7,18]. Indeed, there is insufficient evidence to support the view that inter-organisational collaboration actually leads to the intended improvements in outcomes, while being incredibly difficult to achieve [24][25][26][27]. Thus, collaboration may not be a 'magic bullet' to solve the health system's ills.…”

“…Regional Hospital Inspectorate Lead for National Inspectorate Body (8) Senior Advisor on systems transformation at National Body (9) Patient Representative Lead at Health and Social Care champion body (15) Director of Third Sector/Charity Representative (24) Local Government Association Representative (28) Private Sector Representative with experience of private/public partnership (27) and 90 minutes but were typically closer to 60 minutes in length. Files were sent for verbatim transcription at a third-party transcription service.…”