Abstract
BackgroundHealth systems are facing unprecedented socioeconomic pressures as well as the need to cope with the ongoing strain 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.MethodsThis 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 realist synthesis 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.ResultsFifty-one papers were included, from which 338 CMOCs were identified, where many were analogous. 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.ConclusionThe 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 registrationThis review is part of a larger realist synthesis, registered at PROSPERO with ID CRD42019149009.
Highlights
Global health systems are currently facing unprecedented pressures from a multitude of concurrent events, including limited financial resource, an ageing population, unwarranted variation in healthcare quality, and COVID-19 [1,2,3]
Any conflicting information about the configuration of existing Context-mechanism-outcome configuration (CMOC) was recorded. This process resulted in significantly more overall CMOCs than were present in our prior realist phase, and this allowed us to gain a greater understanding of how the outcomes of certain CMOCs can become a context for another further down the chain. These CMOCs were deductively coded in NVivo 12 into categories, according to their mechanism, to better investigate the literature for Literature selection Included here after screening for relevance and rigour were 25 papers classified as case studies from searches from the second phase of our realist synthesis
Trust versus confidence in integrative and mandated partnership types In phase 2 of our realist synthesis, we identified a common CMOC which suggested that the formalisation of an arrangement through contracting facilitated trust relationships by having potential to act as a buffer where trust may otherwise be lacking [18]
Summary
Background Global health systems are currently facing unprecedented pressures from a multitude of concurrent events, including limited financial resource, an ageing population, unwarranted variation in healthcare quality, and COVID-19 [1,2,3]. There is no ‘magic bullet’ with which to tackle these ongoing issues, one solution has become a focus of current planning in the United Kingdom (UK) and elsewhere – that of ‘partnering’, or collaborating between organisations [1, 4] Such collaborations are purported to foster improved productivity, reduce variation in care quality, and improve financial and clinical sustainability [4]. Inter-organisational collaboration is often touted by policymakers as one of the means for solving the ‘wicked issues’ that contemporary health systems are facing It is not always clear how collaborating will solve underlying issues such as financial pressures [1, 7]. 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
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