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By Dr. Justin Aunger & Dr. Ross Millar

Partnership working and inter-organisational collaboration in healthcare has had a tumultuous history. Better working together has often been a mantra for policy makers, however, such an ethos has often had an uneasy relationship with the hierarchical demands of government accountability and the horizontal demands of market competition.

Since 2014, much has been made of how the Five Year Forward View, and more recently the NHS Long Term Plan, have swung (at least rhetorically) the pendulum further to collaboration as a key means for delivering integrated care. We have seen a variety of collaborative shapes and forms being promoted such as mergers, networks, alliances, and buddying. And now, in the 2020s, with the impact of Covid-19 requiring rapid collaborative efforts and onset of Integrated Care Systems, we are entering a decade that looks to have the focus further turning towards collaborative working to improve population-level health outcomes.

Collaboration has been defined as “a mechanism for developing a multi-agency partnership strategy in which partners work together towards a common set of goals(Apostolakis, 2004). However, working in collaboration across organisations is easier said than done, with scholars such as Huxham (2003) suggesting that “it is generally best, if there is any choice, to avoid collaboration”. Part of this, some would argue, is because collaboration falls foul of what is generally termed ‘magical thinking’ – in this case, that collaboration will solve many ills without any description of how or why. Likewise, collaboration usually means an overall increase in complexity and ‘moving parts’ which pose practical challenges when working on shared aims.

Our research is carrying out a review of inter-organisational collaborations in healthcare with the aim to untangle some of the thinking around how collaboration works, why, and whom it benefits (Aunger et al., 2020b, 2020a). An essential part of this is to go beyond the magical thinking that often surrounds collaboration with the identification of the causal links or ‘mechanisms’ that are associated with effective collaboration (Shaw, 2018).

Our review has identified that trust and faith represent important mechanisms for driving collaborative behaviour. Trust has been defined by Rousseau et al. (1998) asa psychological state comprising the intention to accept vulnerability based upon positive expectations of the intentions or behaviour of another.” In collaboration, building trust can increase actors’ ability to take risks by coming out of their silos to engage in collaborative behaviour. Another key finding we have identified in our review is the concept of ‘faith’ which we have defined as ‘confidence or belief in the venture of collaboration itself’ (Aunger et al., 2020b). Although trust usually relates to inter-organisational relations and belief in one’s partner, faith relates more to how actors within one or more organisation continue to believe in the collaborative endeavour as something that can deliver beneficial change. While trust needs to be in place for a collaborator to be willing to take a risk by acting collaboratively, faith is required for actors to actively work on the collaboration.

Our review also finds that both trust and faith are influenced by a range of other factors, such as conflict, inter-personal communication, power, perception of task complexity, perception of progress, and cultural integration. They also identify factors which can change the degree of trust and faith, such as the size and number of involved organisations (which affects perception of task complexity and thereby faith), geographical proximity (which changes frequency of interpersonal communication and thereby trust), and legal agreements (which can uphold aspects of the trust-to-risk relationship in contract and thereby increase trust).

Whether collaborations are mandated or voluntary, whether they require structural changes for implementation, or whether they are cross-sector or within sector, are likely to have a significant impact in setting the context for any collaboration. One such example from our findings suggests that collaborations requiring more structural changes (e.g. mergers), as well as those that are mandated by regulators (such as some buddying arrangements or Integrated Care Systems), are more likely to rely on a sense of confidence that contractual arrangements will drive collaborative behaviour, than inter-organisational trust. However, our review also points to how a delicate balance is required, as enshrining too much behaviour in contract can lead to an undermining of trust. This is because any collaborative behaviour may then be attributed to an obligation rather than altruistic behaviour (Aunger et al., 2020b).

Given the current policy agenda to implement Integrated Care Systems by April 2021, as well as Primary Care Networks recently (Smith et al., 2020), our findings suggest that their mandated, top-down nature might well pose challenges for areas where historical levels of trust are low and where faith may be compromised. This may be either because of local histories of competition (likely to reduce trust) or the perception that the arrangements pose a threat to the organisations (likely to reduce faith).

Within such mandated arrangements, our review findings suggest a need for implementing an appropriate degree of formalisation through contract to improve confidence, while also allowing inter-organisational trust to be built up. Setting smaller initial targets to allow for ‘quick wins’ can also build up trust, as can employing appropriate conflict resolution strategies, such as having empathetic leaders and independent conflict resolution bodies. These examples are means through which trust, confidence, and faith can be built, allowing these arrangements to achieve a full commitment to collaborative behaviour. Taken together, we hope that these recommendations along with others can support policy makers and practitioners in their efforts to develop inter-organisational collaborations.

To keep up to date with the progress of this project, you can follow @J_Aunger or @DrRossMillar on Twitter, or contact us at or