Our focus in this paper has been on collaboration around service provision and change rather than collaboration in undertaking the peer review process itself, although the latter mirrors the former. We found variability in the way different hospital clinical respiratory departments collaborated with commissioners, and also with managers within their own organisations, which analysis of interviews suggested related to the variable way teams responded to barriers to collaboration.
Our study had several limitations. We were unable to interview participants before they underwent peer review as we began the qualitative study at the same time as the reviews. So pre- and post-review comparisons depended on respondents' recall and reflection. However, our findings are supported by analyses of quantitative data collected before and one year after the reviews [5
]. Our purposive sample of 35 trusts may not have covered the full range of opinions, experiences and contexts within the UK, although we aimed for maximal diversity in our sampling approach (see ) and continued recruiting beyond saturation of themes to achieve a temporal spread. The intervention was based on acute services in secondary care and although the COPD services often involved collaboration across primary and secondary care, and peer review teams often included PCT representatives, interview respondents all came from secondary care. Our main research question and interest was in perspectives from secondary care. Primary care, PCT and patient representation at the peer review visits themselves had been problematic and it was neither feasible nor practical with the resources we had to recruit participants from primary care. We considered interviewing equal numbers of consultants, nurses and managers but nurses and managers were more likely to have moved post or duties by the time of interview, or to be unable to take part in interviews due to workloads, or to have only joined in the small part of the review process that was of most relevance to them. Mostly therefore our findings are based on the perspective of one person in the team, usually a consultant physician, whose views and experiences may have diverged from those of other team members and who may not have been aware of the full range of issues or service changes. Our findings need to be interpreted with this in mind. The study was not designed to explore reasons for differences in attitudes towards barriers to collaboration between different clinicians. We have assumed that it is better to collaborate and our data certainly suggest that collaborations result in better services. However, some hospitals might benefit most from a preserved autonomy; collaborations may reduce their power and consume resources, as systems are developed to enable the collaboration to proceed smoothly [21
]. Certainly the way participants talked about structural service changes suggests some hospitals may feel more vulnerable than others to downgrading and closure and for these, lack of collaboration may be strategic. Quantitative analysis revealed that changes were often modest and, if NCROP is effective (the quantitative analysis may have lacked power) its effect size is likely to be small. This is relevant to any comparison of effective and less effective teams.
The study also has strengths. Our data come from the first randomised controlled trial of peer review, adding to previous research into UK health service collaborative work, which has had a more restricted focus on inter-professional relations. We recruited beyond saturation of themes, and our sample was diverse. The steering group for the study was multidisciplinary enabling a full range of perspectives to be considered during analysis and the writing of this paper. We were able to triangulate our findings with quantitative data from the main trial and an independent analysis of the entire set of change diaries provided by participants in the main study, which has been reported elsewhere [5
]. The same picture emerged from the three different types of analysis.
Clinicians in unsuccessful inter-organisational collaborations told ‘atrocity stories’ of organisational, structural and professional barriers to service improvement, including: financial constraints; managers who did not understand; PCTs seen as the adversary because of their focus on community-based services; a government out of touch with frontline reality. Such clinicians presented themselves as adequately representing their patients but as unable to progress services because of problems beyond their control. In taking this approach, which may involve misattribution of problems [22
], teams may distance themselves from failures and problems and may not address factors that are within their control.
Those in more successful collaborations had weakened some barriers by working with, rather than against the government and PCT agenda of moving services into the community. This ensured they stayed involved in their patients' care and were seen to be on the same side as the PCTs. Aligned agendas have also been considered as critical for success, compensating for issues between sectors and professions, in evaluations of IHI collaboratives [23
] and of policy-driven change in the NHS [24
]; the latter study involved interviews with 30 PCT leads in England and Wales in charge of reconfiguring respiratory services.
Successful change in our study was also associated with the appropriate use within organisations of audit data enabling robust business cases for change to be presented by clinicians to their acute trust managers that recognised the power of cost-effectiveness and cost-benefit arguments. The same benefits were not seen across organisations.
The NHS management literature of the 1990s and early 2000s talks often of a “them’ (management) vs. “us’ (clinicians) schism. This was said to be exacerbated by NHS reforms [25
] that brought to the fore unresolved issues of authority and accountability. Clinicians were generally described as defensive [26
] ‘custodians of clinical care’, fending off managerial encroachment onto their patch (see for example Kitchener et al. [27
, p. 224]). Although we found some support for this in the inter-professional atrocity stories that clinicians told, the alternative stories of aligned agendas support Mueller and colleagues 2001 thesis [26
] that in time the clinical professional value system may evolve to become more in tune with the managerialist value system. Interventions, such as NCROP that facilitate collaborations may contribute to such an evolution. Aligning of agendas did not necessarily reflect a change in underlying belief systems.
Participants identified other individuals working in the same hospital in terms of their professional characteristics. By contrast, individuals within the PCT (encompassing both commissioning and community services as well as general practitioners) were generally viewed through the lens of their organisation, rather than their profession. The exceptions were those who had clinical backgrounds or acknowledged their clinical deficiencies, and these were held in higher regard than other individuals in the PCT. This may reflect the opinion among clinicians that PCT staffs are mainly managerial and as such have no real mandate through which to effect change.
We found many examples of poor intra-organisational collaborative work. Inter-professional barriers might be expected to be less likely within an organisation than across organisations since staff within an organisation should have developed ways of working together. However, the role of managers within acute trusts has changed in recent years [28
]. It is understandable that collaborations between some trusts and PCTs are problematic, given that PCTs have been restructured several times in the last 10 years in ways that have particularly destabilised their commissioning function. This is illustrated by inter-individual problems from restructuring being ascribed by hospital clinicians to changes within PCTs rather than hospitals.
It was observed by our respondents that when clinicians, managers or commissioners within a successful collaboration left post, services sometimes degenerated or change became blocked. This shows the importance of having good inter-individual collaboration and key people in posts leading to change [29
]. Nonetheless, we found that champions and clinicians with an interest in management were not associated with more changes in our study, and so were not critical for change, despite the positive effect of aligned agendas. It may be that NCROP multidisciplinary peer review served a function similar to that of the champion, though in a very different mode. It facilitated collaborative work within teams, and it brought people together across both intra- and inter-organisational boundaries even when this had not previously occurred and the individuals concerned might not normally have reason to meet. It enabled clinicians to highlight successes and continuing clinical needs of which managers and PCT representatives had been unaware, and stress inequities with other hospitals when these existed, while managers and PCT staff could represent their own problems and issues. In these ways, participants were able to reconcile their differences and exchange ideas across boundaries.
An important feature of the peer review was to provide protected time for people who should already be working together, to meet as a team—our data suggest the importance of protected time cannot be overestimated. The opportunity to meet as a multidisciplinary team with another team also appears to be a potent feature—not only allowing exchange of ideas across the teams but also in helping to build team working within the two teams, fostering morale, helping staff feel they were not alone [24
], and enabling team members to shift position by offering new perspectives. Meetings have been described by others [23
] as an important feature of IHI collaborations also.
The NCROP peer review had benefits for all of the types of collaboration that we considered using Scott's model. However, our results suggest that its effects were more modest in relation to inter-professional rather than inter-individual collaborations. This may help explain the lack of significant effect found in the quantitative analysis at one year reported by Roberts and colleagues [5
Collaboration and integration of services across primary and secondary care is embedded in NHS policy [31
] and encouraged by the emergence within the NHS of collaboratives based on the IHI model [13
]. However, the emphasis for long-term conditions is on collaborations between PCTs and the voluntary and community sectors. The aim is for multidisciplinary teams based in primary care or the community to support patients for who self-managed care is insufficient, with the support of specialist advice from secondary care on a limited basis [31
The NHS is promoting managed care networks [32
] as a way of forming or linking services across financial, structural or physical boundaries and therefore enhance the patient's journey through the pathway of care. The NHS differentiates these from other forms of collaboration because they have clear governance and accountability arrangements in place, with a formal management structure and a published strategy [32
]. Networks are structural; many need to join collaboratives based on the IHI model to develop ways of effective collaborative working. The NCROP model differs from networks by including peer review, by its more limited scope, and its more informal arrangement. It differs from many other NHS collaborative initiatives in its setting and from the IHI model and its NHS variants in its more limited scope, its relative simplicity and informality and its emphasis on including managers within the teams [23
]. Peer review, which is central to the NCROP approach, has several limitations, chief among which are its tendency to concentrate on improvement in one specific area, and its relative lack of power to overcome barriers to change.
Overall, the opportunities for collaboration and change afforded by NCROP might seem limited in scope when compared with the IHI model. However, it is encouraging that informants articulated a number of benefits, given that the literature on partnerships in healthcare does not offer robust evidence of their transforming power [33
]. We found that NCROP peer review does provide a degree of mutual benefit, such as social exchange theory requires for sustained interaction between organizations, and it may therefore be more effective than top-down exhortations to change and easier and less costly to replicate than other collaborative models, including the more formal and regulated Dutch system of visitatiae
] as well as the IHI model. Mutual benefits derived from the way NCROP peer review encouraged individuals and teams to work together. Their creativity and flexibility in developing joint problem-solving was more critical than the nature of barriers to change. NCROP peer review facilitated instances of creativity even in teams not previously successful in collaborative work. By increasing understanding and stimulating problem-solving, NCROP peer review has the potential to stimulate more sustained change over time. Whether this potential is realised and is translated into clinical change awaits the results of a further quantitative evaluation of the NCROP peer review, which is currently being undertaken.