A realist approach to understanding alliancing within Local Government public health and social care service provision

Abstract

Background

Within the current context of continued austerity and post-pandemic recovery, it remains important that Local Government services address the increasing needs of residents as cost-effectively as possible. Alliancing, whereby services work collaboratively focusing on the ‘whole-system’, has gained popularity as a tool with the potential to support collaborative whole systems approaches. This synthesis aims to identify how alliancing can be successfully operationalised in the commissioning of public health, wider National Health Service (NHS) and social care-related services.

Methods

A realist literature synthesis was undertaken in order to identify underlying generative mechanisms associated with alliancing, the contextual conditions surrounding the implementation and operationalisation of the alliancing approach mechanisms, and the outcomes produced as a result. An iterative approach was taken, using a recent systematic review of the effectiveness of Alliancing, online database searches, and grey literature searches.

Results

Three mechanistic components were identified within the data as being core to the successful implementation of alliances in public health and social care-related services within Local Government: (i) Achieving a system-level approach; (ii) placing local populations at the heart of the system; and (iii) creating a cultural shift. Programme theories were postulated within these components.

Conclusions

The alliancing approach offers an opportunity to achieve system-level change with the potential to benefit local populations. The realist synthesis approach taken within this study has provided insights into the necessary contextual and mechanistic factors of the Alliancing approach, above and beyond effectiveness outcomes typically collected through more conventional evaluation methodologies.

Introduction

An alliance can be described as a delivery model where individual services work collaboratively with a focus on the ‘whole of system’, rather than the specific performance of their own organisation to ensure their joint goal is achieved.¹ However, an alliance is more than just collaboration between services. Within an alliance, the risk, reward and ownership of the project are shared; reinforced through contracts and throughout the services involved.² Alliancing has gained popularity within public health as a tool with the potential to support collaborative whole systems approaches, in response to ‘wicked’ public health issues with high levels of complexity,³ which require complex solutions.⁴ There is a growing recognition that addressing such problems requires integrated and interagency approaches, which address the multiple factors that impact those in receipt of services.⁵

Within the current context of continued austerity and post-pandemic recovery, it is important that English local government services address the increasing needs of residents as cost-effectively as possible, by reducing duplication, and using the skills of the workforce to improve the lives of a larger number of residents.⁶ Change is required at system, institutional, cultural and individual levels to develop interventions from within the place in which they occur.⁶ Policymakers have highlighted the potential of contractual tools, including alliancing, to improve the integration of services and to facilitate better use of resources, by encouraging providers to work together in different ways.⁷

Alliancing is a flexible approach intended to be adapted to its local context. The approach is typically seen in public service capital build projects and across private sector industries.^7,8 Despite its growing application in public health, there are a number of uncertainties with regard to its applicability and implementation.⁹ Further, little is known about whether the approach improves public health outcomes and if so, how it works and why. The generation of hypotheses (programme theories), explaining alliancing would enable public health teams to implement an approach to alliancing that is tailored to their own context, yet maintains the components (mechanisms) found to be necessary to achieve improved outcomes.

Synthesis purpose

This synthesis aims to identify how alliancing can be successfully operationalised in the commissioning of public health and social care-related services in Local Government. To achieve this, we undertook a realist synthesis to identify what happens when adopting an alliance approach (underlying mechanisms), the contextual conditions surrounding the implementation and operationalisation of the alliancing approach mechanisms, and the outcomes produced as a result.

The primary research question guiding the synthesis was: ‘What are the features of successful alliances in health and social care settings?’ In addressing this question, we explored:

1. What mechanisms facilitate or constrict the use of alliances?

2. In which contexts do these mechanisms apply?

3. What outcomes are produced?

Methods

Realist approach

Realist synthesis is a systematic, iterative, theory-driven approach to identifying and organising different types of published evidence on complex social phenomena. The rationale for using this approach is that alliances are complex, likely to consist of many components, and are contingent on the behaviours and choices of those within the alliance. The realist framing not only considers if alliancing works but ‘what it is about it that works?’ Thus, acknowledging that alliancing takes place within complex social systems with the potential for multiple pathways from implementation to impact. Realist approaches attend to the ways that interventions may have different effects for different people, by trying to understand configurations of contexts and mechanisms that link to outcomes. Programme theories are configured as context-mechanism-outcome (CMO) hypotheses conveying ideas and assumptions underlying how, why and in what circumstances complex social interventions work.¹⁰ They postulate potential causal pathways between interventions and impacts¹⁰ and here, provide a more nuanced account of how alliancing approaches to the commissioning of public health and social care may work.

Synthesis process

Our synthesis was based upon the four stages laid out by Rycroft-Malone et al.:¹¹

1. Define scope of the review

   An advisory group of regional stakeholders including, Public Health practitioners, Public Health Knowledge and Intelligence lead, academics and a parent with experience in accessing alliance services, was convened to assist with framing the review and focusing the search. In addition, the advisory group provided access to, and assisted in locating relevant literature. Through an exploratory literature search, it became apparent that some of the core constructs (mechanisms) of alliance-based approaches were also evident in approaches with other titles; in particular, ‘place-based’. Place-based in this respect related to meeting the unique needs of people in one particular location, often by working together, influenced by local knowledge and information. Therefore, it was decided that papers in the synthesis would include those that relate to alliancing and place-based approaches.

2. Search for and appraise evidence

   We used a recent systematic review of the effectiveness of alliancing, which included 80 studies in a wide range of settings⁸ to identify potentially relevant literature for the synthesis. This was supplemented by searching reference lists of all included documents, sourcing potentially relevant documents along with forward citation tracking. We anticipated that local authority websites would also publish key documents relating to the implementation of alliancing within their local areas in addition to the academic literature searched. As such, we conducted focused searching of local authority websites in England and searched key websites such as the Kings Fund, Joseph Rowntree and Gov.uk. Data searches and reviews stopped when data saturation was reached, i.e. no additional data were found. Additionally, we searched Google Scholar and Web of Science using key terms relating to place-based working and Boolean operators. All searches were carried out in May 2020.

   Results were restricted to literature published since 2000, to include the period leading up alliancing becoming established in health.¹² Two reviewers independently screened all titles and abstracts using pre-specified inclusion and exclusion, retrieved the full papers of all potentially eligible studies and evaluated in full text for final inclusion. Documents were eligible if they documented alliancing based or related approaches within a health and social care context. Documents were excluded if they were not published as full-text or did not relate to health and/or social care contexts.

3. Extract and synthesise findings

   Relevant data were extracted independently by two reviewers and included: the definition/meaning of alliancing used within the paper, context (such as the problem that alliancing was seeking to resolve), mechanism (how alliancing works or not) and outcome. As traditional methods of quality appraisal are not always appropriate for realist synthesis due to the focus on assessing methodological rigour,¹³ the review team as part of the data extraction process, detailed rigour of the evidence in relation to the transparency of reporting. This involved a ‘…series of judgements about the relevance and robustness of particular data for the purposes of answering a specific question’.¹⁰ All papers were shared and discussed within the review team who have extensive experience in public health, social care, local authorities and commissioning, to establish consensus on the credibility of the papers included. No papers were excluded on the basis of our quality appraisal.

   The synthesis and analysis process ran sequentially resulting in the development of programme theories mapping how the alliance intended to work and hypothesised mechanisms influencing outcomes.

4. Develop a narrative

   To ensure postulated theories were in accordance with current thinking and had practical consideration for implementation and impact, the advisory group was consulted and presented with emerging findings. The advisory group provided the platform to discuss, test and refine programme theories and develop the middle range theory.

   The synthesis utilised a piloted bespoke data extraction form to assist with the organisation of data, providing structure to the theming of evidence. Data from these forms were collated and discussed by the review team. Data synthesis then included the organisation of extracted data into evidence tables (context, mechanism, outcome) followed by the analysis and theming of data including linking chains of inference within and between themes, prior to the development of the narrative in the form of programme theory formation.¹⁴

Results

Description of studies

Our combined searches identified 156 potentially relevant documents. Thirty papers met the inclusion criteria and were included in our synthesis (figure 1). Eleven were local authority/Clinical Commissioning Group documents, 10 were academic papers, and 9 were reports. In accordance with RAMESES guidelines,¹⁰ we appraised these documents for relevance and rigour (high, medium and low ratings). We rated n = 17 as being of high relevance, and n = 11 as having a highly rigorous design. Full details of the included documents are reported in Supplementary table S1.

Features of the alliance

Three core features of successful alliances within health and social care settings were identified within the included literature: achieving a system-level approach, placing local populations at the heart of the system, and creating a cultural shift. Data are discussed below under each of these headings followed by detail of the postulated programme and middle-range theories¹, whereby links between context, mechanisms and outcomes relating to improved public health are highlighted.

Achieving a system-level approach

Common to successful alliances was achieving a system-level approach to service provision. Looking at alliancing from a system level allows for mechanisms to be identified that influence strategic decisions pertaining to ‘how’ alliancing brings services together to reduce system fragmentation. Therefore, delivering services that meet the local needs and thus seek to improve public health outcomes.

The alliance approach seeks to provide collective system-wide leadership to influence change at the local level^16,17 in an attempt to reduce existing service fragmentation, thus improving outcomes for local residents.¹⁸ A key resource mechanism of the alliance approach is that it can address service gaps, overlaps, inconsistencies and poor access experienced by service users.¹⁹ Although other commissioning approaches may also address these elements, successful alliancing brings together cross-sector organisations to jointly address issues in a more holistic and joined-up way.^17,20 There is a sustained effort to move away from individual partners focusing upon the operations of their own provision towards different organisations coming together to discuss an issue(s), identifying the challenges in addressing that issue(s), and working together to find solutions.²¹

Alliances are often referenced and formed to develop system-level innovation to improve services for particular populations.²² Commitment and ‘buy-in’ is required from all partners to plan and work together to implement these improvements successfully.¹² Working together is identified as a mechanism by which efficiency within the alliance is increased through bringing about an increase in productivity, rigour and performance management, resulting in a quality service and improved outcomes.²³ In addition, alliancing has been shown to improve relationships between partners.²⁴ Much value is placed upon cooperation between alliance members, including for example, greater importance placed on reciprocal cooperation between commissioners and providers than more traditional commissioning approaches.¹⁹

The alliance contracting approach is thought to deliver more value than traditional procurement arrangements.^22,25 Effective collaboration is underpinned by common goals and integration.^26,27 This approach combines insights, knowledge and key strengths of multiple organisations to avoid duplication and waste.²⁰ This also promotes a diversity of experiences and resources within the alliance.²⁸ A necessary component of a successful alliance is therefore agreeing a shared focus, to which all parties are fully committed to.^12,23 This focus is required if alliances are to offer a coordinated, efficient service²⁹ and achieve a common aim. Furthermore, by aligning priorities of the services involved in delivering on the alliance, the approach has the ability to ‘add-value’ to service delivery.²⁷ Adopting a shared focus has been suggested to result in decisions being based on ‘best for person’ and ‘best for system’ outcomes.^12,25 It also promotes a better service user experience with reduced inequality.²³ Trust, teamwork, mutual understanding, respect and collaboration are all central to the alliance approach.²⁷

In order for the alliance approach to be successful, a whole systems-based thinking approach should be taken.¹² This approach facilitates feedback across the whole alliance, promoting the integration and working within the broader alliance.²¹ System-level outcomes are emphasised, for which the alliance has shared responsibility.³⁰ The system-level CMO configuration is outlined in figure 2.

Figure 1

Flow of studies

Figure 2

System-level CMO

Placing local populations at the heart

Alliances place the population they seek to support at the heart of their work and seek to tailor responses to meet local needs. In doing so, services to meet local needs can be implemented and outcomes to improve local public health can be focused upon.

In order for an alliance to work, it must understand and reflect local need.³¹ This will typically require the establishment of partnerships with local communities.²⁹ This local focus also allows for innovation relevant to the local area to improve services.^17,22 It is the flexibility of the alliance approach which allows it to align with local priorities.¹⁷

At a macro level, it has been suggested that the shift to geographical ‘locality’ based approaches has facilitated the development and success of alliances.¹⁶ This locality focus is often referenced as ‘place-based’ approaches within alliances,³⁰ and has enabled many of the mechanisms for change, including creating the critical mass of change, across professions and organisations which promote successful alliances.² Place-based initiatives aim to achieve local change by bringing cross-sector organisations together, to address the underlying causes of complex social problems in a more holistic and joined-up way (see also system-level discussion above). Evidence suggests place-based initiatives often build on the assets, confidence, capacity and connectedness of local communities, and support people to improve their life opportunities and outcomes.²⁰ Co-production, the bringing together of services and people in designing and delivering services, is highlighted as an essential mechanism of effective alliancing, bringing in the population serviced by the intervention to contribute to its development.²¹ This approach can support change which is built on co-production principles where all voices and perspectives are valued.²¹

Trust appears to be threaded through all aspects of alliancing and features highly in regard to the key mechanisms underpinning successful alliances.^25,27 Trust is documented here within local focus as it is a key feature in forming alliances with a view to working together in order to understand and reflect on local need.^24,27 In understanding the local needs, services can be tailored and thus influence and improve outcomes at the local level. Connected to the notion of trust, is the requirement for integration and a collaborative working arrangement including decision-making processes and governance between parties, if the alliance is to be successful.³² Integration in this sense can include service users, joining-up processes and removing duplication to create a transformative connected programme.²⁴ Integration also requires a shared vision in order to steer successful alliances, with this being suggested as a fundamental mechanism linked to the success of a programme.²⁰ This shared vision needs to be focused through clarity regarding goals and objectives of the alliance³³ and built upon the commitment from senior leaders within the alliancing organisations²⁴ with visible leadership across all levels.²⁹ Strategic commitment is suggested to be supported through the introduction of robust monitoring and evaluation.³³ The local focus CMO configuration is outlined in figure 3.

Figure 3

Local focus CMO

Cultural shift

Establishing an effective alliance often requires a change in culture and behaviour of the services involved. This shift emphasis commitment and trust between services, facilitating collaborative working with a focus on the local population and improving their public health-related outcomes.

The shift in culture at a strategic level is achieved through ‘commitment, capability and time’.²⁶ As well as cultures within services, successful alliances can also change cultures at a higher systems level, and have the potential to reposition service(s) within the marketplace and thus change the nature of the marketplace.³⁴ As well as imposing change externally, alliances are also able to enable systemic change from within, to support new ways of working.³⁵ Having a culture that is a receptive context for change increases an organisation’s ability to develop and employ innovation in their approaches to service delivery.³⁶ Alliancing as an approach enables an underpinning cultural shift as it is a change from normal practices.³³ This shift can assist in focusing services to work together in meeting locally identified public health needs.

There is a need to focus on the staff working within alliances, understanding what experience and resource they are able to bring to the alliance, and promoting their appreciation of the importance of collaborative working practices and behaviours.¹⁷ A successful alliance provides a catalyst for relationship building between staff. Having a passionate and high-quality workforce is thought to enable and promote this culture shift.²³ There is a move away from rigid roles and responsibilities bound by the scope of the employing organisation to a transposing fluidity between members defined by a shared focus upon responding to the need of the population.^24,29 Importance of connections and networks is also stressed in relation to attributes required for successful alliances.³⁰

Underpinning successful alliancing is the joint working of partners within the alliance.³² Using an alliance contract, risk, reward and ownership of the project are shared throughout the services involved in the alliance.¹⁹ This approach is suggested to have the ability to remove barriers and preserve incentives created by contracts and organisational boundaries.³¹ Alliancing is able to reinforce, through contracts, collaborative working across the public, private and NGO sectors.³¹ The cultural shift CMO configuration is outlined in figure 4.

Figure 4

Culture CMO

Discussion

There are increasing pressures in health and social care to respond to complex and cross-cutting public health problems. Our findings further existing evidence around alliancing, through highlighting modifiable and statistic contextual and mechanistic components that can improve the provision of health and social care.

The mechanisms discussed within the synthesis highlight the strategic nature of the alliancing approach, in terms of re-designing and focusing services to work together so that local needs can be understood and addressed, thus creating meaningful change to improve public health outcomes for the local population. Previous collaborative approaches within the English context have highlighted the importance of having clear roles and responsibilities within the partnerships.^37,38 Typically these have based responsibilities on the skills of providers rather than the needs of local populations.³⁷ Conversely, alliances stress the importance of flexibility and fluidity between roles in order to achieve shared goals and included a wider range of partners than previous partnerships.³⁹ Taking this view, alliances can be thought of as a catalyst to promote changes required within a system, enabling services to work together collaboratively to address local needs.

Whilst there has long been an emphasis upon building relationships within partnerships,⁴⁰ previous approaches have been criticised as being ‘talking shops’ which fail to deliver action.³⁹ At a systems level, the alliance was evidenced to be an effective approach in facilitating the working together of services, people, and teams to provide the best possible opportunities to fulfil system aims. In bringing people and services together at all levels, value is placed on the cooperation between members, where trusting and collaborative relationships underpin successful alliance approaches and goes some way to addressing previous criticism that integration attempts ‘build bridges at the margins’ rather than interweaving their mainstream operations and processes.³⁷ Viewing the alliance as an ‘approach’ taken within a politically focused system, allows it to be used as a mechanism by which to formalise common goals throughout the various stakeholders and partners which make up the alliance. A key aspect of the alliance, setting it apart from other commissioning approaches is the alignment of values and resources alongside a sharing of risk across partners. Previous approaches to commissioning have highlighted differences in planning, budget cycles, funding mechanisms and resources flows as barriers to effective joint working.³⁸ By introducing a shared budget inclusive of shared risk, alliancing offers a solution to these barriers which reflects the trusting relationships required in encouraging and facilitating cultural and systemic change, to bring about new approaches leading to transformative change. When such change occurs, alliances have the ability to focus on the commissioning of services to meet local needs.

The synthesis has illustrated the importance of disaggregating the alliance approach into discrete CMO configurations in order to extract and detail practical information for individuals in policy, practice, and commissioning to shape decisions and inform effective alliancing approaches in response to key public health issues. In identifying practical considerations from the synthesis in relation to understanding the use of alliancing in the commissioning and provision of public health and social care-related services in local government, key recommendations from the research include:

• View the alliance as both the context for, and mechanism to, influence transformative change.

• Facilitate and develop an understanding within the alliance about how services are delivered across boundaries through purposeful strategies such as meetings and events.

• Promote cross-system awareness raising at all levels.

• Encourage co-creation of shared outcomes and goals across the alliance.

• Context must promote the core values of the alliance.

• Senior-level involvement is required to provide strategic and political steer.

• Include formal orchestration of shared working and relationship building within the alliance.

Strengths and limitations

The key strength of this synthesis is the disaggregation of the mechanisms within an alliance approach into three central elements. Half of the papers included in the synthesis were grey literature. Whilst grey literature is encouraged to be included within realist synthesis, high proportion could lead to a higher risk of bias. We have looked to mitigate these risks by scoring documents on perceived relevance and rigour. Through the synthesis, overlaps between collaboration approaches to service delivery and alliances were highlighted. Further literature searches and discussion within the synthesis could identify effective mechanisms of collaboration that transfer across to alliancing. However, it was deemed beyond the scope of this synthesis.

Conclusion

Alliancing is more than just another commissioning method. In using a whole systems approach, alliances are able to reduce system fragmentation by integrating services. They have the potential to facilitate innovative and collaborative working practices through developing commitment and trust between alliance partners. This is connected to their ability in building on existing local capacity allowing for services to be tailored to meet local needs and thus influence change at the local level. Our findings further our understanding of the mechanisms, within an alliance approach, which are effective in providing health and social care services that promote and improve outcomes for recipients. The realist synthesis approach taken has provided additional insights into the alliancing approach, above and beyond effectiveness outcomes typically collected through more conventional evaluation methodologies.

Footnotes

1

Middle range theory: ‘…theory that lies between the minor but necessary working hypotheses …and the all-inclusive systematic efforts to develop a unified theory that will explain all the observed uniformities of social behaviour, social organization and social change’.¹⁵

Supplementary data

Supplementary data are available at EURPUB online.

Funding

This project is funded by the National Institute for Health Research (NIHR) School for Public Health Research (SPHR) Public Health Practice Evaluation Scheme (PHPES), Grant Reference Number PD-SPH-2015. EAA is supported by the NIHR SPHR Pre-doctoral Fellowship (PD-SPH-2015). EK is supported by a NIHR Senior Investigator award and is Director of the NIHR Applied Research Collaboration North East and North Cumbria (NIHR200173). JR is funded by the NIHR Applied Research Collaboration North East and North Cumbria. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Conflicts of interest: None declared.

Data availability

There are no new data associated with this article.

Key points

• Alliances need to take a whole systems-based approach, transgressing the individual focus of services, in order to be successful.

• In taking a whole systems-based approach, feedback is facilitated across the alliance, which promotes the integration and working within broader alliance structures.

• Alliances should place the population they seek to benefit at the heart of their work and to tailor responses to meet local needs.

• In order for the alliance to work, it must understand and reflect local need.

• Establishing effective alliances requires a cultural shift, achieved through commitment and trust for transformation, within and between alliance partners.