System wide collaboration? Health and social care leaders' perspectives on working across boundaries

Purpose Structural integration is increasingly explored as a means of achieving efficiency gains alongside improved health outcomes. In 2015, three boroughs in London, England began working together to develop an Accountable Care Organisation for the 750,000 population they serve. The purpose of this paper is to understand the experiences of working across organisational and sectoral boundaries for the benefit of the population, including enablers and barriers encountered, the role of financial incentives and perspectives on Accountable Care Organisations. Design/methodology/approach A single site instrumental case study involving 35 semi-structured interviews using a topic guide, with key leaders and decision makers from the site and nationally, between April 2016 and August 2016. Findings There are differences in levels of autonomy and operational priorities between councils and the NHS. Existing financial mechanisms can be used to overcome sectoral boundaries, but require strong leadership to implement. There are challenges associated with primary care participating in integration, including reluctance for small organisations to adopt the risk associated with large scale programmes. Interviewees were aligned on espoused ambitions for the Accountable Care Organisation but not on whether one organisation was needed to deliver these in practice. Research limitations/implications - Progressing the integration agenda requires consideration of the context of primary care and the core differences between health and government. Further, research into ACOs is required as they may not be required to deliver the anticipated integration and system outcomes. Understanding if there are specific population groups for whom cross-organisation and cross-sector working could have particular benefits would help to target efforts. Originality/value - This paper highlights some of the challenges associated with cross-sector collaboration.