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

Jenny Shand (Department of Applied Health Research, Research Department of Epidemiology and Public Health, University College London, London, UK)
Simon Turner (Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK)

Journal of Integrated Care

ISSN: 1476-9018

Article publication date: 29 November 2018

Issue publication date: 8 February 2019




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.


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.


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.


This paper highlights some of the challenges associated with cross-sector collaboration.



This research was supported by UCLPartners and the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care North Thames at Bart’s Health NHS Trust (NIHR CLAHRC North Thames). The views expressed in this paper are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


Shand, J. and Turner, S. (2019), "System wide collaboration? Health and social care leaders’ perspectives on working across boundaries", Journal of Integrated Care, Vol. 27 No. 1, pp. 83-94.



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