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Conflict and collectivism: the challenges of working across boundaries in health care


In addition to improving patient care, the aim of integrated care – and of the proposals set out in the NHS five year forward view – is for health care organisations to work more effectively across boundaries. Intellectually this idea makes good sense and is attractive and persuasive, but in practice it is not just difficult to achieve – it requires us to confront possibly our greatest flaw as a species.

That flaw is the human impulse (even instinct) to categorise others, on the basis of the flimsiest of differences, into members of 'in-groups' and 'out-groups' and to discriminate in favour of other 'in-group' members or against 'out-group' members.

Early studies of these powerful inter-group processes, in what have become known as the Robber's Cave experiments, demonstrated the fundamental nature of human inter-group prejudice and the potential for associated hostility.

In other research children quickly learnt to be profoundly prejudiced simply on the basis of eye colour. And we can see how inter-group prejudice condemns mergers and acquisitions to limited success or outright failure.

In health care organisations, staff engagement is built by encouraging a sense of distinctive organisational identity, and developing compelling strategic narratives and shared values – precisely to create a strong ‘in-group’ identification. This approach makes it difficult to build cross-organisational co-operation, supportiveness and shared identity in the short or medium term, attractive though the idea might be, because of all the work that has been done to build pride in our existing organisations.

Successful integration requires leaders to find ways of blurring boundaries between pre-existing organisations by emphasising the benefits of the larger grouping (as will be the challenge for Manchester with its new mandate to manage a combined health and social care budget).

But inter-group bias will ensure that integration will not always be easy. People working in health care organisations will inevitably resist the kinds of organisational transformations that NHS leaders are proposing, unless they believe that these changes are for the long term and will not be abandoned, and that they will make a powerful, positive difference to patient care. People also have to be reassured that change will help them do their jobs better and maintain their key working relationships.

What then are the solutions? The first is establishing and promoting an overarching shared vision across newly merged organisations or across health and social care divides. From the perspective of health care staff, this vision must relate to improving the delivery of high-quality and compassionate care. It also means continually identifying, communicating and valuing progress towards achieving shared goals (with outcomes particularly focused on patient care, rather than on less inspiring outcomes such as productivity, cost effectiveness and efficiency).

Second, it is vital that there is frequent and sustained contact between key individuals and groups from the merging organisations. Cross-boundary relationships often spawn conflict because of clashes of values, working methods, identities, territories and inter-group prejudice. The issues need to be identified and resolved quickly, transparently and creatively in the best interests of patient care and all those involved. Cross organisational trust is built through authenticity, openness, fairness and commitment in the process of conflict resolution.

Third, the different organisations that come together or that seek to work collaboratively must build an approach of mutual altruism, mutual concern, unselfishness and an eagerness to work tirelessly at developing cross-organisational or cross-boundary relationships that are characterised by a strong sense of mutual support, belonging, appreciation and trust.

We understand much about inter-group relations; how they affect our ability to work together to solve shared problems (think of the difficulty of nations working together to deal with climate change), and how pervasive this fundamental human tendency is. If we are to be effective in creating the organisational forms and processes needed to meet the health and social care needs of our communities, we have to recognise the problems that will confront us. Good ideas on paper are one thing; the realities of human behaviour are quite another and we can and must adapt our good ideas to take account of this.