Table 3.

Inter-organisational collaboration indicators in London Cancer case study and factors that acted as barriers and enablers to collaboration

Dimension	Indicators	Evidence of degree of collaboration and changes through time
Shared goals and vision	Goals	1. London Cancer articulated goals and objectives. For instance, in the case of urological pathways, the Urology Technical Group was formed before pathway boards. The technical group had representation from all Trusts, undertook options appraisals and designed clinical configurations without specific sites being named or chosen as potential centres. The Urology Technical Group comprised radiologists and oncologists as well as surgeons, nurses, etc. 2. Pathway boards were created to drive the changes and operationalise objectives at the pathway level. 3. Some front-line staff ‘owned’ objectives of improved care delivery and outcomes, while others questioned them. 4. There was loss of trust in process felt by some organisations as not everyone agreed with the goals and the mechanisms through which these would be achieved (i.e. centralisation).
	Client-centred orientation vs. other allegiances	1. A patient-centred focus was established at the outset as the main driver for the centralisation. 2. Some staff members valued other allegiances, often involving loyalty to their employing organisation or a commitment to a service or clinic which contradicted the ‘patient-centred orientation’ set out by the London Cancer network.
Internalisation of interdependencies	Mutual acquaintanceship	There were frequent opportunities for becoming acquainted for some professional groups (i.e. surgeons and nurses), but not for others (e.g. radiologists, oncologists, and allied health professionals).
	Trust	1. Trust was still conditional and in early stages of development in some cases. 2. Some organisations viewed specialist centres as not trusting the capacity of local centres to make good decisions in relation to patient care.
Governance	Centrality	1. Central figures such as London Cancer, pathway boards and system leaders sought consensus at network and organisational levels. 2. While each provider organisation had representatives on the board, not all felt they had the same influence.
	Leadership	1. London Cancer played a central role in the design and implementation of the centralisation. 2. New leaders emerged through the pathway boards and within the different organisations of the networks. 3. Some leadership roles were questioned. For instance, specialist centres were expected to take on the role of ‘system leader’, a role that some non-specialist organisations considered as proof that some organisations would be ‘taking over the system’.
	Support for innovation	Sharing of expertise and good practice was sporadic and fragmented despite being a major component of the original ‘offer’ of these changes.
	Connectivity	There were venues for discussion in some professional groups (in the form of network-level meetings or working groups), but not in others.
Formalisation	Formalisation of management processes	1. Processes such as the development of pathways, guidelines, and structures for joint working were established to reach consensual agreements across the networks. 2. Not all organisations were engaged in the development of pathways and guidelines in the same way. 3. In some cases, these processes for reaching consensual agreement needed to be ratified on various occasions to make sure agreement could be obtained and maintained. 4. These processes were often led by specialist centres.
	Information exchange	1. The network experienced incomplete information exchange infrastructure that did not meet the need of users (these problems were more severe during early implementation stages). 2. Changes in the transfer of information were attempted, but the network continued to experience problems.