Partnership has become a legal, almost moral, imperative in
the health and social care world in recent years. In policy document after policy document the analysis is consistent and welcome. We need
to find new ways of working: "The strategic agenda is to work across
boundaries . . . underpinned by a duty of partnership . . . past efforts to tackle these problems have shown
that concentrating on single elements of the way services work together
. . . without looking at the system as a whole does not
work."1
The result has been an explosion of partnership boards and partnership
meetings throughout Britain
and now there is talk of partnership
fatigue. This fatigue is mostly due to a proliferation of structures
and plans. Yet frustration with talking about partnership should not be
mistaken for rejection of the underlying principle. But now is the time
to ask some hard questions. When is partnership effective? What sorts
of partnerships are fit for what circumstances?
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Summary points
A sense of fatigue and frustration with partnerships shouldn't
obscure the fact that they are necessary and can be powerful ways of
changing whole services for patients and clients
Some partnerships depend on identifying a shared goal: focusing on the
needs of patients helps to do this
Organisations may achieve much with less demanding forms of
cooperationand also help to build the trust necessary for proper
partnerships
Different organisations need to find a shared "currency" for
successful partnership: beds and money often aren't appropriate
currencies
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Understand there are different sorts of partnerships |
The first need therefore is to understand that there are different
sorts of partnerships. Studies of public sector partnerships have shown
various sorts of partnerships, each effective in different conditions.
2 3
This research describes a range of
behaviours that organisations may usefully employ when working together
and suggests that different behaviours serve different purposes. The "model" of partnership that most people imagine is a
"coordinating" partnership, but there are other sorts (such as the
"cooperative" partnership, described later), which demand less
effort and may provide a route to a coordinating partnership.
Coordinating partnershipsThe underlying assumption of
most partnership effort is that all the partners agree the nature of a
problem, the nature of its solution, and how this is to be achieved. Every organisation has to do its own part of the work in a manner that
allows the whole project to be completed. This usually means appointing
someone to manage the joint work, chase everyone up, and hold everyone
to account. It is a high maintenance option. There is a lot of evidence
about what goes on in these "coordinating" partnerships,4 from the 1960s onwards5:
- Interagency tensions will not go away just because there is money
to oil the wheels;
- Partnership between organisations is hard to achieve: cultural,
departmental, and organisational differences are not easily overcome;
- Local power struggles over steering groups and management boards can
become a painful distraction, which may last for years;
- Creating a truly shared purpose is paramount;
- Success will depend on local autonomy and initiative, but tensions will
arise between the centre and localities unless there is a genuinely
mutual process of setting priorities and targets;
- It is relatively easy to mount a collaborative bid and become a
trailblazer: sustaining enthusiasm and commitment over time is
altogether different.
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Find a shared goal |
Finding a truly shared goal requires negotiation and diplomacy.
Often negotiation consists of positional bargaining: each player takes
a position, argues for it, and then makes concessions, which is time
consuming and inefficient and endangers relationships. One practical
way of avoiding this cycle is to start from principle rather than
position.6 An example of this is to start with a service
model which focuses on what is best for the patient rather than the
detail of which institution or what sort of professional.
Service models are really a device for keeping hold of "the whole"
rather than starting with the parts. This requires genuine dialogue in
which all the partners are prepared to question their own assumptions
and to listen to others. It seldom happens in a crowded agenda around a
boardroom table. If the goal really is "to make a difference to the
way we do things around here" then it is crucial to recognise the
worth of bringing all the necessary perspectives together. The
perspectives that are commonly missed out are those of frontline
practitioners and people who use the service. Changing
Childbirth (a policy document on services for pregnant women) and
An Ordinary Life (a paper from the King's Fund that
represented a paradigm shift in designing services for people with
learning difficulties) are examples of long term initiatives where
the importance of the voices of people who use services is paramount.
They help unsettle the status quo and keep the focus on patients and
their experiences rather than reverting to organisational or
professional positions.
Most partnerships, whether between organisations or individuals,
involve differences in status, priorities, resources, power, and
culture. Unless these differences are made explicit and time is given
to reaching common understandings, effective working across boundaries
is unlikely. Mutual trust has to be built; it certainly doesn't come
with the agenda papers. So coordinating partnerships must put a lot of
effort into negotiating the shared goals that could enable them to make
a difference. This is, however, not the only sort of partnership. Given
the amount of hard work involved to achieve coordinating partnerhips,
the partners need to be sure that they can't achieve what they want
with something less.
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Build trust gradually |
Cooperative partnershipsThere are, for example,
circumstances in which partners can pursue their own goals most
effectively by cooperating with othersusing enlightened self
interest. "Cooperative" partnership may be an underused form of
relationship between organisations, although it uses mechanisms by
which lots of individual business gets done: you scratch my back and
I'll scratch yours. This is low maintenance partnership. It does not
require the time and effort to reach collective goals.7
Interprofessional training, for example, is a goal for both health and
social services and has been the focus of many years of joint working.
Yet it hasn't got very far, and one reason may be that focusing on the
core curriculum is just too difficult a place to begin. Different
partners all want different things, and fighting for them is hard
without mutual trust and respectful relationships. It would be easier
to start by cooperating on training that everyone wants for their own
purposes, such as computer skills or equal opportunity interviewing
techniques, and use this cooperating behaviour to develop the trust
that is needed for the hard stuff.
The basis of such cooperation is self interest and the trust that
actions will be reciprocated. Trust is recognised as central to all
partnership behaviours but is often described in personal terms, as an
attribute of individuals, and therefore not something that
organisations can do much about. If, instead, trust is seen as
something which grows through repeated episodes of freely entered exchanges then this offers a practical way of promoting cooperation. People can be encouraged to try and try again when they recognise that
their futures are linked. In practice, it is the experience of this
behaviour that creates an understanding of who is worthy of trust.
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Find a common currency |
Partners cooperate effectively when they are clear about
what constitutes fair exchange between them. This means examining the
currencies they use. Organisations use currencies for two purposes, for
accounting (how much have you got?) and for exchange. Beds are an
example of the former, but it is not hard to see that their value is
limited as a medium of exchange with non-NHS organisations (which
don't have beds). Instead the search has to be for common currency,
and that means finding out what matters to the other partners. Each
must bring something of importance to the others. Successfully opening
up new avenues of fair trading relies on knowing what counts for others
so that offers can be tailored to their needs.
For example, local authorities and NHS agencies are represented
on the many regeneration partnerships that now exist in deprived areas.
Their task is difficult, but one area where both can make gains in a
common "currency" is employment. NHS organisations face problems in
recruiting and retaining staff. Local authorities are charged with
reducing local levels of social exclusion and creating jobs. The NHS is
often one of the largest employers in areas of high unemployment, so
there is scope for new kinds of fair exchange. One example is the
"Pathways to Access" initiative that is funded by the European
Union to bring local people into NHS employment in Tower Hamlets
in east London (www.pathways2access.org.uk).
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Lessons on effective partnership |
Many people share the government's aspirations for partnership.
That may not make it easy to do in practice, and there may be a sense
of frustration and fatigue at present, but the solution is not to throw
the baby out with the bathwater. Working together is not a "once and
for all and you never have to solve it again" ambition, and there are
many lessons worth learning:
- Concentrate on whatever actions are necessary to support working
together, not building boards and planning committees and new formal
structures;
- Partnerships come in many forms, so select the formand the
behaviourappropriate to your circumstances;
- If your purpose is to achieve better coordinated services, start by
focusing on the whole experience for the patient (or client), not
particular professional or organisational
solutions;
- Cooperation may arise entirely out of self interest without the need
for shared goals. Indeed, this can be a useful place to start joint
working. The task here is to develop a sense that people and
organisations have a shared future and to set up repeated opportunities
for exchange from which trust can grow;
- Trust is based on fair trading between partners. Choose a
"currency" that facilitates exchange. This may be different from the in-house currency each partner uses for accounting.
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