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BMJ 2000;320:1723-1725 ( 24 June )

Education and debate

Modernising the NHS

Practical partnerships for health and local authorities

This is the last in a series of seven articles

Diane Plamping, research associatePat Gordon, research associateJulian Pratt, research associate

Urban Partnerships Group, Department of Operational Research, London School of Economics, London WC2 2AE

Correspondence to: D Plamping plamping@lse.ac.uk

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?


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 cooperation---and 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



    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 partnerships---The 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:



    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.

    Build trust gradually

Cooperative partnerships---There are, for example, circumstances in which partners can pursue their own goals most effectively by cooperating with others---using 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.

    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).

    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:



    References

1. Department of Health. Partnership in action. London: Department of Health, 1998.
2. Huxham C. Creating collaborative advantage. London: Sage, 1996.
3. Pratt J, Gordon P, Plamping D. Working whole systems. London: King's Fund, 1999.
4. Pratt J, Plamping D, Gordon P. Partnership: fit for purpose? London: King's Fund, 1998.
5. Higgins J, Deakin N, Edwards J, Wicks M. Government and urban poverty: inside the policy-making process. Oxford: Blackwell, 1983.
6. Fisher R, Ury W. Getting to yes. London: Hutchison, 1983.
7. Axelrod R. The evolution of co-operation. London: Penguin, 1990.


© BMJ 2000

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A breath of fresh air
Dr Chris Manning, Co Chair PriMHE (Primary care Mental Health Education) , Hampton Wick
bmj.com, 9 Jul 2000 [Response]


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