Are partnerships worth it?

In the few months since the health and social care white paper was published, talk about partnerships seems to have gone quiet. Despite welcome pledges on more joint approaches to service delivery, internal NHS issues, such as primary care trust reorganisation and funding difficulties, have moved to the fore.

With new policies on practice-based commissioning and payment by results (as well as an extension of existing policies, such as patient choice, foundation trusts and a greater role for the independent sector), it can be difficult to find the time, space and stability needed to forge long-lasting relationships with partner agencies.

Of these, the biggest short-term impact may come from reorganisation, which inevitably leads to staff turnover and a loss of personal links. In the longer term, it is the introduction of greater choice and of market-based approaches that may be most profound – once these new forces are unleashed there can be many unintended consequences, and no one is sure of the rules of engagement in the new world.

Social care professionals can be forgiven for being bemused by all this. After ongoing changes in local government, should social care change the way it works to fit better with NHS colleagues, or should we wait to see what happens when the dust settles? These dilemmas are by no means new, but the financial context has added bite and encouraged some areas (even those with a strong history of joint working) to focus more on internal issues.

Against this background, the notion of partnership working is increasingly under attack. Like previous buzzwords in the 1980s and 1990s (community, empowerment, involvement), there is a growing frustration that “partnership” as a term means little and can be used to justify many approaches and relationships.

A recent report from the Audit Commission has also raised serious issues about governance, and doubts remain over partnerships being too labour-intensive to be worth the investment of scarce time and resources. In particular, it is difficult in research terms to tell what outcomes a partnership delivers. As a result, most of the literature tends to focus on issues of process (how well are we working together), not on whether this makes any difference for users and carers. Add to this recent tensions between health and social care in Wiltshire – an early partnership pioneer – and the enthusiasm and progress we’ve enjoyed since 1997 seems to be waning.

Yet all is not lost. In May, the University of Birmingham’s Health Services Management Centre hosted an international symposium of policymakers, academics, managers and service users to consider whether partnerships improve outcomes for users and, if so, how, for whom and under what circumstances. With papers from leading national and international commentators, the symposium sought to explore the state of play in UK partnerships and to identify the implications for future research, policy and practice. Although the papers will be published as a special edition of Health and Social Care in the Community, some key questions and messages came out of the event:

  • Partnership working is never a panacea, and it is important for local agencies to be clear about the outcomes they are trying to achieve, the extent to which current approaches deliver these, and the best way forward. Although a form of partnership might be the best way to achieve desired outcomes, another way of working could be equally suitable or more so.
  • Much of the academic theory behind partnership is economic in nature, and it is important to be clear about the real reason for partnership working. Is this about improving outcomes for users, or is it more about organisational benefits (in terms of financial savings and reducing duplication, for example), and to what extent is it possible to do both at the same time?
  • How can local agencies manage through the bad times? Working together is easy when things are going well, but it takes time, effort and commitment to stay together during tough times. While we know something about what makes good partnerships, we know less about how to keep this going under pressure.
  • There is a danger of trying to encourage partnership working by imposing top-down structural solutions. Instead, many delegates expressed a desire for a more bottom-up approach, which tries to create the right conditions for people from different professional backgrounds to work together effectively, but which allows time for this to develop.

This is something we find difficult in health and social care, where the tendency is to encourage voluntary networks of practitioners, but to quickly turn these into more formal hierarchies as soon as the issue at stake becomes important. Key examples include the development of community mental health teams from local and informal approaches in the 1980s into structured, nationally prescribed services under the National Service Framework for Mental Health, and the changes under way to former area child protection committees.

Above all, however, those with significant experience of working in partnership would still do now what they did then, when they began to champion partnership approaches. With hindsight this seems the most significant lesson of all from the symposium.

With any new way of working, there is always a higher test of evidence for the new than for the old. Even if we’re not sure about the extent to which partnerships deliver better outcomes, we know there is a lot wrong with the current system and that much of what we do fails to deliver desired outcomes.

Against this background, perhaps the best way forward is not to identify the evidence for “what works”, but to start with what we know “doesn’t work” and test other approaches. If doing things on our own can be problematic, doing some of them together must surely be preferable.

Deep down, despite the research complexities of linking partnerships to improved outcomes, there remains the sense that (intuitively) working in partnership must be a good thing. Like previous notions of empowerment and community, the term may be problematic and capable of cynical manipulation, but underneath the semantics there’s surely an element of truth that is worth striving for. 

Jon Glasby is head of health and social care and a senior lecturer at the Health Services Management Centre, University of Birmingham, and a board member of the Social Care Institute for Excellence. 

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Despite health and social care partnerships being a key feature of the health and social care white paper, partnership working has come under attack recently. With NHS financial difficulties, reorganisation and concerns about governance, more people are starting to ask whether partnership working is worth the time and resources it takes to make it work effectively. This article reports on these issues and draws lessons from an international symposium on health and social care partnerships.

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