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Working In Partnership In Health And Social Care Assignment Of Contract

How to create successful partnerships—a review of the literature

Authors

  • Valerie Wildridge,

    Corresponding author
    1. Information and Library Service, King's Fund, London
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  • Sue Childs,

    1. Information Management Research Institute (IMRI), School of Informatics, Northumbria University, Newcastle upon Tyne
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  • Lynette Cawthra,

    1. Information and Library Service, King's Fund, London
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  • Bruce Madge

    1. Patient Advice and Liaison Service, National Patient Safety Agency, London, UK
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Valerie Wildridge, Enquiry Services Librarian, Information and Library Service, King's Fund, 11–13 Cavendish Square, London W1G 0AN, UK. E-mail: v.wildridge@kingsfund.org.uk

Abstract

This literature review covers a wide range of publications (articles, books, reports and government publications) that provide an overview of the wider topic of partnership working. It is not a systematic review, but the authors’ personal review, drawing largely on the resources available in the King's Fund Library. Partnership working is a key component of the UK government's modernization agenda, particularly in the health field. However, the principles of achieving successful partnership are generally applicable. The review therefore concentrates on literature that can provide guidance for people planning to set up a partnership, or re-evaluating an existing partnership. The sections of this review comprise: definition of partnership working; types of partnership; partnership initiatives; drivers; critical success factors; barriers; benefits; the process of partnership working; evaluation and assessment tools; demolishing the Berlin Wall: government policy on partnership working; exemplars of library information service partnerships.

Introduction

We live in a global society. It is no longer effective for organizations to work alone. Within the public, private and voluntary sectors, the need for partnership working, often cross-sectoral working or working beyond the boundaries, is recognized as a vital component of success. In the UK, partnership working is a key component of the government's modernization agenda, particularly in the health field. As the focus moves away from the centralized, government provision of public services, cross-sectoral partnerships involved in service delivery are becoming more common. How can we respond to this partnership imperative? The overall aim of this literature review is to provide practical guidance for people planning to set up a partnership or re-evaluating an existing partnership. Individual partnerships operate within very specific, localized contexts. They are strongly dependent on the history of past relationships between the organizations involved and local requirements and circumstances. However, the thesis of the authors of this review is that the underlying principles behind creating and maintaining a successful partnership are generic. The introduction to the Partnership Assessment Tool developed by the Nuffield Institute for Health1 p.1 states that:

‘It is important to stress that we think the partnerships principles are generic, i.e. that although developed in one particular policy area they can be applied in others. We would also argue that they apply to different organisational levels and, indeed, to intra-organisational as well as inter-organisational partnership or joint working. [However] Although the principles are generic, the way they are used will obviously vary according to the context’.

Additionally this review seeks to demonstrate that:

  • • partnerships are not a soft option but hard work;
  • • partnerships take time to develop;
  • • partnerships must be realistic and aim for what can be achieved, not be set up to fail by being too ambitious;
  • • partnerships can, if successful, achieve more than individual agencies working alone.

The following quotes illustrate these points:

‘Partnerships are hard work.’2 p.11

A partnership is ‘an emergent process.’3 p.11

‘You can integrate all of the services for some of the people, some of the services for all of the people, but you can’t integrate all of the services for all of the people.’4 p.83

‘… although partnership working is challenging, and more partnerships fail than succeed, successful partnerships can achieve goals that individual agencies cannot.’5 p.42

This article is not a systematic review, but the authors’ personal review drawing largely on the resources available in the King's Fund Library. To support the authors’ aims discussed above, items for inclusion in the review were selected on the basis that they provided guidance on the principles of successful partnership working, not just descriptions of the activities of specific partnerships. This guidance covers topics such as definitions of partnership working, types of partnership, drivers, critical success factors, barriers, benefits, the process of partnership working and evaluation and assessment tools. Where applicable, examples from the health field are given. Such guidance is valuable as the scale of the task needed to create a successful partnership is often underestimated. Successful partnership working is all about human interaction and requires a long and complex process. The government partnership agenda, as a significant driver, is covered in some depth, with reference to the wide range of relevant policy documents. Finally, exemplars from the library information field are presented. Partnerships can provide significant benefits. The act of working together is a benefit in its own right, alongside any anticipated improvements in service delivery. However, partnerships are not a panacea and are not appropriate in all contexts. The guidance presented here also enables people to identify whether or not a partnership is the solution to their problem.

Definition of partnership working

The New NHS: modern, dependable6 places a great deal of emphasis on partnership working with many other New Labour documents following suit (see section ‘Demolishing the Berlin wall: government policy on partnership working’ below) but ‘little substantive guidance is given about what is even meant by partnership’.7 p.781 There is confusion around the definition and terminology of partnership working, with many other labels—collaboration, co-ordination, co-operation, joint working, interagency working, networking and others—being used.8–10 Whichever term is used, it can mean different things to different people under different circumstances.11–13 Some commentators14 p.117,15,16 agree that there is ‘no universally accepted definition of partnership’17 p.39 or that it is rare to find one.18 Indeed, there is no universal theory of co-operation either.19 A contract will tend not to be a partnership.17,20 However, Crawford21 sees it as a necessary component.

Attempts have been made to define what is meant by partnership or partnership working. Lowndes22 p.2 describes it as ‘a variety of arrangements with different purposes, time-scales, structures, operating procedures and members’. Common to the definitions are:

  • • between organizations, groups, agencies, individuals, disciplines;3,14 p.118,16,23,24
  • • common aim or aims, vision, goals, mission or interests;3,5,14 p.117,23,25–28
  • • joint rights, resources and responsibilities;23,29
  • • new structure(s) and processes;5,24,26
  • • autonomous, independent;5,14
  • • improve and enhance access to services for users and carers;24,30
  • • equality,21,25 although Peckham27 p.61 says that this is ‘rarely the case in reality’;
  • • trust.14,28

Huxham8 p.2 adds to this, stating that collaboration achieves what ‘would be difficult or impossible for an organization to do on its own’—collaborative advantage.

Types of partnership

The New NHS white paper6 requires a formal duty of partnership between the National Health Service (NHS), local authorities, local voluntary and for-profit organizations. Formal partnerships are described by the Audit Commission5 p.16 as one where an entity or process has been set up, whereas an informal partnership is where ‘organizations behave to one another as partners regardless of the formal links’. Partnership in Action31 p.6 sees the need for formal joint working at three levels: ‘strategic planning, service commissioning and service provision’. Formal partnerships will also include joint budgets.27 p.72 Informal partnerships will have staff working alongside one another, mainly in the community.27 p.72 Ling32 has developed a typology to assist in comparing partnerships: partnership members, links between partners, scale and boundaries, and context of partnership. Examples of the scales include national/local/global. In the context of public health, Peckham27 describes partnerships as international, for example, WHO; national—‘joined up government’; local, for example, health action zones; and with communities such as the neighbourhood renewal programme. Public–private partnerships33 is a further category.

Partnerships have been defined in levels. Glendinning13 p.140 commentates on three levels: (i) macro-level—these take place within a national or state ministry or on a country level; (ii) meso-level—local service level; (iii) individual service users level. These levels are seen as horizontal. Horizontal activities occur on the same level of the process; for example, the provision of one service alongside another within an acute trust.34 Vertical integration is where different processes are ‘sequentially related to the same final product’.34 Challis34 uses the example of an acute trust integrating with a community trust for improved continuity of care.

Looser definitions of the types of partnership can be found,16,35 with levels referred to as loose networks, liaison and alliance structures and federative systems. Balloch and Taylor25 p.6 feel that the ‘essence’ of partnership working has been ‘captured by Pratt’. Pratt, Gordon and Plamping36 divide partnership into four types of behaviour—competition, co-operation, co-ordination and co-evolution—with true partnerships including parts from each and movement between them. Gray3 p.15 distinguishes between collaboration (‘a temporary and evolving forum for addressing a problem’), co-operation (informal arrangements to achieve reciprocity) and co-ordination (‘formal institutionalized relationships’). The process of collaboration can entail co-operation and co-ordination. Gray3 p.179 presents a framework of collaborative designs, comprising appreciative planning, collective strategies, dialogues and negotiated settlements. Other frameworks2 p.7 show levels of partnerships from networking through to collaboration, with increasing formal structures and committed resources.

Partnership initiatives

There is no space here to examine the many specific partnership initiatives, only to list them and refer to the major literature. A few publications describe several partnerships.33,37–40The NHS in England 2003/04: A Pocket Guide39 includes a diagram of the policy context for health partnerships. On-line glossaries include the Our Healthier Nation's Website41 and the national Public Health Electronic Library (PHeL).42 Many NHS trusts also produce on-line definitions that include some of the initiatives.

The following list of partnerships is by no means exhaustive:

Primary care groups/trusts/organizations

Within the context of PCGs in England, Hudson and Hardy43 highlight six types of partnership: governing partnerships; intra-NHS accountability partnerships; purchaser-provider partnerships; NHS-local authority partnerships; partnerships with patients/public; central-local partnerships. ‘Primary care trusts are the NHS organizations responsible for providing primary care, commissioning hospital care and co-ordinating community health services and social care in England.’44 The King's Fund Information & Library Service provides a reading list on current issues for PCTs/PCOs.45

Health improvement and modernization plans (HIMPs)

Now referred to as local delivery plans (LDPs), HIMPs were introduced in The New NHS.6 Elston and Fulop12 p.207 put them at the ‘heart of the UK government's agenda’. HIMPs placed a statutory duty on the NHS and local authorities to work together, and reinforced this with a ‘duty of partnership’. Ling32 explores this partnership further.

Health Action Zones (HAZs) (also Education Action Zones, Employment Zones)

First announced in 1997,46 HAZs are partnerships across all sectors—NHS, local authorities, community, voluntary, private—to improve the health of the most deprived communities.37,47–49

Health Act flexibilities

The ‘flexibilities’ were introduced in the Health Act 1999.50 They allow the NHS and local authorities to pool budgets, delegate commissioning and integrate health and social care staff.40,51–53

Care trusts

The NHS Plan54 introduced care trusts as a higher or new level of primary and/or mental health and social care trust.39,40,51,55

Clinical networks

Originating in Scotland,56 clinical networks make sure that health professionals from different NHS organizations, across boundaries, can work together within a specific disease or patient group.39,57–60

Public finance initiative (PFI)/public private partnerships (PPP)

The idea of PFI was first introduced in 1992 by the Conservative Chancellor, Lamont, and then re-shaped by the Labour government.32,61,62‘PFI, often now known as “public private partnership”, is now the dominant method for procuring public services involving capital spending in the NHS.’63 Kelly64 views PFI as an example of a PPP.

Local strategic partnerships (LSPs)

‘Non-statutory bodies, bringing together at local level the different parts of the public sector as well as the private, business, community and voluntary sectors.’42 The brief for LSPs varies by area but they are concerned with the national strategy for neighbourhood renewal as well as deprivation, social exclusion and health inequalities.40,65

Compacts

Compacts are the formal agreement between the government and voluntary and community sectors for the delivery of social policy.40,66,67

Drivers

It might be agreeable to think that the main driver for organizations choosing to work in partnership is a vision of how life should be for service users—which they are offered a service that appears seamless,54 p.5,68 p.33 because the partnership ‘relates to the whole life of a person’.69 p.11 In practice, of course, more pragmatic drivers spur agencies on.

The Audit Commission5 p.11 and others3 p.10,20 p.16,70 p.163–164 talk about ‘wicked issues’ as being a strong driver—problems that are both complex in themselves and also cross traditional organizational boundaries, so that agencies can only hope to tackle them adequately by working together. Gray3 p.29 identifies six factors that increase the occurrence of the ‘metaproblems’ that require a collaborative response. These factors include: rapid change; blurring of boundaries between government, the public sector, civil society organizations and the private sector; decreased finance from government sources. However complex the issue, organizations need to start by acknowledging the need for partnership working, because of either internal or external rationales. The ‘internal’ rationale is a belief that working in partnership rather than alone has benefits that outweigh the costs. This may, for example, be because there is a prior record of successful partnerships in an area,71 p.13,72 p.53 or because agencies feel that together they can create a ‘critical mass’ that will open doors previously closed to them.53 p.30−31 The usual ‘external’ reason is central government imperative.1 p.10,71 p.13,73 p.6

Critical success factors (CSFs)

Starting from a basis of recognized need and/or previous joint achievement can help organizations achieve a shared vision, something regularly cited as key to a successful partnership.1 p.12,3 p.8,10 p.23,15 p.3–4,35 p.146,69 p.12,74 p.287,75 p.160,76 p.122 Of the managers in the public, private and voluntary sector interviewed by Wilson and Charlton,16 p.30 for instance, over half mentioned some variation on a ‘common vision’ amongst their top critical success factors. Although, as the same authors state, this is ‘plain common sense’, that does not mean it is easy to achieve. Vision needs, too, to be allied to very practical processes such as planning and monitoring.

Developing a shared vision means being prepared to explore new options for services.68 p.33 This leads to another commonly agreed vital ingredient, trust.1 p.16,3 p.261,5 p.26,15 p.5,19,71 p.14,72 p.57,77 p.235 The consensus is that, although it is possible to work jointly with little trust between partners, the most successful partnerships have (and, through hard work, maintain) a strong level of mutual trust. Ensuring smaller partners are seen as bringing equal value to the collaboration, through resources such as knowledge and local legitimacy, is seen as helpful.60,72 p.57,76 p.123 Sharing rather than hoarding knowledge6 p.46,78 p.9 can engender trust.

The role of clear, consistent communication is at least implicit and sometimes explicit in much of the literature. One specific form of communication which needs addressing is linking with stakeholder groups, to ensure their involvement.16 p.22−25,79 p.4−6 Inclusion of service users’ perspectives, for instance, can make the difference between a project being taken seriously or not.17 p.213–230,80 p.32–36,81 p.112,82 Partnerships need to ensure they are clear whether they are seeking such engagement to inform priorities or simply in order to keep people up to date.79 p.4,80 p.35 In general, including all affected stakeholders and maintaining good relationships with the constituents of each stakeholder organization is vital.3 p.261

To ensure progress is maintained as they develop, partnerships must find effective means of making decisions and of ensuring accountability.1 p.18,3 p.11,5 p.23&36,17 p.231–246 Joint ownership of decisions and collective responsibility for the direction and activities of the collaboration are required.76 p.123,83 Partnerships can be less clearly accountable than their individual members, so addressing corporate governance issues early on is important for external purposes, just as clarity about respective agencies’ responsibilities is for a partnership's internal smooth running. However, a successful partnership will keep its principal focus on process and outcomes rather than structure and inputs.3 p.261,5 p.26,69 p.7,72 p.60 As Banks69 p.7 says, ‘the issue is not about how we develop organizations, it is about how we develop the delivery of services’.

The process of managing change must be done well; having aboard people who can work with change will help.78 p.9,81 p.111,84 p.14 Linck et al.15 suggest that partnerships can actually be a source of stability at times of organizational change. Similarly, Banks69 p.9 offers clinical networks as an example of groups working across professional and organizational boundaries in a way which may support cultural change. Small changes to how things run can make a difference,72 p.55,81 p.111 and may help maintain participants’ commitment, which is another key success factor.85 p.365 All partners must feel involved if they are not to become disengaged.5 p.22 Celebrating and publicising success can counter scepticism.1 p.20 Appropriate seniority of commitment can also help, particularly if key decision-makers establish personal connections that help develop trust.1 p.14,68 p.33 Continuing, visible and joint commitment from individuals in positions of leadership and influence is always important.1 p.35,10 p.22−24 In fact, Banks69 p.4 advocates investment in leadership development for middle managers.

A further key staff attribute is seen to be skills in working across professional, organizational or other boundaries. Individuals described as ‘boundary spanners’ or ‘reticulists’ and often working at the front line1 p.14,10 p.25,69 p.10,72 p.57,74 p.287,76 p.124,132 are seen as of central importance. The question of boundaries in partnerships is the topic of entire journal articles.13,85 The surmounting of boundary lines is a success factor, while failure to do so can quickly create a barrier to success.

In summary, the Wilder Research Centre have analysed the research on partnerships and identified 20 critical success factors, grouped into six categories.86 p.8 These 20 factors have been extrapolated through an extensive review of the literature and are quoted below.

Environment

  • • history of collaboration or co-operation;
  • • collaborative group seen as a legitimate leader;
  • • favourable political and social climate.

Membership

  • • mutual respect, understanding and trust;
  • • appropriate cross section of members;
  • • members see collaboration as in their self-interest;
  • • ability to compromise.

Process and structure

  • • members share a stake;
  • • multiple layers of participation;
  • • flexibility;
  • • clear roles and policy guidelines;
  • • adaptability;
  • • appropriate pace of development.

Communication

  • • open and frequent;
  • • informal relationships and communication links.

Purpose

  • • concrete, attainable goals and objectives;
  • • shared vision;
  • • unique purpose.

Resources

  • • sufficient funds, staff, materials and time;
  • • skilled leadership.

Barriers

Sometimes an awkward boundary demarcation may indicate a case where a partnership is simply not the best approach to an issue—for example the topic proposed may be primarily the responsibility of one agency, with others having only a marginal interest.5 p.14 It should not be assumed that partnership working is a good thing per se.77 p.232 Sometimes central policy may require a partnership approach, but if the driver for agencies working together is principally government insistence on them acting thus, the internal dynamic for collaboration may be weak.69 p.6−7,77 p.233 This may lead to a partnership failing to move beyond a ‘demonstration project’ phase, without any lasting impact.76 p.139 Gray3 p.255 notes a number of situations where collaboration between potential stakeholders is not appropriate, including fundamental ideological differences, significant disparities in power, a history of antagonism and failed attempts at working together, and significant costs to working together.

Linked to this is a potential barrier familiar from many other situations, under-resourcing—lack of appreciation of the work involved in a partnership, for instance, or reluctance to fund administration costs as well as direct service delivery costs.71 p.13,79 p.3 Peck’s68 p.5 survey of staff involved in a new partnership found work overload, including a reported increase in bureaucracy, given as a major concern. A partnership activity may be viewed as not after all offering ‘added value’, and therefore to be requiring disproportionate effort.87 p.177 A perceived imbalance of power between partners is a frequently cited destabilizing factor for those undertaking collaborative activities.20 p.64,78 p.8,88 p.50–53,89 p.139–44 Not only do partnerships risk appearing tokenistic, but it has been suggested77 p.239 that if a partnership starts out on a basis of unequal power then the most powerful partner will get the greatest benefits and the least powerful will incur a larger burden of costs. Conflicts over resources may also lead to ‘cost shunting’ between or within partner agencies, and this can build distrust.10 p.25,69 p.9,71 p.15 Perverse incentives, to hit targets or manage performance, may lead to ‘shotgun marriages’ of organizations,16 p.21−22,69 p.1−2 create preconditions for later conflict,71 p.11 or mean partners focus on problems with a high political profile rather than working together on local priorities.69 p.2

Cultural clashes can often be expected between people who come from different sorts of organizations and need to find ways to work together. NHS and social services staff, as an obvious example, may well have different perspectives on tackling joint issues. Furthermore, they may view each other in a stereotypical way.16 p.20–21,71 p.13–14,68 p.24 The title of one article on the topic, ‘Interprofessionality in health and social care: the Achilles heel of partnership?’,38 sums up the risk—although in fact the writer propounds an ‘optimistic model’ of interprofessionality. On a practical level, the fact that different agencies may have very different structures, or indeed even cover different geographical areas, can make it difficult for staff to link with their opposite numbers.71 p.15,76 p.120,81 p.100,90 p.38,91 p.4 Furthmore, different lines of accountability can contribute to a lack of role clarity—at management, team or personal level—which may hinder a partnership's effectiveness. Staff may be uncertain of the extent of their own responsibilities or concerned that they are taking on what should be other professions’ roles; managers may perceive a loss of autonomy or authority.68 p.18−21,72 p.54

All of the above concerns can mean that organizations find themselves spending more time on the mechanisms of partnership working than on achieving outcomes.1 p.18,5 p.26–27,77 p.242 Indeed, achievements reported in the literature often relate to the process of partnership working itself rather than any difference the partnership has made (or whether it was necessarily ‘a good thing’ in the first place).53 p.16,71 p.15,73 p.7 Evaluation of a partnership will always be important, even if finding clear indicators for measuring success is not easy.5 p31–6,14 p.118–125,16 p.53–55,20 p.94–103,69 p.12–13 The Audit Commission79 p.3 states that organizations need to develop specific outcome indicators relevant to the partnership and its remit, a process it links to the need of every partnership to develop a shared vision at the outset. Also, whether the end of a partnership signifies success or failure, it should be planned for in advance, as part of discussion about what the partnership plans to achieve.16 p.6,20 p.61–62,79 p.39–41 Every partnership needs to know what factors will indicate that its work is complete, and what will happen at this point. Evaluation that allows partners continuously to seek improvement by reviewing activities and learning from each other can be particularly valuable in the longer term.92 Many partnership schemes exist on the periphery of organizations, and feeding learning from the partnership back into the wider organization is important both to inform other partnership projects, and to demonstrate that barriers can be overcome.1 p.20,72 p.61−62

The legislation which places a duty of partnership on health bodies and councils, the Health Act 1999,50 acknowledged and removed some of the obstacles to partnership working by introducing flexibilities around pooled budgets, and by stating that one agency can take lead responsibility for commissioning services on behalf of partner organizations.53 p.4,69,71 p.9,81 p.100,90 p.38 There is some evidence that using these flexibilities can enable a ‘whole systems’ perspective to develop, by removing difficulties such as separate budgets, which may have been used as ‘excuses’ for organizations not working together. Might this even allow the needs of the service user to become the starting point of a partnership's work?13 p.144−145

Benefits

Partnership working is seen as providing benefits that are not achievable by other means. Gray3 p.22 identifies, among a number of possible benefits, improved quality of solutions and increased capability of and capacity for response. The improved relationships between the stakeholders is a benefit in itself. The Audit Commission5 p.41 identifies similar benefits: ‘aligning services more closely with users’ needs’; ‘making better use of resources’; stimulating more creative approaches to problems; wielding more influence on others.

The process of partnership working

A common experience in developing successful partnerships is that they require time and effort; they do not happen overnight. Gray3 p.11 uses the phrase ‘an emergent process’. There are stages to this development which need to be gone through in turn, laying down the necessary foundations. A planned and phased approach is necessary. A number of examples of partnership life-cycles are given below, from a range of different sectors. They all bear a lot in common as the principles are generally applicable even if implementation for individual partnerships is contextual and specific.

The Nuffield Institute for Health partnership principles1 p.9 concisely summarize the key stages of partnership working, quoted below:

  • • Principle 1—Recognize and accept the need for partnership.
  • • Principle 2—Develop clarity and realism of purpose.
  • • Principle 3—Ensure commitment and ownership.
  • • Principle 4—Develop and maintain trust.
  • • Principle 5—Create robust and clear partnership working arrangements.
  • • Principle 6—Monitor, measure and learn.

Child and Faulkner19 discuss in depth the following development stages for managing alliances in the business field:

  • • the nature of co-operation: motives for establishing a partnership; developing trust;
  • • establishing co-operation: selecting partners; deciding on the form of the partnership; power and trust; negotiation; valuation of the partners’ contribution;
  • • managing co-operation; management; control; HR; successes; cultural diversity; improving cultural fit; partner objectives;
  • • the maturing relationship: organizational learning; evolving the partnership leading to extension, separation or divorce.

Childs and Dobbins93 p.59 looked at partnership working between NHS and HE libraries. They developed a model, ‘The Developmental Process of Successful Partnership Working’, comprising three main stages:

  • • Starting the process: a champion to kick start the process; a vision; a willingness to forget about the past history of relationships; the principle of a joint venture with the partners working in a climate of equality.
  • • Achieving agreement: additional champions in the partner organizations; an ‘implementor’ to carry out the practical work; honest communication; creating goodwill and commitment; listening to the views of all the stakeholders; reaching mutual understanding; establishing trust; gaining the support of top management; emphasizing the benefits to all stakeholders; establishing ownership in all stakeholders; agreeing a partnership pattern or ‘implementation model’; establishing clarity about what each partner is giving to the partnership and what each partner will receive from the partnership.
  • • Creating a self-sustaining partnership independent of the presence of specific individuals and robust in a climate of change: ownership and commitment at the highest levels in the partner organizations; establishing partnership structures; quickly demonstrating the practical value of the partnership to the partner organizations.

This process requires time.

Gray3table 4 identifies three phases in the collaborative process:

  • • Phase 1: problem setting—defining the problem; committing to collaboration as a method of addressing the problem; identifying appropriate stakeholders; establishing the level of participation of individual stakeholders; identifying the convenor (who will bring the stakeholders together); identifying resources.
  • • Phase 2: direction setting—establishing ground rules of openness and mutual respect; setting the agenda of what is to be done; organizing the process of collaboration; obtaining information; exploring options; reaching agreement.
  • • Phase 3: implementation—obtaining agreement of the constituents within each stakeholder organization; obtaining external support; setting up the necessary structures and any required changes; monitoring activities and obtaining compliance.

A report for the Joseph Rowntree Foundation16 p.1 describes a five-stage development model:

  • • Stage 1: coming together because of a recognized need; overcoming differences and building trust; building capacity.
  • • Stage 2: process of dialogue; establishing common ground; agreeing a vision; identifying the task and actions required.
  • • Stage 3: establishing a formal structure; setting targets; establishing a management team.
  • • Stage 4: delivering the action plan; maintaining partner involvement; evaluating the partnership and refining the action plan.
  • • Stage 5: planning an exit strategy where appropriate.

Ourpartnership.org.uk94 is a Cabinet Office project with the aim of helping voluntary and public sector organizations work in partnership. It was developed jointly with the NCVO. The project has drawn up a ‘Partnership Lifecycle’ comprising ‘five key stages in the life of a partnership’:

  • • Connecting: how potential partners can get to know each other and plan their future activities together.
  • • Contracting: how to negotiate and decide roles, rules and funding.
  • • Conflict: how to manage the inevitable conflict between partners.
  • • Collaborating: how to keep the momentum going when the partnership is working well.
  • • Closing: how to end a partnership, or to end one partner's involvement.

The website provides guidance, through questions, stories, models and activities, to help people implement these stages.

Evaluation and assessment tools

A number of tools are available to assist in establishing the readiness for partnership working and actions that need to be undertaken to deal with the gaps identified. In general terms, these tools ask people considering partnership working to consider whether or not a partnership is appropriate, to evaluate the presence of CSFs, often by use of a checklist, and to consider how to establish or improve these CSFs if they are lacking or poorly developed. Additionally, some tools can be used to evaluate the progress of existing partnerships.

A number of tools have been developed within the health field. The Learning Disabilities guidance95 provides an audit tool both to establish whether the key components are in place, and if not how to establish them, and what the right partnership model is, taking into account local history, structures and arrangements. A health community-wide self-assessment tool is available96,97 for Local Implementation Strategy (LIS) groups to assess if they are ready for joint working and to identify where they need improvement. The Institute of Public Health in Ireland2 has produced a framework to help groups set up new partnerships or improve and/or evaluate existing partnerships. It is based on work by the National Network for Collaboration in the US. The Nuffield Institute for Health1 has produced a partnership assessment tool based on its six partnership principles.

Tools produced for other sectors are also relevant. The Audit Commission5 has produced a management paper looking at stages in the life-cycle of a partnership, problems encountered and how to deal with them. They give a set of key questions for each stage which can be used by organizations to review their own partnership. CIPFA (Chartered Institute of Public Finance and Accountancy)20 provides a checklist to create and manage a partnership plus tools for evaluating their effectiveness and efficiency. The Employers’ Organisation for Local Government92

COUNTRY / LOCATION: United Kingdom
Keywords: partnership working, pooled budgets, integration, legislation

Section 75 Partnership Agreements: NHS Act 2006 - integrated budgets

 

Summary

Section 75 partnership agreements, legally provided by the NHS Act 2006, allow budgets to be pooled between local health and social care organisations and authorities. Resources and management structures can be integrated and functions can be reallocated between partners. Legal mechanisms allowing budgets to be pooled (the section 75 partnership agreement) are thought to enable greater integration between health and social care and more locally tailored services. The legal flexibility allows a strategic and arguably more efficient approach to commissioning local services across organisations and a basis to form new organisational structures that integrate health and social care. This practice example reviews the function and impact of Section 75 partnership agreements and covers different local approaches to restructuring services.

What is the main benefit for people in need of care and/or carers?

Flexibility across health and social care budgets can allow resources to be used where they are most needed. For instance health money could be used for preventative community services.

What is the main message for practice and/or policy in relation to this sub-theme?

The legal freedom for partners to pool their budgets has the potential to make service design more tailored to local population needs. Organisations have used budget pooling in different ways and evidence suggests that forming new joint structures can take a lot of time and commitment.  

 

Why was this example implemented?

Legal mechanisms allowing budgets to be pooled are thought to enable greater integration between health and social care and more locally tailored services. The arrangements allow commissioning for existing or new services, as well as the development of provider arrangements, to be joined-up. They were previously referred to as Section 31 (1999) Health Act flexibilities.

A clear gap filled by the work underpinned by Section 75 partnerships is the gap in the patient care pathway. Integrated structures serve to reduce problems in transition between service providers e.g. intermediate care services.

The specific objectives for implementing Section 75 agreements are:

  • to facilitate a co-ordinated network of health and social care services, allowing flexibility to fill any gaps in provision
  • to ensure the best use of resources by reducing duplication (across organisations) and achieving greater economies of scale; and
  • to enable service providers to be more responsive to the needs and views of users, without distortion by separate funding streams for different service inputs.

Learning disability services are the type of provision most commonly grounded through use of Section 75 agreements. Councils tend to host these services after the transfer of funds from NHS Trusts. However there are several examples of integrated provision locally tailored towards older people, this often takes the form of community-based multi-disciplinary nurse-led teams and equipment.

Description

Section 75 partnership agreements, legally provided by the NHS Act 2006, allow budgets to be pooled between health and social care planners/providers, resources and management structures can be integrated. Most NHS Trusts, Care Trusts and councils have some form of pooled funding arrangements, with pooled funds amounting to around 3.4% of the total health and social care budget.

Legislation was drafted nationally and followed on from the previous (1999) Health Act. Joint working and the use of legal flexibilities, such as the Section 75 Partnership Agreement, were encouraged through national policy agendas such as World Class Commissioning, ‘Strong and Prosperous Communities’ (2006), ‘Our Health, Our Care, Our Say’ (2006), ‘Putting People First’ (2007) and ‘Transforming Community Services’ (2009). Integrated provision structures scored highly in World Class Commissioning assessments (partnership working is a key competency), providing localities with further incentives to build joint structures within health and social care.

At a practical level NHS and local council managers and directors are directly responsible for initiating and developing the partnership agreements. This involves an often lengthy process of local negotiation resulting in a new legally binding partnership framework agreement. Arrangements can also be complex, requiring careful consideration to reach clarity around accountability and governance frameworks.

Within LTC it is community services rather than residential care settings that have most potential to be developed through pooled budgets and joint action plans. Through joint structures with pooled finance, multidisciplinary nurse-led teams have been established to support older people living in the community. Such services have been seen to enhance access to community health professionals such as physiotherapists and speed up the assessment process and distribution of assistive technologies within people’s homes.

There is much consensus that setting up a partnership agreement and implementing organisational change is a complex, labour intensive task often involving initial tensions of organisational cultures whilst roles and responsibilities are redefined. However, evidence of efficiencies gained by forming single structures gives incentives to embark upon the route of pooling budgets and forming joint structures.

The development of new services and organizations based on Section 75 has been ongoing since 1999. This activity occurs at a local level.

What are/were the effects?

Evidence from the UK around integration remains limited and focused on process rather than outcomes. Despite this there are promising indications from individual projects that joint working leads to positive outcomes for service users.

The impacts of integration have been highly commended in localities and include: improved accessibility to intermediate care, occupational therapy, physiotherapy and district nurses; faster rates of assessment, provision of care and installation of home equipment; and reduced use of acute hospital services. Impact evaluations have been piecemeal including: independent evaluation and commentary e.g. the Audit Commission; individual project evaluations; local government assessments and outcome data.

One example of efficiencies created through joint structures can be seen in the city of Liverpool, where a single commissioning unit was created using a Section 75 partnership agreement. Back office savings are estimated to be around €1.5 million per annum. These savings result from shared systems and overheads used by the integrated unit team. The location of the team in shared premises, single health IT system, single performance management system and aligned indicators and shared outcome goals contribute to more efficient and focused working practice.

Another example of impact can be seen in the locality of Knowsley’s Health and Wellbeing board, with a pooled budget and joint commissioning activity. The approach has allowed a significant level of flexibility around use of resources. For instance, NHS funds have been used to support community projects which target the causes of local health inequalities. By shifting health budgets into community services the preventative potential of these flexibilities can be seen.

In another northern town, Barnsley, the local council and health authority pool their budgets and have reorganised their services for older people into an integrated commissioning level and an integrated provider level. The Council take a lead in the commissioning of services and the health authority lead the provision. The area have received excellent inspection reports for their services, including a drop in the ratio of older people admitted on a permanent basis to residential or nursing care.

What are the strengths and limitations?

The legal flexibility to pool budgets provides a clear opportunity for local health and social care organisations to form integrated services. The legislation is versatile, leaving localities to shape new systems of governance and provision to suit the capacity of local partners and the needs of their populations. Local evidence suggests that integrated management structures and services have several beneficial outcomes for users and can make efficiency savings by avoiding duplication.

A weakness in current arrangements is the time-intensive nature of setting up a Section 75 partnership agreement. Managers report that paperwork can be demanding and strong and dedicated leadership is needed to steer localities through such restructuring processes.

The Audit Commission (2009: 19) observe that one possible reason for the absence of formal joint financing arrangements is that the provision of social care is means-tested. Charging is most common for older people’s services. Although there is no legislative barrier to service integration where charging for the council element is involved, partners need to be clear on the mechanics of these arrangements. This complication thus providing a disincentive to pooled funding options.

Both the sustainability of existing partnership agreements and a simplification of procedures needed to establish partnerships are promised in the Department of Health white paper (2010). Many of the efficiencies and user outcomes covered in this example relate to the new integrated management structures and services. Setting up a Section 75 partnership agreement is currently the process that enables such services to be established. However, feedback from actors suggests that there is scope for the process to be simplified and improved.

Credits

Author: Kerry Allen
Reviewer 1: Ricardo Rodrigues
Reviewer 2: Laura Cordero
Verified by:

Links to other INTERLINKS practice examples

External Links and References

  • Allen, K., Glasby, J. and Ham, C. (2009) Integrating Health and Social Care: a rapid review of lessons from evidence and experience. Birmingham, HSMC
  • Audit Commission (2009) Means to an end: joint financing across health and social care. London, Audit Commission
  • Communities and Local Government (2008) 'Creating strong, safe and prosperous communites: statutory guidance’
  • Department of Health (2006) ‘Our health, our care our say’
  • Department of Health (2010) ‘Equity and Excellence: Liberating the NHS’
  • Department of Health (2009) Transforming Community Services: enabling new patterns of provision
  • Dickinson, H. (2008) Evaluating outcomes in health and social care. Bristol, The Policy Press Glasby, J. and Dickinson, H. (2008) Partnership working in health and social care. Bristol, Policy Press
  • HM Government (2007) Putting people first: a shared vision and commitment to the transformation of adult social care. London, HMSO
  • Ham, C. (2009) Only connect: policy options for integrating health and social care (briefing paper prepared for The Nuffield Trust). London, The Nuffield Trust

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