The Department of Health website (DOH, 2004) states that
New powers to enable health and local authority partners to work together more effectively came into force on 1st April 2000. These were outlined in Section 31 of the 1999 Health Act .
This has further been reinforced by a plethora of government legislation and directives such as The National Service Framework for Mental Health 1999 and the Health and Social Care Act 2001. Charlesworth (2003) points out that there has always been a tendency for different care agencies to work together, and previous attempts by governments to facilitate this since the 1973 NHS Act proved unsatisfactory. Hudson et. al., (2003) also point to the shift in government ideology of New Labour since its election in 1997 towards an emphasis on collaboration between existing services rather than upon the development of quasi-competitive markets which typified Conservative government health policy after 1979.
For the purpose of this essay, healthcare can be said to be related primarily to the NHS; whereas the notion of social care might be that care aimed at the social inclusion of disadvantaged people (Aldgate and Dimmock, 2003). In practice, such needs are answered by both statutory and voluntary (or private) agencies.
To require something is to consider it obligatory, or useful, just or proper (Word Web, 2004). To analyse something is to consider in detail or break it down into its essential components (Word Web, 2004). The notion of partnership is however more complex. Definitions can range from a pair in a marriage (Oxford, 2001) to a contract between two or more persons who agree to pool talent and money (Word Web, 2004). One commentator has described the process of partnership between care agencies as a shotgun wedding (Batty, 2003a) and a rocky marriage (Batty, 2002b), since the assertion is that it is a hastily-concluded process beset by problems. One manager pointed out that any inter-agency partnership does not get off to a good start when the partners feel compelled to enter it (Open University, 2003). Another barrier to partnership might be that different organizations will enter into it from different forms of self-interest (Seden, 2003). A quick glance at media comment reveals much incredulity and scepticism about the practicality of the Government’s plans for partnership in health and social care: Batty (2002) and Banks (2002) are merely but two examples.
Any examination of the virtues of partnership must consider what the Government intends by its use of the term. The consensus appears to be that what is meant is inter-agency collaboration, which according to Hudson et. al (2003) has for many years been accepted as a self-evident yet elusive virtue in the provision of health and social care.
For Charlesworth (2003), the government means agencies working across boundaries, and notes how it is a concept which has many terms. The notion of partnership in health and social care is logical when, as she suggests, people have complex needs which cut across the types of specific services which have historically been offered. From a resource point of view, partnership precludes duplication of resources and provides best value (Charlesworth, 2003). It enhances communication between different agencies or elements of the partnership, and draws on a variety of skills and knowledge. This will benefit the service user, who is subject to only one assessment and whose needs can be coordinated across different service providers. There may also be a realization that single agencies or organisations have been unsuccessful in the services they have provided due to limited resources or expertise. Partnership offers a wider range of both. This would be true, for example, in the case of statutory authorities partnering community or voluntary groups. The mutual advantage lies in the larger statutory bodies having access to service users and the local community; for smaller groups in partnership the attraction is that they now have the ear of a statutory body and access to funding (Charlesworth, 2003). These financial elements may also prove a barrier to partnership – for instance, if organizations within the partnership have different mechanisms and foundations for funding.
Hudson et. al. (2003) however suggest that the political use of the notion of collaboration is based upon assumptions about individual and organizational behaviour which are unrealistic. That is, that every individual and every organization wants (or is ready) to work across professional and organizational boundaries. Hudson et. al. imply that the issue is more complex, not least because of what such a work-pattern might mean to both the professional and the organization, and to those who fear change. A manager will find skills in managing change useful in this context (Charlesworth, 2003). Due to the environment of new health and social care frameworks and tight constraints on resources, having new managers acquire skills in change management takes priority over other skills. This leaves managers having to keep up with the sheer pace of change, so obfuscating their role of prioritizing and allocating services (Charlesworth, 2003).
Some professionals feel threatened by what they might see as the dilution of their role, and for them issues of demarcation are crucial. Professionals working within an inter-agency partnership may also have conflicting views about the roles and interests of service users (Seden, 2003). Charlesworth (2003) observes that though this is often the case initially, professionals report that in fact inter-agency collaboration can come to enhance their own role and improve their understanding of colleagues who work in another field. They come to appreciate difference. In terms of the organization, collaboration can be a means by which an organization can manage its own survival. In the rapidly changing environment in which health and social care is provided (Clarke, 2003) the organization can negotiate its environment by collaborating with others (Seden, 2003). However the logical conclusion of this might be integration or merger, with a concomitant loss of individual organizational identity (Charlesworth, 2003).
Partnership can also amplify the differences between organisations and between professionals (Charlesworth, 2003). For example, pay and conditions may be different between professionals which can cause hostility and resentment, and hinder the development of the inter-professional team. Some professionals may resist taking on work which they formerly believed belonged to professionals in another organization even though both are now in partnership. Organizational partnership sees a shift for front-line staff from multi-professional working to inter-professional working. The former can be considered as a co-operative undertaking, while the latter implies a willingness to share or even give up exclusive claims to specialized knowledge and authority (Hudson et. al., 2003). A team needs to be ready for change in order to implement the partnership at organizational level. A manager can ensure this by clarity of purpose, organizational learning, commitment and shared ownership, and robust and coherent management arrangements (Hudson et. al., 2003).
There may also be a clash of organizational cultures, such as between health and social care providers, which can arise from different management structures. For instance some managers may have more autonomy to make decisions and to commit resources than managers in partner organisations. A partnership will fail if the managers in one organization fail to meet the commitment of the other. The perception of a threat to professional identity can also lead to the assertion of status and power by certain professional groups. Voluntary organisations regularly complain that they feel excluded from partnerships because of the jargon which statutory authorities use, and because they consider themselves a small part as against the funding giants of statutory authorities. Service users likewise feel excluded by the language used and are humbled by their lack of formal qualifications (Holland, 1998; Read, 2003). This is an especially important issue, since the same government legislation emphasizes the direct involvement of service users and service user groups in the planning of services (Hickey and Kipping, 1998). Some members of a partnership may also perceive differences in legitimacy between elected and appointed representatives (Seden, 2003).
For Hornby and Atkins (2003) the notion of leadership is vital. The idea of partnership and collaboration implies some form of equality and democracy, of a shared vision together with a clearly agreed strategy, mission and objectives (Hudson et. al., 2003). Cross-boundary working requires a clear idea of what all parties jointly want failure will result (Charlesworth, 2003). Likewise a partnership becomes unbalanced when one organization is leading another, for this organization can exploit the power balance by dictating the agenda to other partner organisations and agencies which it views as inferior. All partners must feel they have an equal voice and be willing to share the power for partnership to be effective. Voluntary organisations and service user groups are often disadvantaged in partnerships because they do not have financial power and feel their membership is merely tokenism. It is vital for managers to address power imbalances and structures because the vital links that voluntary organisations have with service users is needed by statutory agencies. Managers need to find ways to overcome these imbalances (Charlesworth, 2003).
While the government emphasizes partnership other parts of its agenda to modernize contemporary health and social care services place pressure upon the potential of a partnership to succeed, serving to limit the vision. One manager described how pressure to measure rigorous performance targets and outcomes deflects attention away from working with partners; and some smaller groups can find this form of organizational culture intimidating and alien. Service users have high expectations of the pace of change promised by the government, but may be frustrated by the apparent sloth of services to implement such change in practice through inter-agency partnerships (Charlesworth, 2003).
According to Hudson et. al., (2003) there are three main forms of collaboration. The rationale behind partnership is indisputable, and each different form of partnership each has its advantages. The network is any system of contacts, with no particular expectations or commitment to working together; the coalition initially involves the sharing of information but later matching (even joint) strategic service plans; and thirdly the unitary model sees a pooling of resources to serve a single set of objectives. Some organisations might be better suited to different models of partnership. Hornby and Atkins (2003) suggest that the way in which an organization in partnership is able to function is limited by the environment in which it operates, and by the social and psychological needs of the group or team within the organization.
Partnership requires the manager to use skills of analysis, dealing with the community, diplomacy, negotiation, empathy, being able to look to the distant future as well as at the immediate future – all skills which Charlesworth (2003) points out many managers already possess perhaps without realizing they are already using them. She suggests joint training so that others involved in the partnership are given the opportunity to acquire such skills. Also of note is the observation that traditional forms of professional training have not traditionally focused upon the development of skills for partnership.
Partnership is the logical way forward for contemporary health and social care. Duplication of resources is expensive for the service provider and annoying for the service user. Whilst partnership on one level satisfies the political brief of health and social care organisations, it also cuts across boundaries to answer the complex needs of people. It makes sense for organizations to pool their resources and through partnerships to access the expertise and knowledge of other organizations. Resources which were previously duplicated can now be freed up to broaden and enhance the service. However it is a process fraught with difficulties which need to be identified and solutions to them implemented. The manager’s role in this process is three fold insofar as they identify barriers to partnership; they establish and work alongside organizational partners, ensuring a commonality of purpose as they do so; and implement skills of change management in taking their organization along with themselves. For this the manager needs leadership and clarity of purpose, and an understanding and acknowledgement of their lateral (i.e., to staff and to service users) and vertical (i.e., corporate) responsibilities. The author feels that such a conclusion is wide open to the charge of naiveté, and concurs with Hudson et. al.’s qualified assertion that “collaboration is ‘generally a good thing’” (Hudson et. al., 2003, p.232).
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