Find a common currency/fair exchange

The concept of exchange is seen as the key to under-

standing collaboration. Regardless of the overt pur- pose of
an organization (e.g. to provide services or meet client
needs), most organizations are also con- cerned about
preserving their interests – to ensure adequate resources,
their autonomy, status and authority. Working with other
agencies results in some loss of independence and control and
necessitates the
investment of scarce resources into building partner- ships,
the outcomes of which are by no means clear. Consequently,
organizations only enter into collab- orative working if they
can see that the needs of their organization are being met
and they will benefit in some way.
One of the key factors in effective collaboration is
achieving an interagency equilibrium where power is balanced
among the participating agencies. A sense of equality among
partners is important in generating commitment. This can be
problematic when partner organizations vary widely in
terms of size, status and funding, and span across the
statutory and voluntary sectors. The role of service user
partners, who may not have the backing or resources of any
agency or organization behind them, is particularly fragile.
The source of power for an organization varies. Local
authorities are controlled by elected politi- cians; voluntary
organizations are accountable to management committees and
their client group; health authorities have a duty to develop
mech- anisms for consultation but have no direct local
accountability. The different bases of local and health
authorities’ membership can create different priorities. Local
authority officers who have to work from election to
election can find longer-term stra- tegic planning difficult.
Health services’ accountabil- ity is governed by the
Patient’s Charter and various statutory responsibilities and
the recently embraced principle of participation and the need
for consulta- tion and involvement (see Chapter 7).
Box 7.11 Discussion point
What factors might constitute ‘power’ for an
organization in a partnership?
Power might include information, access to impor- tant
networks or groups the organization is intended to serve,
and, crucially, sources of funding. Power also manifests
itself in partnerships through the way participating
organizations negotiate the remit of the partnership and
whether they are ‘invited’ to join a partnership by a lead
agency. This can lead to the
work and contribution of partners not being equally valued.
The exchange theory of organizational rela- tions suggests
that for partnerships to develop, there needs to be some
brokerage and matchmaking, recognizing what each brings
to the task and nego- tiating on points of conflict. Financial
clout is at the heart of power relations. Organizations may be
wary of joint working if they are concerned about their
partner’s commitment but may equally embrace it if they
believe it will increase access to other pots of money.
Clarify vision and objectives
Partnerships often emerge as strategies to bid for specific
funding streams. This can lead to conflict. In a resource-
starved environment, different imperatives become clear. The
pots of money that are available for new initiatives such as
Sure Start or Neighbourhood Renewal can lead to competition
rather than develop- mental commissioning. Differential
budget growth, a reluctance to share resources, and different
budget cycles may all be barriers to successful public sector
partnerships. Partnerships where time has been taken to allow
a common shared vision and objectives to be defined are
much stronger, more stable, and stand a better chance of
survival. It may be difficult to take time out at the outset of
partnerships to establish a shared vision, but experience
suggests this is time well spent.
Box 7.12 Practitioner talking
This isn’t a very successful partnership as we seem
rather peripheral. There isn’t a stable and linked
structure for the Sure Start programme so we don’t
link in with people as well as we should. Where we
do, it’s because I go round chasing and go out to
meet people. But I am not sure we know who the key
partners are. Certainly I don’t think I know much
about what is happening. There’s supposed to be a
system of communication and feeding back but it
doesn’t filter through

Box 7.12 Practitioner talking—cont’d
to the ground and there isn’t a good uptake of people
at the meetings. We just don’t have time and it
doesn’t get prioritized.
This partnership includes a major agency from the
voluntary sector. What they seem to be doing is
trying to promote themselves. They want an active
role like having their facilities used even when it isn’t
necessarily the most effective or cheapest option. It’s
like they are competing for resources and leadership.
I know it’s important within such a tight geographic
boundary to include all the organizations but
everybody needs to be considered and
acknowledged equally.
Commentary
A shared set of values is deemed the most important
prerequisite for a partnership (DETR 2001). In this
Sure Start partnership there appear to be different
priorities. Large-scale programmes such as this have
major funding attached
that provides an incentive to organizations to work
together. This seems to have supported innovative
projects but has not had much impact on the
departmental ways of working. Existing power
relationships remain and practitioners (and service
users) are at the margins of the partnership process.
The partnership ‘table’ takes people away from ‘the
Includeand
frontline’ a wide range of stakeholders
their constituency. Those left delivering
the
Many issues involve a wide range of as
service can become resentful they get and it is
stakeholders
stretched and may feel that they have
important to identify gaps and duplication beenin ser- vice
neglected for more attractive work. Along withinthe
provision. Stakeholder mapping is a term used project
cultural challenge, there are structural andindividuals or
management to describe a process where all the
managerial challenges as well requiring ways of
groups that are likely to be affected
sharing and disseminating information.
by the activities of a project or involved in an issue are
identified and may then be sorted according to how much
they can affect the issue and how much the issue can affect
them. This information is used to assess how the interests of
those stakeholders should be addressed in any strategic or
project plan.
Some partnerships tend to focus on statutory agencies
only. Although there may be professional barriers, there are
also commonalities – a professional work role, a service sector
employer, and bureaucratic work cultures – which make it
relatively easy to work together. To embrace voluntary
agencies and service users as equal stakeholders represents a
much greater challenge. Voluntary sector organizations
sometimes find it difficult to be active partners. They are
unable to commit funds to joint working and their organi-
zational culture is different from the statutory and private
sectors. Although they are not bound by the roles of the
statutory sector, they may be perceived as amateurish and as
not accountable and unable to deliver. Voluntary groups may
not only feel com- pelled to be part of partnerships because
of access to extra funding but also feel that their lobbying
role is thereby compromised. What voluntary organizations
do bring is the understanding of the perceptions, attitudes
and values of service users which will ulti- mately determine
how acceptable and effective ser- vice provision is.
Understanding this different, but equal, basis for
stakeholders is one important aspect of successful
partnerships.
Box 7.13 Activity
Think of a partnership where you have been a
partner. Were there any partners who questioned
their participation? What did each of the partners
bring to the alliance?
Have good communication, visibility
and transparency of working
Good communication, including the transparency of decision
making, is a central factor underpinning effective
partnerships. Communication includes
face-to-face contact such as in meetings as well as written
documentation, and increasingly, email networks. Every
avenue of communication needs to be scrutinized to ensure
that it is inclusive, accessi- ble and understandable to all
partners. For example, acronyms and abbreviations that may
be obvious to practitioners may be unknown to other agencies
or service users. Everyday words (e.g. assessment, scru- tiny)
may mean something quite specific in policy or programme
terms. Good practice includes spelling out every acronym
in full the first time it is men- tioned, and including a
glossary of terms in every report or document.
Develop human resources
Most studies on interagency working have concen- trated on
the structures of organizations and the context in which it
takes place. Nevertheless, most partnerships attribute their
success or failure to ‘per- sonalities’ and individual members.
Whilst the role of personalities can be overplayed, most studies
suggest that ‘networking’ is at the heart of collaboration and
that nurturing relationships is crucial. Group theory can
help us understand how networking takes place, how groups
can fail to achieve their task, and how conflict can arise.
Box 7.14 Discussion point
What reasons might there be for conflict in joint
working?
As we saw in the previous section, organizations have
partisan interests and want to hold on to their resources and
autonomy. In addition, there are pro- fessional constraints on
collaboration. Lack of role clarity is often cited as an
explanation for conflict when members are not clear about
their contribu- tion or that of others. Sentiments such as
these are commonplace:
• ‘I don’t know what I’m doing here or why I’ve
been invited. I’ve got nothing to do with health’.
• ‘The PCT (or any of the other participants) are just
doing this to get more money for themselves’.
• ‘This is just a talking shop. It’s got nothing to do
with our priorities’.
Davies et al (1993) identify a key role in alliances for the
mediator, who can resolve conflicts through bar- gaining and
exchange. They also identify a role for ‘the reticulist’ – someone
who plays a bridging role, span- ning organizational
boundaries, and who can harness energies and skills. It is often
necessary for a formally appointed coordinator to take on
this bridging role.
Box 7.15 Activity
Belbin’s research into the working of teams (Belbin
1981) has been extremely influential in
understanding the particular problems which may
arise in groups and how the contribution of
individuals can be enhanced. Belbin identified eight
roles which together create a balanced, high-
performing group:
leader (the coordinator)
task leader (the shaper)
ideas person (the plant)
analyst (the monitor/evaluator)
practical organizer (company worker)
fix it (the resource investigator) mediator (the
team worker)
details person (the finisher).
Can you identify the role you normally play in
groups?
Tuckman’s model of group development (Tuckman 1965)
has been influential in showing how groups have common
characteristics in their development. Tuckman describes
groups as moving through five identifiable stages:
1. Forming – in which a group first meets and
works out the roles of members and tries to agree
upon a task and some way of working.
2. Storming – in which the group becomes polarized
and may form subgroups. There may be reactions to
power distribution and some resistance to the task.
3. Norming – in which the group begins to
establish some shared goals and to find a way of
working. Members take on roles to support the
group in its task or to help the group to work
well together.
4. Performing – in which the group begins to work
well. There is more trust and acceptance of the
contribution of each member. Interpersonal issues
get resolved. Members approach the task with
energy.
5. Mourning – the group disbands, sometimes
reluctantly, and there may be attempts to
continue the life of the group.
In the initial stages of partnerships, there may be
competition (the storming phase) as the balance of power
within the group is worked out. For a group to move on,
however, a safe enough environment has to be created.
Box 7.16 Activity
Think of a partnership where you have been a
partner. Can you identify stages in the ‘life’ of the
partnership? What helped to move the group through
the stages or did it get stuck?
Participants have to relinquish some control in joint
working. For professions in health and social care which
have been seeking to define their professional competence and
difference such as nurses and health promotion specialists,
crossing professional boundar- ies and finding ways to work
together can be challeng- ing. Beattie (1994) cites the
following as common barriers to intersectoral working:
1. professional ambition and competition
2. territoriality and protectionism
3. information used as a major source of power and
shared only reluctantly
4. different terminology and jargon.
In partnerships, participants often focus on the task for
which they have come together. Difficulties
arise over the nature of the task and the role of the
participating agencies in the partnership. What often gets
ignored in partnership working is the ‘mainte- nance’ of the
partnership – those ways of being which help people to work
together. Markwell (1998), for example, identifies the
importance of making sure that participants are acquainted.
The motivation of someone drafted in or someone who has
little influ- ence or knowledge of the echelons of their own
agency may be limited. So effort in communicating about the
work and keeping participants on board is vital. Having a
task focus with equal opportuni- ties for contribution and
responsibility through, for example, the setting of the
criteria for the alliance and chairing meetings can help to
defuse power con- flicts. Conventional ways of working,
such as com- mittees, steering groups and formal minute
taking can hamper the development of ideas and inhibit the
contribution of community representatives who may be
unused to such ways of working.
Beattie argues that groups also need to develop the
ability to give feedback on how the group is working and
that there is a strong case for draw- ing on ‘the theory and
practice of psychodynam- ics of relationships within
institutions to explore the significance of emotional
processes and inter- personal defence mechanisms’ (Beattie
1994, p. 119). Members need to spend time talking over
dif- ferences and reviewing relationships within the
partnership. The Health Education Board for Scotland
(HEBS 2000) also identified ‘transpar- ency’, ‘mutual
trust and confidence’ and ‘open and honest
communication’ as key indicators of successful
partnerships.
This section has looked at organizational and
interpersonal issues drawing on established theo- ries
from management and organizational studies and social
psychology and psychodynamic work. These ideas help us
to make sense of those fac- tors, identified from
empirical studies, which are the ingredients for
successful collaboration. The insights gained from
practice can also help us to ‘test’ these theories to see if
they do offer explana- tions of what goes on in
collaborative and alliance work.
 Box 7.17 Example
Healthy schools partnership
Read the following information about a Healthy
Schools Partnership and then answer the following
questions.
The healthy schools partnership has existed
for nearly 10 years. It has always been a small
group of key people, chiefly from the council and
the primary care organization. It has principally
focused on the process issues associated with the
implementation of the healthy schools programme
in the borough. It has no links or reporting to
wider strategic partnerships in the area such as
Children’s Board or LSP.
Its purpose is to
• oversee the implementation of the healthy
schools programme in the area
• agree the allocation of resources to support
the implementation of the programme.
The partners involved are
• Local authority Children’s Services
• Health Promotion staff
• Primary School Head Teachers × 2
• Secondary School Deputy Head Teacher
× 1 (a member, but in practice struggles to
attend)
• There used to be a wider reference group
involving a range of partners, but this has not
met for a number of years.
So far, it has overseen a process which has
exceeded the government targets for the area.
All local schools are participating in the scheme
and many have already achieved the standards
required. There is good communication and
dissemination of information, with a website
dedicated to the programme in the borough and
regular newsletters sharing good practice. There is
a bi-annual health-related behaviour survey funded
by the primary care organization. All schools are
invited to participate in the survey to provide
them with an up-to-date snapshot of the
health behaviours of their pupils in order to
help them
plan in relation to need. Half of the eligible schools
take up the offer.
The people directly involved in the partnership
are at middle management level. They all feel
that the programme does not have the profile
it deserves across agencies. There have been
tensions between the council and the Primary Care
Organization about the use of resources throughout
the period that the partnership has operated. The
council physically holds the money, and ultimately
takes the decisions. Whilst there is a nationally set
target for local areas regarding healthy schools
programmes, this is not included in the Vital Signs
targets of the Primary Care Organization or the 198
National Indicator Set that councils are measured
against. Healthy schools is not a target for the
Local Area Agreement between primary care and
local authority in this area.
• Does the partnership appear to have
common agreed goals, shared targets,
commitment and effort?
• Does there appear to be good participation of key
stakeholders, agreement of relative roles and
clarity of expectation? Are the right people
and partner agencies
involved?
• Is there evidence of needs assessment and
appropriate policies, plans, objectives,
targets, delivery mechanisms and funding?
• Is there evidence of the partnership enabling the
sharing of knowledge and skills across
boundaries and groups and supporting
innovation?
• Is there evidence of the sharing of human,
financial, technical and information
resources?
• Is the partnership clear about what success
looks like and whether it is achieving it?
Conclusion • Do professional education and training courses
equip people to work effectively in partnerships?
The existing literature on partnerships is based on process
evaluations, although there is an implicit
Recommended reading
assumption that partnership working is ‘a priori’ a
good thing. However, theoretical frameworks and reported experiences of participants reveal a num- ber of common
themes concerning the difficulties and opportunities for successful collaboration. There are obvious costs and
benefits involved. Partnership working is about compromise and entails some change in normal patterns of
working. It may require additional and specific skills such as effective group working and management skills.
Partnership means relinquishing control and the inclination to put one’s own interests first and it entails crossing
professional boundaries. Strategic partnerships are very expensive in time and resources with little evidence to date
of effective outcomes.
On the other hand, at the level of a specific project or campaign, partnership working may lead to synergistic
working with the achievement of more significant and long-term outcomes than would be achieved by agencies
working in isolation. It may have a ‘trickle down’ effect whereby partner agencies become more committed to public
health and health promotion and gain new insights into problem def- initions and possible solutions. Where
partnerships include voluntary organizations and members of the public, there may be additional benefits of
empower- ment and increased social capital. Partnership work- ing offers the potential of more ‘transparent’ ways of
working, with greater accountability to a variety of interest groups. Most fundamental of all, however, is that it
can bring about a cultural change that rec- ognizes health as a multidimensional concept that reaches far beyond the
health services.

Further discussion
• Is partnership a consequence of joint working?
• Is the commitment to partnership working by government more rhetoric than reality?
• Balloch S, Taylor M: Partnership working: policy and practice, Bristol, 2001, Policy Press.
A collection of case studies of partnerships in health, social care and regeneration.
It examines the theoretical and practical reasons why partnerships do or do not work.
• Glasby J, Dickinson H: Partnership working in health and social care, Bristol, 2008, Policy Press.
This book provides a very useful introduction to partnership working, summarizing current policy and
research, and setting out useful frameworks and approaches. Others in this practice-based series include
guides to effective team working (Jelphs K and Dickinson H) and managing and leading in interagency
settings (Peck E and Dickinson H).
• Glendinning C, Powell M, Rummery K: Partnerships, new labour and the governance of welfare,
Bristol, 2002, Policy Press.
An edited collection examining the political drivers to partnership working as a means of ‘joined up’
government.
• Health Development Agency: The working partnership, London, 2003, HDA.
http://www.nice.org.uk/nicemedia/ documents/working_partnership_3.pdf
A manual that examines the evidence from community involvement, business excellence and
partnership dynamics for common features of successful partnership
working. It includes assessment tools so that partnerships can identify their achievements and areas for
improvement and capacity building.
• Health Education Board for Scotland: Partnerships for health: a review, HEBS working paper No.
3, Edinburgh, 2001, HEBS.