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Collaboration rather than partnership: a different approach in health and social care

Steph Palmerone of the NHS Partners Network, director of strategic initiatives at Barchester Healthcare, investigates collaborative working that delivers quality services for the public, brings benefits for the organisations involved and is efficient and effective use of public funds.

Although partnership working has been actively encouraged across health and social care services in England it has not always been successful. However, it is possible to develop a new way of working with strong links to the Government’s current push for integration that is achieved through clear connection and clarity of purpose rather than imposed restructuring.

The key is collaboration rather than partnership, yet in both the private and public sectors, true collaboration seems so difficult to achieve. For many years independent sector organisations have been delivering services for people with long-term conditions and providing services free at the point of delivery to the NHS. This article guides organisations through what they need to do to achieve effective collaboration based on Barchester Healthcare’s experience of working with other providers.

It is often stated that an organisation’s culture and capacity to keep evolving and developing is set by the leadership. While this may be obvious, leadership development approaches which only draw on the ideas and talent pool of one organisation are in danger of continuing to do the ‘same old thing we keep saying but never achieve’.

Professional and organisational confidence derived from believing the way you work is better than others is both positive and negative. But, at a time of resource constraint and the need to deliver quality outcomes, finding ways of working together that reduces inefficiency and enables access to services and support must be worth exploring.

Understand the history

It is important to understand an organisation’s historical experiences of partnership. In particular, the idea of private-public partnerships in health and social care have had a rocky past. But these partnerships were imposed, rarely sought. For example, commissioning additional capacity of elective procedures was a policy and commissioning decision; not something developed with the local NHS provider organisation.

In 2002, there were over 5,500 local partnerships spending approximately £4.3bn (Jones and Stewart quote research from Sullivan and Skelcher in 2002). Perhaps not surprisingly, this multitude of partnerships resulted in confusion, lack of understanding and accountability issues, which are considered so important in auditing use of public funding.

When questioned as part of a development programme, a small sample of people described going to partnership boards as good for networking and/or understanding the commissioning view but having little impact on their day-to-day work. But it is also important to recognise the perceptions of others, or myths and dragons, and acknowledge that some people have had bad experiences of working in partnership and these get embedded into organisational culture.

Clarity over what is possible

Be clear about what your organisation believes is possible to support collaborative working. For example:

• Partnership with a commissioning organisation isn’t possible unless every provider they commission from can do the same thing – a commissioning relationship is not a shared collaboration. However, all health and social care providers from all sectors should be included in discussions with commissioners about how to transform services on a local basis.

• It is possible to have collaborative relationships with other provider organisations within the current procurement framework. These do not fall outside the current competition framework as both organisations involved need to have a range of different relationships. • Being part of a partnership board approach is not a collaboration. But the value of these boards should be recognised for planning and networking purposes.

• Collaborations cannot be imposed, only developed where two or more organisations can see the benefit.

Leadership and organisational readiness: choose carefully

One of the key issues in developing collaborations is the human factor, highlighted by Rosabeth Moss Kanter in the Harvard Business Review 1994. While many foundation trusts may feel comfortable working with a small voluntary sector organisation, a large private provider may feel too threatening. Conversely, the public sector may perceive the private sector as a funder, investor or sponsor rather than a collaborative partner.

Good process doesn’t stifle innovation

An early lesson Barchester Healthcare learnt was that real willingness to try something new needs process to support it.

Possible processes to consider are:

• Identify three or four people from each organisation who have responsibility to keep projects on track and ensure terms of reference are agreed and supported by whatever internal board process is in place.

• Have a symbolic ritual that confirms how you behave together. For example, broad ‘terms of engagement’ setting out the behaviours of each organisation can be useful.

• Establish how you will decide on the areas you might work on and develop measures that help articulate the benefits internally for both organisations. Use language that isn’t ‘public’ or ‘private’.

• Keep reminding people that they have organisational support to try new things together.

• Make sure projects and ideas have a rationale as to why they are being done together.

• Be clear about communications and connections. Ensure early on that everything meets the legal and local political framework you are working in and agree who will be responsible for it.

• Spot the stars who ‘get it’ and support them, but recognise big organisations have culture carriers and work together to find a way of linking them in.

• Keep an eye on the investment of time, energy and development, and whether it is justified.

Celebrate the differences but keep it routed in quality and productivity

There is little point in developing a collaboration with another provider if you can’t demonstrate the gains. One of the advantages Barchester Healthcare has is that it does not compete with the NHS in relation to most of its business. It is able to take its skills base of working with people with complex needs and or long-term conditions and link those to NHS priorities. What we learnt:

• There is an understandable anxiety about how we define quality and how working with us will not diminish the perceived quality of the organisation you are working with. If we can’t evidence what we do it won’t help demonstrate the benefits.

• There can be an equal anxiety that your own organisation can lose its reputation for delivering quality services if your collaborative partner has a bad CQC  assessment or local challenge. But work together through the good and the bad. No provider does what it says on the tin all the time.

• At the very start it is important to agree what will be the deal breakers and acknowledge them.

• Even if the people get on, the geography is right and the early discussions seem to identify a mutual benefit, sometimes it just doesn’t happen. Timing, organisational readiness and local context is key. Barchester Healthcare has examples of developing the same idea with two different organisations in different parts of the country. One has taken off and one hasn’t. While this shouldn’t put you off, don’t flog a dead horse.

• Have a clear risk matrix, either written down or discussed together, that you use to keep checking out ideas so that even if the venture doesn’t happen you will learn from the experience.

• Don’t overstretch the number of true collaborations you have, otherwise the value is diminished.

• Keep reminding people who should benefit from what you are doing.

• Productivity, like quality, is often measured differently: check what you mean and how you can evidence it. It might be as simple as the price of a bed, or cutting x assessments out of someone’s contact with the system. Importantly, agree who needs to be involved in defining and measuring it.

Why it is different: organisational benefit and choice points not care pathways

Partnership approaches often struggle because although the people involved can articulate the benefits for service users, they cannot see the organisational benefit.

The organisational benefit should be based on offering something they don’t have. For example, widening out a customer base is one of the clear reasons businesses enter into a collaboration. Outside the challenges of provider organisations trying to work together, even pooling health and social care budgets has proved challenging. In 2009 the Audit Commission identified 32 PCT/LAs that had pooled budgets but recognised that very little work had been done on evaluation, reporting that “the focus locally and nationally has been on process rather than outcome measures, which are rarely quantified or monitored”.

In addition, there is scant evidence that integration across health and social care systems produces cost savings. However, few studies have actually addressed the issue of cost and fewer still have attempted to quantify it: ‘therefore there may be a problem of absence of evidence, rather than evidence of absence’. So it needs to be clear from the outset that if the joint venture or a specific project cannot bring wins for the organisation it probably won’t succeed. The table above shows three key wins and the rationale behind them.

One area Barchester Healthcare has been very aware of since the outset is how to achieve these wins and still support the concept of personalised approaches and choice for individuals and commissioners. What is needed is a common sense of what ‘quality provision’ means and a jointly developed understanding of how two organisations can pragmatically develop sensible options that work. For example:

• A shared sense that choice isn’t about which A&E department you want to go to within a 70-mile radius when you have been in a catastrophic accident is helpful. 

• Recognition that even though you can offer someone a joint long-term package of support, they may choose another option.

• Commissioned care pathways that offer a range of qualified providers at different parts of the pathway may be one solution, and you should relate to that system. 

• Be clear that you offer choice points throughout the process developing together, recognising that commissioners (including people with personal budgets or, in future, personal health budgets) will be expecting that.

Recognise but don’t reinforce the myths and dragons

Acknowledge that people working in health and social care do stereotype. At Barchester Healthcare, we developed a summary of some of the myths and dragons that are used by different parts of the system, to enable early and open conversation.

Although blunt, it proved extremely helpful in assessing organisational and individual readiness, internally and externally. It can form the basis for discussions about behaviours and, in particular, how organisations support each other internally. But if people are not prepared to meet people rather than myths, you have to accept that it probably won’t work.

Issues to consider:
• Everyone has experiences that will reinforce the myths and dragons: joint ventures are about individual organisations and the people who work in them.
• If things keep not working, it’s probably because of the myths and dragons held by the people and, if they can’t be changed, it’s not worth the investment of time.
• Make sure you don’t reinforce them in the way you behave.
• Recognise that some things are out of control of the individual or the organisation they work for and are an external requirement. Separate this out from myths and dragons. Some process is good and linking joint ventures to delivering business plans is important.
• If the joint venture is between more than two organisations, double check the myths and dragons.

Networking, stakeholder management and collaboration

Jargon is one way of keeping organisational or personal power. However, even something as simple as the meaning of the word ‘partnership’ can lead to miscommunications from the beginning. Some leaders view networking as the key to making things happen based on mutual connection, others see that ‘collaboration has to make something happen, otherwise it is just networking’. In the development of collaborations it is important not to see the relationship as networking. The outcome has to have measurable impact that both organisations are signed up to, but you may jointly agree the stakeholders you need to manage to support your shared objectives. So, a way of differentiating these three important words is:

• Networking: a set of individual relationships connected to paid work that enable the individual to link into other individuals who connect their work colleagues and objectives. It might lead to a collaborative approach but will certainly impact on whether it can work. People check out other people and organisations through their networks, so if your network tells someone that you or your organisation are not to be trusted, it is unlikely to happen.

• Stakeholder management: agreeing a defined number of people needed to support the plans you have for a particular timeframe. The individuals involved are connected to you because of their job, without any personal or individual connection. When the task is achieved the stakeholders may stay involved or not. From this structured connection, some networks may develop.

• Collaboration: where two or more organisations represented through individuals agree to work together for mutual benefit. They need to agree stakeholders and, if the collaboration is a trusted one, begin to share networks. If the collaborating partners don’t agree on the stakeholders, the mutual benefit is unlikely to be realised and together their networks will either support and enhance the collaboration or dampen it down from the beginning.

The pragmatic part is best summed up by recognising this way of working really is about seeing the bigger picture. It is about finding the common purpose but respecting the different requirements and non-negotiable of each sector that you can help each other achieve. What this adds up to is moving away from vertical power relationships to those that are flexible but have enough clarity to meet the need of each separate organisation. It isn’t about translation; it is about sitting inside both organisations and supporting innovation where people can create something new that helps them personally as well as the people they work for and with.

This should be exciting, about having fun and learning. However it must also be about being able to say ‘this isn’t worth it any more’. It is about taking risks but always assessing them – not about sitting with a lot of people for a lot of time with no measurable outcome.

Steph Palmerone is director of strategic initiatives for Barchester Healthcare. She is a qualified occupational therapist and worked in senior positions with the public and voluntary sector before joining Barchester Healthcare in 2007.

A longer version of this article, with references, can be found on the NHE Website.

Essential early considerations 

1. Understand both your own and your potential collaborative partner’s business plan and strategy.
2. Ensure potential collaborative partners can contribute to where you are going – and be clear about that. Similarly, use the fact that the private sector has more flexibility in some areas to adapt what you can do.
3. Don’t enter into many relationships in the same geographical area and be true to your word about how you will behave in the local region.
4. Make sure you know and agree who local competitors are and ensure neither you, not your potential partner, is working with them. But, be honest if you are and work through the consequences.
5. Board level linkages are important but it doesn’t always have to be CEOs at meetings – a culture of open and supportive joint venture working set by the organisational leaders is more important. But ensure that leaders get on and understand each others’ business and priorities.

Common myths about other sectors

The third sector

• Poorly staffed and lacking expertise
• Totally reliant on grants
• Unfocused and lack business skills
• The voice of the person who uses support services
• Small and unsustainable
• Great at low level support but not at supporting people with complex needs •
Political at a local level
• Regulated in a different way

The private/independent sector

• Only interested in profit
• Poorly staffed and lacking expertise
• Operating outside of governance and regulation processes that drive public sector provision
• Funded by different funders
• Trying to suck people in
• Run by people who have no commitment or values
• Don’t understand quality services
• Don’t want to work with other organisations
• Are wanting to ‘privatise’ public services
• Don’t invest in staff or community

People who use support structures and their families

• Unable to be involved in strategic discussion
• Only focus on their own needs
• Slow down the work and make it too simple
• Can’t get involved in decisions about resources
• Negative and complaining
• Can represent everyone in a local community
• Have a long term relationship with services

The public sector

• Full of hierarchy and meetings but nothing changes
• Wasteful and focused on professional need not consumer need
• Lacking talent management
• Has no real strategy
• Full of do-gooders rather than doers
• Trying to assess people out
• Don’t understand productivity
• Don’t want to work with other organisations
• Believe they are immune to

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