Partnership Working in Wolverhampton Health Action Zone

A process report by:

Patricia Daniel

EXECUTIVE SUMMARY

Centre for International Development and Training, University of Wolverhampton. Contact: P.Daniel@wlv.ac.uk

1. 1. What changes in partnership working at senior level in the borough from 1998 to 2000

can be identified and what impact has this had on service delivery within the borough?

 

2. 2. What effect does partnership working have on the length of time needed for HAZ project development?

3. What factors are significant in moving partnerships forward?

4. What factors are significant in slowing down the development of partnership?

3. 5. What level of partnership has the HAZ been able to develop with different sectors?

5.1. Voluntary sector

4. 5.2. Community sector
5. 5.3. Public sector
6. 5.4. Private sector
7. 5.5. Public participation
8. 5.6. Involvement of Black and Ethnic Minority Communities
9. 6. How does partnership operate within a HAZ workstream at the level of service delivery?
10. 7. How does partnership operate within a HAZ workstream at the level of decision-making, monitoring and evaluation?
11. 8. How does partnership operate within a HAZ workstream between levels in terms of the relative health of partnership at one level impacting on joint working at another level?
12. 9. How have working practices changed through experience of partnership?
13. 10. How have attitudes to work changed through experience of partnership?

1. Introduction

This report describes the results of a process study of organisational and inter-organisational change through partnership working under the Wolverhampton Health Action Zone. This is within the context of the central government drive towards joint working and the HAZ ethos of promoting social inclusion. The research forms part of the overall evaluation of the HAZ. Interviews were carried out with 20 members of the HAZ Steering Group between November 2000 and March 2001, to discuss their perceptions of the HAZ partnership, how it works and the impact it has had, around a list of ten key areas. The Partnership Assessment Tool developed by the Nuffield Institute for Health, in collaboration with the NHS Executive, was used to triangulate findings from the interviews. Triangulation was also carried out through reference to documentation from the HAZ Steering Group and different workstreams. Analysis of the evidence from interviews does not rely on any one external model of partnership. It attempts to present a flavour of the Wolverhampton HAZ partnership itself, giving a voice to the people interviewed, and highlighting areas of contradiction as well as consensus.

2. Main findings
1. The research suggests that the HAZ Steering Group is a healthy and effective partnership overall, although some aspects may need further exploration. Key elements which have contributed to the success of the partnership include the following:

1. the HAZ was built on existing partnerships, including the original Health Forum, the Older People Strategy, SRB4 Wolverhampton Connects. It continues to develop links with other partnerships and to forge new ones
2. through the formation of the Health Forum and the two bids to become a HAZ (the first being unsuccessful) there was time to develop a shared vision, understand each others’ agenda and create trust
3. key responsibilities were allocated to the different partners so that key players had a vested interest in making the partnership work. Previous political differences have been bridged through this mechanism.
4. the leadership had a total commitment to making the HAZ partnership work and to move forward joint working in general in the city
5. flexibility and autonomy were incorporated into working structures, allowing diversity and creativity in different areas of work
6. the partnership, and its individual members, meet new challenges with creativity and the desire to be true to the original aims of the HAZ - that is, to deliver a local heath agenda around access, equality and participation

1. Attitudes and working practices have changed, positively and sometimes radically, through involvement in the HAZ partnership, at least for many members of the Steering Group. It is clear through this research that there are added value benefits to working in partnership, which are not reflected in government targets for service delivery. Analysis of these has provided a basis for incorporating this added value into the overall evaluation of Wolverhampton HAZ (see table A).

3. While the evidence in this report indicates real changes in attitude and working practice at the strategic level, there is a need to collect evidence of the impact of the HAZ on middle managers and frontline staff. In addition, service users’ perspectives on the success of partnership working need to be investigated through the Community Evaluation and Workstream Evaluations. This would include both the HAZ impact on the services they receive and on their increased opportunity and capacity for participation through contact with HAZ projects.
4. A number of interesting dichotomies arose through analysis of differing perceptions among members of the partnership. These testify to the complex nature of partnership working. It is recommended these issues be addressed, both as a means of strengthening the HAZ partnership and also to underpin the future health of partnerships in Wolverhampton.

 

0. It is clear that, at the public sector level, the HAZ has provided the impetus to institute real changes at a strategic level in attitudes towards joint working across the city and the delivery of services. Despite this fact, there is still some perceived problem in the lack of willingness of all bodies to share budgets and new ideas, with some fears that partnership working may slip backwards after HAZ. While HAZ has been incorporated into the Health Improvement Programme, and HAZ groundwork has supported other initiatives, there is a question over whether the HAZ is leading new strategic developments as much as it could.
1. One of the strengths of Wolverhampton HAZ has been that the Steering Group, from the outset, has been both responsible for the delivery of the HAZ as well as accountable for it. This combination of strategic and operational responsibilities has kept the partnership together politically. However, there is a tension between the two functions of the partnership, which has affected the clarity of its role and the effectiveness of its meetings. Is it a strategic group concerned with performance management? Or is it a forum where those involved in implementing the HAZ can forge genuine partnerships between themselves to exchange and develop new ideas. Many perceive it to fulfill neither role satisfactorily. Different members may also perceive their own role within the Steering Group differently, for example as representing people, an organisation or an area of work; providing strategic oversight or leading developments.
2. Many perceive the HAZ Steering Group as a clique, which has the benefits of people feeling comfortable and working well together. However, not everyone feels included in that clique. Moreover, there is the perception that decisions are made, and influenced, by only a few key players. Interestingly, although attendance is irregular among some members, they still feel the group is cosy. Yet most respondents saw that this cosiness had become a weakness, in that members were reluctant to criticise or to analyse others’ performance in detail. There are radically opposing feelings about the HAZ, for example, in its relationship with the Primary Care Groups. One member feels this has been entirely positive and constuctive while another feels that the HAZ has been difficult to work with, that it didn’t take up their suggestions. Agendas from elsewhere may be played out in the HAZ arena.

There are a number of dichotomies here. Feelings about the partnership tend to coincide with level of seniority, length of time of membership and related sense of ownership. Personality or personal approach is also a factor (open and cooperative versus guarded and competitive) and this may be gendered although not exclusively. But there is also the nature of consensus: people apparently participate as equals in a decision making process but don’t necessarily feel ownership of it. Circulating minutes to those who have not attended does not seem to help.

3. There has always been clarity about the importance of the partnership itself; however, this may sometimes have adversely affected operational decisions. In other words, the leadership has been effective in keeping the partnership intact perhaps at the expense of rigorous planning and evaluation of HAZ delivery and this in turn may have had the effect of alienating some support. In the longer term, as regards future joint working in the borough, this emphasis may or not prove to have been the wisest course.
4. In the initial architecture of the HAZ, care was taken to make the Steering Group representative of the community-voluntary sector through the integration of several bodies: the Wolverhampton Voluntary Sector Council, the Wolverhampton Race Equality Council and the Community Health Council. There are different perceptions among these bodies themselves about whether the others do actually represent grassroots community needs and interests. However the reality is that it is impossible for one or two individuals to adequately represent the rest of the population. This is particularly so, given the heterogeneous nature of the very active but fragmented community-voluntary sector in Wolverhampton, the lack of democratic structures at street level and the resulting problems of communication between policy makers and the grassroots.

This is an important lesson for future (local) government regeneration developments. Participatory systems and approaches across the sectors and from the grassroots upwards need to be in place and fully integrated into the planning stage, so that all stakeholders, including service users and frontline staff, have a real voice. The HAZ has provided the impetus for developing a range of innovative pilot projects and strategies at grassroots level, to increase community participation and public ownership of healthy living initiatives, that could form the basis of a more general, systematic participatory system in Wolverhampton.

5. The HAZ has also developed a range of initiatives related to the needs of Black and Ethnic Minority groups. However, many of these have been top-down initiatives, rather than as a result of grassroots consultation. Additionally, because of the often marginalised nature of BME communities and the lack of suitable communication channels, many of the HAZ successes are not generally well-known or understood. Through the HAZ a range of issues have been highlighted relating to the difficulties of developing partnership with the BME community. Firstly, it is heterogeneous. There is also a lack of partnership between different BME groups themselves. There is reluctance to confront endemic problems in BME communities for fear of being labelled ‘racist’. BME representatives on local committees may lack experience of taking part in formal meetings and feel they are not being heard. For all these reasons there is a feeling in the BME community that their concerns are not being taken seriously by HAZ, despite the commitment that the Steering Group feel they have made to BME health equality. The HAZ now has the opportunity to build on these lessons learnt. The Black Strategic Health Group is hopefully one way of helping to develop a constructive partnership both within the BME community itself and between HAZ and the BME community.
6. While the HAZ has worked hard to develop transparent and objective procedures for allocating funds, these have not always been understood by the community. The serious misunderstandings surrounding the awarding of the Innovations Projects grants provide a very clear example of the communication problems in the HAZ. Problems arise because of ‘cultural’ differences between professionals at strategic level and local community members. They can also arise because of the intermediaries through which messages are transmitted. This can perhaps create the ‘Chinese Whispers’ effect, leading to both misrepresented and misinterpreted ‘information’. The example highlights the need for appropriate bottom-up / top-down (and horizontal) communication systems and dissemination channels. These have to be built into the initial structure and operation of any new city-wide partnership work; this issue is closely related to the development of participatory systems and integrated services. Work in the Public Participation Workstream contributes to the bridging of the communication gap. In addition there been the appointment of a (part-time) HAZ Communications Officer.
7. The six Workstreams each operate in quite different ways, having set out with different agendas, leaders and support systems. Some, for example, grew out of existing partnerships while others started from scratch. There is also a discrepancy in the current amount of co-ordination time each workstream is allocated, and the level of authority held by individual Leads / Coordinators within the HAZ. Each workstream has developed a range of different types of partnership which have contributed to effective service delivery and successful projects. It has not yet been possible to analyse the exact partnership factors contributing to success of specific projects at service delivery level. Although it is difficult to draw comparisons across the Workstreams, there are many potential strengths in this diversity. Unfortunately, there has been little cross-fertilisation between the workstreams themselves, even at the level of information exchange as opposed to joint planning. This is despite the fact that the Workstream Leads / Coordinators recognise that there is much scope for integrating the cross-cutting issues of age, race, gender, etc through greater collaboration.

Evaluation is an aspect of the HAZ partnership where opinions have radically diverged. In order to safeguard the partnership, monitoring and evaluation were given a low profile at the outset. This decision was not necessarily consensual and some members regret this happened. However, it meant that, with the exception of some individual projects, the collection of baseline data was overlooked across the workstreams. This makes it more difficult to evaluate progress, particularly in some of the experimental work being undertaken. A common performance management framework was hammered out in consultation with the Workstream Leads/Coordinators. However they don’t all like it and have developed additional methods of evaluation. Sharing of lessons learnt has not yet taken place between the Workstreams, although the diversity of their methods is potentially valuable. Much clearer links could have been made between setting clear objectives and evaluation criteria at the project design stage. However, people on the operational side do not necessarily see that ‘getting the job done’ may also include planning, monitoring progress and disseminating success. One Workstream uses the Logical Framework Approach (LFA) which is widely used in other HAZ zones for evaluation. The Innovations Projects will all be evaluated according to the LFA. Evaluation of the Innovations Projects will be particularly important to assess the effectiveness of the bottom-up approach to tackling health issues. It may also be possible to compare the usefulness of the LFA with the Performance Management Framework.

8. There is a passion about radical change among the Steering Group members and yet this is not always reflected in regular attendance at meetings. There seems to be a pattern whereby members will attend consistently for a short period of time in order to push through the next new development, but then attendance will drop off, leaving the implementation of the development to a self-selected core working group. This has happened, for example, with the Evaluation Network. Problems of attendance can cause frustration or apparent lack of continuity and seem to impede progress. But perhaps it is one characteristic of the HAZ and other new initiatives, that change agents have involvement in many different projects and don’t have time to commit equally to all of them all the time. Recognition of this characteristic may lead to the development of different methods of participating, or different expectations on participants over a period of time. Other methods of working in partnership may help to facilitate change more effectively, for example, partners sharing an office.
9. Health Action Zones were set up with the intention of changing the way people worked in their existing jobs rather than creating more jobs for middle managers. However, the experience of Wolverhampton has shown that it is not possible, in the short term, to bring in rapid and radical change without creating additional posts to support the day to day management and administration of innovation. Change takes time and involves piloting, evaluating, producing evidence, developing others’ capacity to work differently, influencing attitudes, finding extra funding, disseminating success etc. It is also necessary to provide sufficient resources for tasks related to maintaining and developing the partnership itself: even at the level of time for representation, consultation and dissemination by members; monitoring the health of the partnership (producing reports such as this one); keeping people on board; administrative support, developing databases and so on.

Training and capacity building for public participation and partnership is needed, not only for people at the grassroots but also at the strategic level. There are constant changes and uncertainties in HAZ work and this impacts on staff. Some find it difficult to work in a different, largely unstructured environment. It is therefore necessary to provide support systems and development for HAZ staff. (See Table B).

10. On the other hand, the transitional management and support requirements for innovation could be argued to have created a parallel or virtual organisation with its own bureaucracy - a bureaucracy which is based closely on the traditional ways of operating among public services. The need for strict procedures on performance management, progress reporting and financial accountability is seen as part of this trend. It may be that the HAZ bureaucracy has also stifled certain opportunities for creativity or greater risk-taking, for example with allocating money to community groups or developing new processes for involving people in decision-making. Conversely, Wolverhampton HAZ has worked hard to maintain its original aim of reducing inequality, by rebadging existing projects under new government priority labels; there still seems to be space for local subversion within the central government HAZ initiative.

2. The Partnership Assessment Tool (PAT)