What is partnership working?

A variety of terms have been used to describe collaborative working across organisational boundaries to provide more holistic, more patient-centred services. For example, the terms joined-up working, joint working, cross-cutting working and partnership working appear to be synonymous. Despite a plethora of research into partnership working, defining the concept is difficult. One useful definition describes it as:

Partnership working in theory

The size and scope of partnerships vary, but in its paper on partnership working the Audit Commission (1998) identifies four main models:

1. • separate organisation with its own legal identity

2. • ‘virtual’ organisation, where the partners create separate identities but without legal arrangements in place

3. • co-location of staff from partner organisations with common aims

4. • steering group without dedicated staff resources, whose aim is to deliver coordinated services across organisational boundaries.

The advantages and disadvantages of each model are listed in Table 1.

Table 1 Models of partnership (Audit Commission, 1998)

Level of model	Advantages	Disadvantages
Separate organisation model: longer-term formal partnership, with its own legal identity	Strong identity Greater credibility Achieves more than two or more organisations working separately Dedicated partnership staff Reduced risk of dominance of single partner Legal status clarifies accountability and responsibilities	Legal formalities unsuitable for smaller community organisations not used to working in this way Partners risk becoming detached from original remit, with staff moving away from originally agreed objectives
Virtual organisation model: separate identity without legal status, but with own name, logo and premises. One partner employing and managing staff distinguishes more formal agreements	Distinctive identity without having to address complex legal issues	Responsibility and accountability potentially unclear Risk that partner with employment and management responsibilities dominates partnership
Co-location model: informal arrangements to meet common agenda. Resources (e.g. the use of shared premises) may be pooled but staff resources kept separate	Suited to partnerships where strong separate identities are unnecessary	Working within informal partnership requires trust between partners Risk of confused staff loyalties
Steering group model: the least formal arrangement.	Involves steering group members with authority to ensure that partnership objectives are met by partners’ existing staff. Purpose of partnership is to improve coordination of day-to-day cross-agency service delivery	Unsuitable for long-term partnership objectives or where separate identity is needed by partners to provide motivation to meet aims or establish external credibility

Recent policy context

In the context of NHS reform, the role of the voluntary sector in delivering health and social care services by working in partnership with statutory agencies has been a political priority for over a decade. The Government's commitment to supporting the significant role that the voluntary sector plays in delivering public services is reflected in numerous policy documents published in recent years (Box 1). Following a government consultation exercise, a National Strategic Partnership Forum (NSPF) was set up to review the progress of the Strategic Agreement between the Department of Health, the NHS and the voluntary sector. The aim of the NSPF was to identify good ideas to promote and provide guidance on the development of effective partnership working that overcomes the many barriers to successful partnerships.

Why choose partnership working?

The Audit Commission (1998) identified five main reasons justifying the proposed growth of working in partnership with the voluntary sector:

1. • delivering coordinated services

2. • tackling ‘wicked issues’ (i.e. complex problems, such as community care and health improvement, that cross traditional professional boundaries)

3. • reducing the fragmentation of local service delivery

4. • bidding for new resources

5. • meeting statutory partnership working requirements.

It is widely assumed that partnership working results in more effective provision of services, provides a wider range of services within the community, better meets service user needs and benefits the professionals involved in the partnership. However, there is as yet very little research evidence to support these hypotheses. Here we therefore provide a summary of the reasons given in the literature for mental health services and the voluntary sector to work in partnership, including the potential benefits (Box 2) and negative effects of such a relationship.

Examples of good practice

Despite the numerous barriers to partnership working between statutory mental health services and the voluntary sector, there are many examples of good practice within England (Box 3).

Meeting the diverse needs of mental health service users often requires resources or expertise not readily available within the NHS. The voluntary sector has a crucial role in complementing the skills of the statutory mental health sector by contributing expertise and local knowledge to service provision within mental health, essential features that are valued by service users (Reference Milne, McAnaney and PollingerMilne et al, 2004). The voluntary sector delivers a range of local social care and mental health services to adults with mental health problems. These include specialist counselling services and information about and access to education, welfare benefits, housing, and employment opportunities. It also plays an advocacy and campaigning role in improving mental health services both nationally and within local communities. For example, many early intervention services for young people with first-episode psychosis typically collaborate with voluntary organisations such as Turning Point (Box 3) for substance use support, and with large national organisations such as the Prince's Trust for employment and training support (Reference Lester, Tait and ShahLester et al, 2006).

Recent partnership initiatives between the NHS and the voluntary sector that reflect the national policy direction set out by the Department of Health (2004a) demonstrate the ability of that sector to deliver new service options. For example, Leeds North East NHS Primary Care Trust is working in partnership with a voluntary agency, Community Links (http://www.commlinks.co.uk/view.aspx?id=95), in the provision of early intervention services for young people experiencing a first-episode psychosis. This specialist, community-based team is staffed by multidisciplinary professionals and shares the aims and values of statutory sector services. Furthermore, in the near future, primary care trusts will be expected to fund community development workers to provide services to Black and minority ethnic communities and the voluntary sector has been identified as a potential source from which these workers will be commissioned (Department of Health, 2004b ).

In addition to filling gaps in specialised services, voluntary sector provision can complement mainstream mental health services by providing access to services for hard-to-engage groups and provide meaningful community engagement (Office of the Deputy Prime Minister, 2004). In London, roughly one-third of assertive outreach teams are managed by the voluntary sector (Reference Wright, Burns and JamesWright et al, 2003). For example Impact, a voluntary sector team in west London (Box 3), offers assertive outreach services to people who have a history of non-engagement with statutory mental health services. This includes work with people with severe mental illness who have substance misuse problems, housing problems or are in contact with the criminal justice system. Specialist services such as these may have substantial statutory duties, including care management, care programme approach (CPA) coordination, risk assessment and duties under the Mental Health Act 1983 (Reference Wright, Burns and JamesWright et al, 2003).

Addressing complex social and mental health needs

Individuals with mental health problems and their carers are among the most socially excluded and disadvantaged groups in society, with limited opportunities to engage in their local communities in terms of employment, education, leisure and social activities (Office of the Deputy Prime Minister, 2004). Meeting their needs often requires help in areas beyond healthcare, such as practical and financial aspects of daily life, including housing and benefits advice, and employment support. Addressing these complex social and mental health needs requires responses from multiple agencies (Sainsbury Centre for Mental Health, 2000).

The Social Exclusion Unit has suggested that better use should be made of the expertise within the voluntary sector in tackling the social exclusion experienced by people with mental illness (Office of the Deputy Prime Minister, 2004). Service users can find it difficult to negotiate their way through the sometimes complex bureaucracies and multiple agencies providing mental health and social care. Therefore, well-coordinated services, at the point of contact, are needed to provide seamless pathways into care (Sainsbury Centre for Mental Health, 2000). Furthermore, when people with mental health problems are in crisis, often NHS services are perceived as unattractive because of the statutory powers and legal responsibilities of statutory services. The voluntary sector, operating outside the statutory framework, is recognised for its ability to reach out to hard-to-engage individuals (Sainsbury Centre for Mental Health, 2000). In addition, the perception of the voluntary sector as being more flexible and responsive to local needs emphasises the unique benefits of its delivering services to local communities (Office of the Deputy Prime Minister, 2004).

Voluntary sector organisations, through their community links and knowledge of local community needs, can make significant contributions in helping to shape national and local policy and influence the organisation and development of services at local primary care trust level (Department of Health, 2004a ).

Unique features of the voluntary sector

The characteristics and approach of the voluntary sector make it an ideal partner of mental health services. Its ‘mission-driven’ rather than ‘profit-driven’ nature enables a user-focused approach to meeting service users’ needs, and its inherent flexibility and often innovative outlook contributes to the delivery of services that are responsive to users’ needs. Where service users have lost faith in statutory services, the voluntary sector is often trusted more because of its advocacy role and independence from government control (Reference AldridgeAldridge, 2005). Use of the voluntary sector can also help to address some aspects of the stigma attached to using statutory mental health services. The practical support that the voluntary sector provides in meeting immediate needs helps to build rapport and service credibility, particularly with young people with mental health problems. However, service users and carers can often experience fragmented services, a lack of continuity and conflicting information if local agencies fail to collaborate effectively (Reference Preston, Cheater and BakerPreston et al, 1999).

Effect on service users

Although the NHS Plan (Department of Health, 2000) requires engagement with service users in service planning and delivery, user involvement in ‘mainstream’ mental health services is often tokenistic (Reference Tait and LesterTait & Lester, 2005). In addition to meeting service users’ needs in the provision of responsive services, the services provided by the voluntary sector are often led and managed by service users themselves. The benefits of service user involvement in mental health services are significant (Reference Tait and LesterTait & Lester, 2005):

1. • users are experts about their own illness and need for care

2. • users may have different but equally important perspectives about their illness and care

3. • user involvement may increase the existing limited understanding of mental distress

4. • users are able to develop alternative approaches to mental health and illness

5. • users may find being involved to be therapeutic in itself

6. • user involvement may encourage greater social inclusion.

Delivering service improvements requires statutory health and social care professionals, together with service users, carers and the voluntary sector, to work together in redesigning services, with all parties involved in decision-making processes. Reference AldridgeAldridge (2005) highlights the potential of the voluntary sector in engaging the community through volunteering. The voluntary sector is more likely than the statutory sector to invest in volunteers, provide training and ensure that the community is involved in decisions about public service delivery. Volunteering can also provide valuable opportunities for service users to become involved in the community.

Effect on the statutory sector

In addition to structural barriers to effective partnership working between statutory services and the voluntary sector, there are attitudinal and cultural barriers to be addressed. It is assumed that if partnership working structures and written policies and procedures are in place and agreed between organisations, individuals from the different organisations will automatically work well together (Reference HudsonHudson, 2002). However, evidence suggests that interprofessional conflicts can occur for a number of reasons. For example, a survey study of 244 community mental health team (CMHT) professionals working in east London explored their perception of interprofessional working within their teams (Reference Larkin and CallaghanLarkin & Callaghan, 2005). Most participants believed that they had well-defined roles within their team, but they thought that other professionals within the team did not understand these roles. This is an important issue for multi-agency partnership working because differences in understanding may arise as a result of role ambiguity, leading to a misunderstanding of each other's roles and responsibilities, ways of working and lines of accountability (Reference Larkin and CallaghanLarkin & Callaghan, 2005).

One solution to the problem of unclear roles and responsibilities and lack of knowledge about the services other agencies are able to provide is multi-agency training, which would also help raise awareness of the perspectives of other agencies (Reference Secker and HillSecker & Hill, 2001). Incorporating interprofessional sessions in courses for social workers and nurses, for example, allows students the opportunity to experience the perspective of other professionals (Reference Fowler, Hannigan and NorthwayFowler et al, 2000).

There may be concern that the increased involvement of the voluntary sector in providing public services may lead to statutory services being seen as more expensive, leading to a movement of resources away from NHS provision. The voluntary sector is often wrongly perceived as being staffed by ‘unskilled amateurs’, which may lead to its organisations being viewed as a ‘cheap option’ (Reference BhuttaBhutta, 2005). Responsibility to avoid this lies with the voluntary sector itself, as well as with potential partners within the statutory sector. For example, the voluntary sector is staffed by highly qualified professionals but it needs to demonstrate this. Statutory sector partners need to establish good communication between the sectors to facilitate openness, transparency and greater understanding of the contribution the voluntary sector can make to public service delivery (Reference BhuttaBhutta, 2005).

Effect on the voluntary sector

If the contracts within a partnership arrangement are too rigid the autonomy of the voluntary sector partner could be undermined and any of its services that fall outside the priorities of the statutory service partner may be lost (Reference VallenderVallender, 2006). This creates an interesting tension since one of the reasons for working in partnership is to give groups that fall outside of mainstream service provision access to appropriate care (Audit Commission, 1998).

As already mentioned, the voluntary sector plays a key role in providing care to service users that statutory services find hard to engage (Sainsbury Centre for Mental Health, 2000). It is often trusted by socially excluded service users who view it as independent of government (Reference AldridgeAldridge, 2005). However, there is a risk that the voluntary sector might find it difficult to maintain this independence when working in partnership with the statutory sector (Reference Osborne and MclaughlinOsborne & McLaughlin, 2002). If it changes too rapidly, by taking on a greater public service delivery role, there is a danger that it could become more like a statutory provider, losing its unique identity and benefits (Reference AldridgeAldridge, 2005). Greater involvement by the voluntary sector in the planning stages of the partnership may help to guard against such potential loss of independence (Reference AldridgeAldridge, 2005).

Continuous reorganisation

Continuous organisational change within the NHS, including mental health services, has been identified as a potential threat to partnership working (Reference BanksBanks, 2002). Partnerships, and local network links and partnership relationships, take time to develop, and the organisational change inherent in modernising services presents a challenge to the partnership process. It is difficult to see how effective partnership working between the voluntary sector and statutory mental health services can be expected to occur in a policy area subject to constant change. For example, the major restructuring of the NHS in recent planned reforms (Department of Health, 2005a ) that reduce the number of primary care trusts is likely to affect the potential for effective partnership working with the voluntary sector. Merging primary care trusts into larger organisations could put at risk both the local knowledge of community services built up over time and existing partnership links between the trusts’ commissioning managers and the voluntary sector.

Barriers and strategies to overcome them

As partnership with the voluntary sector has become an important part of the Government's vision of a greater range of agencies delivering public services, particular challenges to successful partnerships need to be recognised. In a literature review we identified several barriers to partnership working between the NHS and the voluntary sector (Box 4).

Setting up policies and procedures

When forming partnerships with voluntary sector organisations it is important to clarify and agree on a range of joint policies and procedures to ensure effective clinical governance. These should include written policies and procedures for the implementation of the CPA.

Most specialist mental health services are provided by the statutory sector, with voluntary sector organisations providing service user and carer support. However, for some services substantial statutory duties, including care management and CPA coordination, are based within the voluntary sector (for example the national organisation Mind and Impact, the assertive outreach team mentioned in Box 3). Several key documents offer guidance on how best to support partnership working between statutory mental health services and the voluntary sector and how to ensure that the needs of service users continue to be met: these include the national mental health policy governing the CPA (Department of Health, 1999a ) and national minimum standards for providers of public and voluntary sector healthcare (Department of Health, 2002) – both currently under review – and the Audit Commission's (2005) advice on improving the governance of partnerships.

Agreement on operational procedures within the partnership is essential to an integrated and seamless service and to comply with the existing and future Department of Health regulatory framework covering a range of providers. Box 5 lists important operational issues that need to be considered.

Confidentiality and information-sharing

Confidentiality and access to patients’ information are potential sources of problems and may hinder greater collaboration between agencies. The dilemma of disseminating information across agencies has been well documented as a barrier to partnership working (Reference Secker and HillSecker & Hill, 2001). Regular discussions and agreements between clients (patients) and professionals involved in cross-agency work about the extent of information that can be shared is both an example of good practice and a possible solution to the challenge of information-sharing (Reference Sharples, Gibson and GalvinSharples et al, 2002).

Where statutory services and voluntary sector organisations are working in partnership all parties must ensure that service users can entrust their personal information to them: it must be kept confidential and used only for the purposes agreed at the outset and explicit consent must be obtained for sharing information for non-healthcare reasons (Royal College of Psychiatrists, 2006a ). All partnership parties are responsible for ensuring that their staff are trained to understand their personal responsibility in complying with the law in relation to the use of personal information. Jointly agreed protocols can be used to ensure that there is appropriate information-sharing between agencies.

Shared and independent domains within partnerships

In developing partnerships with the voluntary sector it is important to reach agreement on the coordination of respective roles and responsibilities of each agency, for example for areas of work where it is appropriate to assume joint responsibility and areas that are the sole responsibility of one partner. Joint assessments by both partners, medication management by a statutory partner, and housing, employment and training as the sole responsibility of the voluntary sector partner are instances of shared and independent domains within partnerships.

Governing partnerships to improve accountability

Community support workers are playing an increasingly important part in the mental health workforce, for example as advocacy workers, floating support workers and ‘support time and recovery workers’ for service users with mental health problems. Many people who fulfil these roles come from the the voluntary sector (Reference Sharples, Gibson and GalvinSharples et al, 2002). The development of these new roles and increasing emphasis on partnership working across the NHS and voluntary agencies present a number of challenges surrounding effective accountability (such as performance management, risk management and disciplinary matters) owing to differing policies and procedures within each sector (Audit Commission, 2005). Insufficient thought given to risk management may expose organisations to legal risk should things go wrong in partnerships, particularly where clarity about indemnity cover and public liability for partner members is absent (Audit Commission, 2005). Careful consideration needs to be given to governance issues such as the accountability and regulatory framework and risk management systems that will best support partnership working. The National Audit Office's (2001) guidance on establishing clear lines of accountability are summarised in Box 6.

New Ways of Working and the role of consultant psychiatrists

The Government's modernisation agenda for the NHS and the New Ways of Working for Psychiatrists initiative (Department of Health, 2005b ) envision fundamental changes in mental health services and a shift in emphasis to partnership working. All NHS staff, including psychiatrists, will be required to work in different ways, acquire new skills and adjust to working with staff from non-NHS sectors. Effective leadership skills, particularly those provided by local ‘champions’, are crucial to the successful development and maintenance of partnerships (Reference Evans and KilloranEvans & Killoran, 2000). Strong leadership is key to successful partnership working, particularly where the partners are not equals.

Consultant psychiatrists can play a crucial role in the establishment of effective partnership working through their strategic and leadership responsibilities, particularly within functional, multidisciplinary teams and CMHTs. Consultants are expected to contribute to service development and are indeed suited to this role through their extensive knowledge of the effective planning of mental health services and their detailed knowledge of local service delivery (Royal College of Psychiatrists, 2006b ).

The confusion surrounding the extent of psychiatrists’ responsibility and accountability for the clinical practice of other professionals (Department of Health, 2005b ) may present a challenge to their involvement in partnership working with voluntary sector organisations. It must be clear where the boundaries of responsibility and accountability lie when care is provided by other agencies. Without such clarification, psychiatrists may find themselves resistant to supervising or collaborating with staff from other agencies. The New Ways of Working programme, involving the Royal College of Psychiatrists, the Department of Health and NHS mental health trusts (e.g. Avon and Wiltshire Mental Health Partnership NHS Trust), recognised the importance of resolving these accountability issues and has provided guidance on redefining and clarifying the roles and responsibilities of consultant psychiatrists working within multidisciplinary mental health teams (Department of Health, 2005b ).

New Ways of Working includes a range of suggestions specifically regarding ways consultant psychiatrists can contribute to the challenges of social inclusion, which includes focusing on ‘social networks, education, employment, volunteering and other forms of community participation’ (Department of Health, 2005b : Appendix 3, p. 104). Changing the day-to-day practice of mental health services is necessary to achieve these objectives and the New Ways of Working guidance (Department of Health, 2005b ) emphasises the central role psychiatrists can play in implementing this change of focus, particularly with the increasing emphasis on the involvement of the voluntary sector in these areas.

There are other ways in which consultant psychiatrists can be involved in the development of partnership working. It has been suggested that involvement in the commissioning of mental health services is an area where there is scope for consultant psychiatrists to influence the allocation of resources (Reference SimpsonSimpson, 2000).

Putting partnership working into practice

Studies evaluating partnership working in the context of mental health are lacking. However, a number of key factors in deciding how to work in partnership have been suggested (Box 7) and should be considered at the outset. In addition, ‘partnership assessment tools’, useful websites and best practice guidance documents for partnership working have been developed that are applicable to a wide range of contexts (e.g. Reference MarkwellMarkwell, 2003, and http://www.ourpartnership.org.uk). These guidelines are now in existence to facilitate partnership working. There remain barriers to partnership working, and identifying and challenging these is necessary if there is to be a useful partnership between the NHS and the voluntary sector.

Declaration of interest

None.

MCQs

1. 1 Partnership working is:

   1. a a new phenomenon

   2. b ineffective and costly

   3. c to the benefit of all multi-agency partners

   4. d where two or more agencies work across organisational boundaries towards some positive end

   5. e likely to increase the fragmentation of local services.

2. 2 Policy context of partnership working:

   1. a primary care trusts have the option to work in partnership with local and community organisations

   2. b ‘the compact’ is an agreement between the NHS and local government

   3. c Government policy indicates that the voluntary sector can offer public services cheaply

   4. d primary care trusts have a statutory duty to involve service users and the public in planning service delivery

   5. e local strategic partnerships are optional.

3. 3 Benefits to partnership working include:

   1. a cheaper running of mental health services if the NHS works with the voluntary sector

   2. b the voluntary sector's ability to access hard-to-reach groups that sometimes fall out of reach of statutory mental health services

   3. c staff from different organisations easily work together if organisational structures are in place for partnership working

   4. d the endless amounts of funding available to the voluntary sector

   5. e the opportunity for statutory mental health services to show the voluntary sector how to be more professional.

4. 4 Barriers to partnership working include:

   1. a the absence of government policy encouraging partnership working

   2. b the fact that the voluntary sector offers nothing different from statutory mental health services, so partnership is not necessary

   3. c the inability of NHS services to work in partnership with voluntary sector organisations

   4. d the inability of the voluntary sector to work with the NHS as the two organisations are too different

   5. e the sometimes tokenistic nature of statutory services’ involvement of the voluntary sector.

5. 5 Good practice in partnership working includes:

   1. a joint training, as it offers staff the opportunity to view the perspectives of different organisations

   2. b separate bases for teams

   3. c organisations working towards separate goals

   4. d one contact point at each organisation

   5. e short-term contracts.

MCQ answers

1		2		3		4		5
a	F	a	F	a	F	a	F	a	T
b	F	b	F	b	T	b	F	b	F
c	F	c	F	c	F	c	F	c	F
d	T	d	T	d	F	d	F	d	F
e	F	e	F	e	F	e	T	e	F