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Explicating the role of partnerships inchanging the health and well-being of localcommunities in urban regeneration areas:

A Case Study Approach

an evaluation of the Warnwarth Conceptual Framework for Partnership Evaluation

URBANregenerationm a k i n g a d i f f e r e n c e

Volume 3: 2009 Editors: Karen Holland, Tony Warne & Michelle Howarth: Salford Centre for Nursing, Midwifery and Collaborative

Research University of Salford

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Urban Regeneration: Making a Difference

Contents

The project context

Chapter 1: Partnership Working in Health and Wellbeing Regeneration

Initiatives - An evaluation of the framework: Michelle Howarth,

Tony Warne & Karen Holland

Chapter 2: Case study 1: Explicating the role of partnerships in Northumberland

FISHNETS: Glenda Cook, Pam Dawson & Denise Elliott

Chapter 3: Case study 2: Urban Regeneration: Making a Difference? A Case study of a

New Deal Partnership in action: Terry Allen & Melissa Owens

Chapter 4: Case study 3: Explicating the role of partnerships in changing the health and

well-being of local communities - A New East Manchester Case

Study: Ryan Woolrych & Judith Sixsmith

Chapter 5: Case study 4: Swimming in Both Waters: A Case Study of the Manchester

Learning Disability Partnership: Garry Diack & Eileen Fairhurst

Chapter 6: Case study 5: Partnership Working in Therapeutic Services:

Claire Hulme & Paula Ormandy

Summary: Key factors to ensure successful partnerships: Karen Holland

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Copyright ©The Chapters in this report are the property of the authors and their respective organisationsand should not be reproduced without their authorisation

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The Project Context

Introduction

This is one of threeoutputs from a project: Explicatingthe role of partnerships in changingthe health and well-being of localcommunities, one of a number ofprojects in a larger Higher EducationFunding Council StrategicDevelopment Fund project (HEFCE)entitled: Urban Regeneration: Makinga Difference. This was a collaborativeventure between ManchesterMetropolitan University, NorthumbriaUniversity, University of Salford andUniversity of Central Lancashire.Bradford University was an affiliatedpartner.

Health and Well-Being Theme

The North of England has some ofthe worst health profiles in the UK,with startling inequalities in thehealth experience of differentpopulation groups as defined bygeographical and social group.Relative proportions of deaths fromcancer, heart disease and stroke inparticular, have been rising in recentyears. Rates of long-standing physicaland mental health are also highcompared with other parts of thecountry. The North of England has some ofthe worst health profiles in the UK,with startling inequalities in thehealth experience of differentpopulation groups as defined bygeographical and social group.Relative proportions of deaths fromcancer, heart disease and stroke inparticular, have been rising in recentyears. Rates of long-standing physicaland mental health are also highcompared with other parts of thecountry.

These patterns are manifestations ofthe degree of well-being in thecommunity, which is affected by awide range of factors, includinghousing, poverty, transport,employment etc, covering the wholespectrum of regeneration issues.Availability for work is a naturalconsequence of health and well-being, with some parts of the Northhaving amongst the highest figures ofworklessness in the UK.

Whilst the public sector is themainstream provider of support,through the National Health Serviceand local authorities, the non-statutory sector plays a vitalcomplementary role and is critical tosustaining the welfare of some of themost vulnerable communities andsections of the population. Thisincludes charities and not-for-profitorganisations such as housingassociations. It is a diverse andfragmented sector with an ability tobe highly responsive to new ideas.

Effective cross-sector working isfundamental to the challenge ofmeeting the needs of vulnerablepopulations and working towards theinclusion of marginalised groups.Universities have a key role to play inthis process, yet this form ofknowledge transfer is only in itsinfancy, with huge potential fordevelopment.

The NHS and local authorities areheavily dependent on the highereducation sector as a source ofprofessionally qualified people and asa resource for further professionaldevelopment and research andevaluation. This is complemented bypractical, action-research in a numberof HEIs, which is focused on theneeds of communities of practice.

The Health theme identified 4important areas which link health toregeneration:

• Health, employment and well-being, including the social andeconomic dimensions ofregeneration;

• Ageing and disability, including thehealth and social care dimensions ofregeneration;

• Enabling environments, includingthe physical and cultural dimensionsof regeneration;

• Public health and primary care,including health inequalities.

In addition, a core focus across all ofthe projects will be on increasing theskill and knowledge level of thoseworking in health and well-beingregeneration. (From(http://regennorth.co.uk)

The Project: Explicating therole of partnerships inchanging the health andwell-being of localcommunities

It is clear that concepts of partnershipand collaboration underpin thesuccessful implementation of urbanregeneration initiatives. What is lessclear is how partnership workingimpacts upon the health and well-being aspects of urbanregeneration. Evaluations ofoutcomes are limited, and littlecomprehensive information isavailable as to the extent of any suchactivities across the North West andNorth East regions. This projectsought to examine the issues inrelation to these and to develop aframework for supporting the analysisof effective partnership working.

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Key aims of the project

There were four main aims of theproject:

1. A scoping and mapping exercise todevelop a profile of communityhealth and well-being needs andassociated neighbourhood renewalactivity in Salford and thenorthwest, and in Newcastle andthe northeast

2. A review of the literature anddevelopment of a conceptualframework for partnershipevaluation

3. Evaluation of the framework inaction through a series of casestudies of partnership working indesignated urban regenerationareas

4. Determine the key factors ineffective partnership working

Conclusion

The project was in itself a recognitionof the need for partnership workingbetween Universities in order tomaximise the value of sharedknowledge and experience inaddressing a common aim. It was alsoan opportunity to engage with localcommunities in urban regenerationareas to identify their needs andexperiences in relation to their healthand well-being and also determine away in which effective partnershipworking could be assured.

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Chapter 1: Partnership Working in Healthand Wellbeing Regeneration Initiatives - An evaluation of the framework


Authors: Michelle Howarth, Tony Warne & Karen Holland, University of Salford

Summary

Partnership working in urbanregeneration heath and wellbeingcontexts have been inadequatelyevaluated as a consequence of poorlyarticulated conceptualisations ofpartnership working. The Warnwarthconceptual framework was developedto address this evaluative weakness.The framework is predicated on thenotion, of the ‘good enough’partnership. This chapter examinesthe Warnwarth framework withinilluminative evaluations of urbanregeneration health and wellbeingpartnerships.

In a form of bricolage, a series ofinterrelated case studies explored theeight key aspects of the ‘goodenough’ partnership that make upthe Warnwarth framework. The casestudies focused on partnerships thatare concerned with promoting healthand wellbeing within communities.Data were drawn from a range ofparticipants within the case studies,including managers, service users,educationalists and practitioners. Thefindings showed that the WarnwarthFramework could be applied across awide range of organisationalcontexts. It helped facilitateexploration of partnership workingwithin health and wellbeingregeneration initiatives.

1. Partnership Working inHealth and WellbeingRegeneration Initiatives.

Introduction

Innovative methods of raising publichealth awareness have been at theforefront of UK health and socialcare. Recent policy guidance (DH1999; 2000a; 2000b; 2002; 2004;2006) signalled the UK governments’vision for healthier communities. As aresult, the focus of public healthmoved toward a community ‘handson’ approach predicated onpartnership working between theNHS, local authorities andindependent agencies, with particularinvestment being made for theregeneration of urban communities.Currently, local regeneration initiativesconcerning health and wellbeing havebeen at the vanguard of communityand public health development.Essential to the success of suchinitiatives is achieving effectivepartnership working .This chapterfocuses on the development of aframework used to evaluate the roleof partnership working in health andwellbeing initiatives in urbanregeneration areas.

The Relationship betweenRegeneration and Wellbeing

In their report, ‘Action forSustainability’, the North WestDevelopment Agency (NWDA 2000)set a series of long term strategicgoals for the North West Region. Thisincluded the need to develop safe,and healthy communities in a regionwhich uses resources wisely and thatwhich attracts high employment withan appropriate infrastructure. Theoperational challenge faced by the

NWDA (2000) was to ensure thatpartnership working was effectiveand sustainable for the North Westregion to develop. They assert that:

“Mainstreaming sustainabledevelopment principles at policy andstrategy level, together with robustapplication of these principles atprogramme and project delivery levelare vital to the sustainability of theNorth West. Policy-makers andpractitioners must continue to worktogether to push the boundaries ofunderstanding to ensure that therelevance of sustainability to allNorth West activity is clearlyidentified and progressed” (NWDA2000 pg 9)

The state of public health in theNorth West of the UK has witnessedincreasingly negative public healthstatistics. For example, those living inthe North West have a greater chanceof developing Coronary Heart Disease(CHD), Cancers, and have some ofthe worst mental health problems inEngland. Despite a recent decrease inthe number of deaths from coronaryheart disease in the North West,current statistics indicate that 220 per100,000 people in the North Westdies from CHD (British HeartFoundation 2006). Cancer incidencein the North West is also amongst thehighest in England. (Shack et al,2007). In relation to mental health,the North West has the largestnumber of people misusing drugs andthe biggest number of people withsevere and enduring mental healthissues.

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Public Health and Communitiesunder Strain

An increased older population adds tothese worrying public health statistics.The result is often local communitiesexperience considerable socio-economic and public health strain.This is manifest through the numbersof carers needed, home supportservices and the economic andemployment stability of thecommunity. Such health and socialinequalities need to be addressed toreduce the incidence of cancers,mental health and CHD in the regionand facilitate a prosperous regionwithin which communities can expectto live a healthier, safer life. Since themid 1990s, a number of urbanregeneration initiatives have beenundertaken, with a focus on healthand wellbeing. The partnershipsinvolved however, were multi-agencyand often complex. Many of theoutcomes of these partnershipapproaches have not been examined.There was an evaluative need toexplore the extent of partnershipworking within health and wellbeingregeneration initiatives, and whateach partnership had been able toachieve.

2. The Project: UrbanRegeneration: Making aDifference

Tackling this problem the HigherEducation Funding Council in Englandfunded five Higher EducationInstitutions’ under the umbrella titleof ‘Urban Regeneration: Making aDifference’. This initiative had two keyaims based on the inter-disciplinarycollaboration and the development oflong term strategic alliances betweencore Universities through knowledgetransfer to meet the needs ofbusiness and the community.

The contextual focus was on urbanregeneration. Prosecuting the wideraims involved a number of smallersub-projects around four key areas ofactivity: community cohesion,enterprise, crime and health andwellbeing.

One of the sub-projects: ‘explicatingthe role of partnerships in changingthe health and wellbeing ofcommunities in urban regenerationareas’ aimed to evaluate partnershipworking through a number ofdifferent case studies in urbanregeneration areas .To undertake thiswork however required an initialanalysis of the key literature todevelop a conceptual framework withwhich the case studies could beanalysed and subsequently inform thewider project outcomes. This Chapterwill discuss the development andearly application of the WarnwarthFramework which was designed toexplicate the role of health andwellbeing partnerships in the urbanregeneration case sites.

3. ConceptualisingRegeneration withinHealth and WellbeingPartnerships.

Nationally, the health and social careagencies and Primary Care Trusts(PCT’s) faced a number of publichealth concerns. Addressing thisproblem required collaborationbetween many agencies, partnersacross health, social care, housing,built environment, local authoritiesand the voluntary sector. As a result,local NHS Trusts have adapted policiesto help secure and grow sustainablecommunities that are healthier andsafer. A range of partnerships hasdeveloped over time, each withvarying agendas, priorities andpartners.

Booth (2005) argues that urbanregeneration has generally beendescribed as being 'market-led' andthat this characterisation’ fails toembrace the complexities reflected inthe development of urbanregeneration over the past 25 years.Although there is a wealth ofevidence about partnership workingand sustainability (Glasby 2006), mostof these partnerships have beenmeasured by their successful ability tofoster joint ventures which embracean array of complex attributes, whichmay also fuel further ambiguity aboutthe partnership construct and itsgoals.

Our review explored the extent of thispartnership working for health andwellbeing within urban regenerationdevelopments. A structured searchstrategy was developed to captureprevious studies on the extent ofpartnership working in urbanregeneration areas.

Partnership working has been definedin numerous ways which provided agood starting point from which toview the evidence base. This plethoraof definitions however, was notwithout its complications. To developa framework that truly assessedpartnership working meant that theconcepts needed to be grounded inoperational practices helping in orderto validate the framework withinfamiliar constructs and discourses.

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Additionally, as the crux of the reviewwas to locate evidence aboutpartnership working for health andwellbeing in urban regeneration, theconcept of health and wellbeing wasalso explored. However, locating aconsensus on the definition of healthand wellbeing proved difficult due tothe many abstract conceptualisationsavailable. The World HealthOrganisations (WHO 1998) definitionsuggested that health and wellbeingis:

“A state of complete physical, mentaland social wellbeing and not merelythe absence of disease or infirmity"…“So health and wellbeing areoften used synonymously. Healthand wellbeing can be described interms of function (physical, mentaland social) and feeling (physical,mental and social). When there is animpairment of function (which mayor may not be related to active on-going disease), this can betermed disability”.

However, this definition has longbeen viewed as being contentious.Indeed, several critics (Saracci 1997,MacDonald 2005) have refused tosubscribe to the WHO’s definitionarguing that “it incorporates totalwellbeing under the concept ofhealth”, and that “the definition isnot a relational claim between thevarious parameters of total wellbeingand a more limited range ofcomponents identified as health.Rather, it is an identity claim such thatan individual is not truly healthyunless they have complete wellbeing.In this instance, the idealizedcondition of complete wellbeing andthe concept of health aresynonymous” (MacDonald 2005). Assuch, many question the relationshipbetween health and wellbeing anexample being that a person could bechronically ill yet spiritually happy:

“health and happiness distinctexperiences and their relationship isneither fixed nor constant” (Saraicci1997 p1409).

The concept of urban regenerationexacerbates this conceptualswampland by calling on the dualnotions of ‘health’ and ‘wellbeing’almost interchangeably. In the contextof urban regeneration, health isusually linked to the social andcommunity outcomes. Sampson(2003 p53) asserted that:

“Health-related problems are stronglyassociated with the socialcharacteristics of communities andneighbourhoods. We need to treatcommunity contexts as importantunits of analysis in their own right,which in turn calls for newmeasurement strategies as well astheoretical frameworks that do notsimply treat the neighbourhood as a"trait" of the individual”.

It appears that this remains acontentious issue as it is still assumeda strong relationship between healththe community and wellbeing. Giventhe problems operationalising thedefinition, it is not surprising that‘context’ is importantly seen as theinfluencing common denominator inattempts to define urbanregeneration. Within this study,Robert and Sykes (2000) definition ofurban regeneration was used inbecause it embraces the complexitiesinvolved by asserting that it is:

“a comprehensive and integratedvision and action which leads to theresolution of (urban) problems andwhich seeks to bring out a lastingimprovement in the economic,physical, social and environmentalcondition of an area that has beensubject to change” (Roberts & Sykes2000, p17).

Based on the limited contemporaryevaluations and the copious (andoften somewhat spurious) evidenceso far, defining the key elements ofpartnership working within healthand wellbeing proved to beproblematic. With no clearoperational definitions, it becameevident to the team that anypartnership evaluation tool wouldneed to embrace and harness suchcomplexities so as to provide enoughflexibility in use so as to facilitate a‘representative’ account ofpartnership working.

4. The Warnwarth Framework

Atkinson (1999) asserts that there isno fixed descriptor or definition ofpartnership working. The complexitiesinvolved render any attempt atdefinition as futile. However, for thepurpose of our review, we used theterm ‘partnership’ to encompass alltypes and levels of collaboration. Indoing so, we took the opportunity toadopt a more pragmatic approachwhich allows the term partnership toembrace a range of attributes andconstructs. Partnerships thereforereflected a broad range of jointventures and activities. Whilst therange of activities within partnershipsis recognised as diverse, attempts toundertake too much at any giventime can be deleterious for thepartnership (Long & Arnold 1995,Atkinson 1999, Powell & Darling2006). As such, the team needed tobe mindful of the pre-requisitenotions attributed to successfulpartnership working and develop aframework which both fitted anacceptable definition and alsoembraced diversity. Partnerships needto reflect changing contexts and roles(Warne & Howarth 2009).

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In our review therefore, we drew onthe previous work of Warne (1999)and Macaulay (1963) to conceptualisepartnerships as being:

“A relationship that exists on acontinuum characterised bypermanence and transition(Macaulay 1963 pg 27) where at anyone time, the location andeffectiveness if the partnership islikely to be dependent upon anumber of dependent, independentand interdependent factors (Warne1999).

The ‘Good Enough’ Partnership

In the context of our review we wereinterested in understanding howpartnerships facilitate health andwellbeing within and acrosscommunities. Moreover, we wereacutely aware of the inherenttensions within partnerships and theinfluence this has on the process andoutcomes. These tensions areinterlinked and often reflect thepartnership ‘synergy’. For example,we found that ‘leadership’,‘administration’, ‘non-financialresources’ coupled with ‘partnerinvolvement challenges’ and the‘community relation challenges’ arejust some aspects that influencepartnership working. In addition otherprominent elements include thevision, commitment, financialresources and shared history.Combined with wider factors such asthe prevailing culture, politics andpower relationship, there is aconvincing argument that all theseelements subjectively ‘feed’ apartnership. These often difficult tomeasure subjective factors add to thecomplexity.

We argue that these complexreciprocal processes within thecontext of partnership working couldbest be described as being situatedwithin a ‘good enough’ relationship.Taken together, the steps towards agood enough partnership have beenbased on Winnicotts (1965)psychoanalytic idea of the ‘goodenough mother’ and viewed this inthe ordinary colloquial way of ‘is itgood enough to do the job?’ Toanswer this, eight key characteristicsof the ‘good enough partnership’need to be considered. These are theright reasons, high stakes, rightpeople, right leadership, strongbalanced relationships, trust andrespect, good communication andformalisation.

In determining the right reasons for apartnership, a shared vision, a strongdesire to work in a partnershipcoupled with and easily understoodand agreed life span and goals mightindicate the rationale for thepartnership. High stakes suggests thatthere are usually compelling reasonsfor undertaking a partnership, inwhich there is a visible contributionaround finance and resources and anagreed partnership outcome. Rightpeople, are those who have the mostappropriate skills and attributes andare able to empower others andagree to equal representativness. Theright leadership consists of manytraits and descriptors are notexhaustive. What is evident is theneed for strong clear lines ofaccountability and leadership whichfosters openness and respect withother partner members. Akin to theneed for strong leadership is thenotion that relationships play a pivotalrole in determining how partnershipsdevelop. Although thought to bechallenging and time consuming,there is a need to ensure thatrelationships reflect reciprocalarrangements which endorse a wellmanaged, and organisationallysupported approach to partnership

working. An authentic ‘values inaction’ approach is essential tocement a trusting and respectfulrelationship. All partner membersneed to feel valued and respected atall levels within the organisation.However, without goodcommunication to support andbolster a partnership, efforts todevelop any sustainable relationshipsmay be limited from the outset.Effective communication processesare arguably one of the mostimportant elements of successfulpartnership working. Without thispartnerships will struggle to sustaindevelopmental momentum. Finally,the way in which partnerships areformalised suggests that even in theembryonic stages of development,partners need to consider governancesystems which may support thedecision making processes. Due tothe fluid nature of many partnerships,it is essential that these arrangementsbe monitored and adapted on aregular basis. Good formalisationprocesses provide managerial leverageto support longevity and sustainabilityof the partnership. Given the contextof urban regeneration in heath andwellbeing – this sustainability is ofincreased importance.

The Warnwarth framework embracedthe complexities of the good enoughpartnership working alongside theconcept of urban regeneration andhealth and wellbeing. The Warnwarthconceptual framework provided apartnership evaluation approachwhich was used to undertake casestudy evaluations of a range ofdifferent current health and wellbeingregeneration projects. It provided “aframework upon which theories andissues that develop around and fromthe case studies could eventually beintegrated into an analyticallycoherent whole” (Warne & Howarth2009 pg 50). (See Figure 1: TheWarnwarth Conceptual Framework)


Methodology

To identify whether the WarnwarthFramework helped determine the‘good enough’ partnership, anilluminative evaluation approach wasundertaken. Illuminative evaluation isnot a discreet methodologicalpackage but a general researchstrategy (Parlett and Hamilton 1976).This approach lends itself to a rangeof methods that may be used in astudy which should follow from thedecisions in each case as to the mostappropriate techniques. This meansthat the problem being investigateddictate the method. This triangulationof methods ensures that a rich sourceof data is tapped thus providing amore complete picture of the

partnership. In this way, researchersengaged in evaluating the variouspartnerships were encouraged to actas bricoleurs, whereby, they becomeadapt at using a range of methods tosupport their enquiry and thus ensurethat the methods follow the problem.Put simply, bricoleurs have beendescribed as being:

“Jack of all trades or a kind of do ityourself person who deployswhatever strategies, methods, orempirical materials are at hand……if new tools or techniques have tobe invented or pieced together, thenthe researcher will do this” (Denzinand Lincoln 2000p4)

Originally the case site researcherswere encouraged to act as bricoleur’swhen developing their local approachto case study evaluations. A groupdiscussion held after the case siteshad been evaluated using theWarnwarth framework explored theextent to which the case siteevaluators applied the ‘good enough’concepts and how far they adoptedthe position of bricoleur.Understanding this provided a uniqueinsight into the utility of theWarnwarth framework in determiningthe extent of partnership working ineach of the case sites. Data relatingto its usefulness can help ensure avalidated framework capable of beingtransferred to other contexts.

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Figure 1: The Warnwarth Conceptual Framework.

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In total, five case sites (see Chapters 2 - 6) applied the framework togauge the partnership working. Eachsite was ideally placed within anurban regeneration area and hadfocussed on different population andcommunity needs. These included anolder people partnership, a New Dealpartnership and a regeneration‘wellbeing’ community projectpartnership. All five sites wereencouraged to use the frameworkand report on its applicability andusefulness. In addition, the flexibilityof the framework can be readilyadapted to any partnership contextbecause it lends itself to a range ofdata collection methods. In this way,the researchers acted as bricoleurs inthe way they used the frameworkand adapted it to their ownpartnership contexts. A discussiongroup was held with the case studysites where they were asked tooutline how they used the Warnwarthframework and their perceptionsabout its utility.

The Messiness of Real WorldPartnerships in Regeneration.

The group discussions facilitated frankexchanges about the frameworkbased on their experiences. The casestudy researchers indicated that theWarnwarth framework had helpedthem to unpick the many elements ofpartnership working. The frameworkhad been used to support thedevelopment of an interview schedulein one site. In this example, theresearch team used the key elementsof the ‘good enough’ partnership toguide their interview and probe therespondents for in-depth details.Membership, roles, communicationand involvement in the partnershipwere explored and whist there are nodata yet available to discern the levelof partnership working in this case,the way in which the framework wasused to explicate this knowledge is

heartening and suggests an elementof success. In particular theresearchers remarked on theframework’s flexibility andapplicability to the context andsuggested that the tool was helpful indisclosing the key elements ofpartnership working in the case site.

One case site suggested that theWarnwarth framework acknowledgesthe messiness of real worldpartnership working and as suchhelped the researchers capture thecomplexities and interrelatedness ofpartnership working. This particularcase used the 8 elements of the‘good enough’ partnership to frametheir analysis and in doing so, arguedthat this contextualised the process,but neglected the outcomes. Theyused the ‘good enough’ concept as aspring board from which they wereable to discern whether the‘partnership had been good enoughto do the job and achieve its aim’.The team looked beyond what hadbeen developed and explored howthe services had developed throughpartnership working. Using Dowlinget al (2004) as a starting point, thiscase team examined the outcomesthat were achieved as a consequenceof the partnership. This resonateswith the partnership synergydescribed in the Warnwarthframework. The outcomes describedby the team and how these wereachieved appear to relate to thesubjective phenomena of apartnership which are often hard tocapture. This included, for example,the ‘drama triangle’, which embracesmany of the subjective elements ofpartnership working:

“The scripts for these dramas arisefrom how individuals, groups andorganisations add or respond to theturbulence of ‘everyday’organisational life. These dramas arecharacterised by relationships that useand misuse of power, whether this beeconomic, gender, psychological,

relationships where trust, positional,personal rationale is present orabsent, and which are culturallydefined by resistance to oracquiescence of the prevailing local,national, organisational andprofessional norms. Partnershipworking therefore, can beexperienced as a messy reality despitethe often authoritative rhetoric andguidance that is readily available andused in policy documents” (Warne &Howarth 2009,pg 43).

So in this example, whilst theWarnwarth framework didn’texplicitly relate to outcomes per se, itdid incite this response andsubsequent exploration of outcomes.

Fitting the Mould.

A strength of the Warnwarthframework is its ability to be relevantacross a wide variety of contexts. Thiswas highlighted by the case siteexamples through which theWarnwarth framework was readilyapplied to a range of settings.Arguably this was also due to theresearchers acting as bricoleurs whomby adopting this approach were ableto use a more flexible approach. It isalso acknowledged that there is anumber of existing partnershipevaluation tools that have originatedfrom business and health whichfurther support the needs for aflexible approach. Indeed, our originalworking concepts outlined apartnership as a continuumcharacterised by permanence andtransition. This suggests that the lackof consensus about the definition ofpartnership has ironically provided aplatform for developing a flexibleevaluation tool.

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Sketching out the determinants of aflexible partnership is not new. Manyhave distinguished the importance offlexibility in an effective partnership.A case in point is Druce & Harmer(2004) whose exploration of the keyelements of effective partnershipshighlighted the need for flexibilityadvising that this could improve andhelp build ownership. In addition, thefluidity of the partnership – whilstpromoting a flexible and realisticapproach to successful working mayalso deter some; causing ambiguityabout the nature and goals of thepartnership. For example, Reich(2000) asserts that:

“the rules of the game’ forpublic−private partnerships are fluidand ambiguous, and constructing aneffective partnership requiressubstantial effort and risk, as nosingle formula exists” (Reich 2000p618).

This would suggest therefore aparadox when determining a ‘flexible’or fluid approach to partnershipworking. From the beginning, manywould suggest that process andoutcome need to be considered andthat in doing so, the partnership maythen be better able to survive againstthe influx of unpredictability.

5. A Paradigm Shift fromProcess to Outcome?

In his paper exploring collaborativecontext and policy, Bob Hudson(2007) suggests that there is a movetowards a more performancemanaged arrangements based on thenotion of outcomes. Concerns aboutwhether process or outcome shouldbe measured within a partnership areresonant in the literature. Atkinsonand Maxwell (2007) describe multi-agency outcomes-based performancemeasurement model used inChildren's Services Planning tomonitor agreed outcomes.

This method aligns itself withperformance management and theauthors argued that this allowed forthe identification of new measurableindicators that could be used toassess needs. In particular, they assertthat this involved a:

“paradigm shift from collectingactivity data on an organization byorganization basis to managinginformation on a multi-agency basisusing indicators based on outcomesas part of an integrated performancemeasurement system” (Atkinson &Maxwell 2007 p 15).

In our study, the use of outcomemeasures as a method of evaluatingthe partnership was drawn on by twoof the case sites. They remarked onhow the Warnwarth framework hadhelped evaluate the partnershipprocess, but cautioned that there wasalso a perceived gap in relation to theoutcome of the partnership.Originally, the review team consideredprocess ‘versus’ outcome as a keyelement of partnership working. Thisled us to question what partnershipworking does and/or provides and itwas through this process that wenoted a difference between‘provision’ and ‘doing’. In our originaldiscussion we agreed that the term‘do’ denotes partnership internalfunction as opposed to externaloutputs and that ‘provision’ suggestssome form of output. So, in relationto ‘output’ we questioned how wewould ascertain that the act ofpartnership working was solelyresponsible for any outcome. Forexample, what outcome would haveoccurred if partnership workingwasn’t evident? We also questionedwhat the partnership ‘does’. Forexample, function, doing andoutcomes have a commondenominator. Enabling services to joina partnership could be seen as afunction, process or outcome and thedifference between the two remains

ambiguous. As such, we believed thatprocess and outcome wereintertwined, inseparable andentangling. This symbiotic relationshipis not explicit in the Warnwarthframework, although when used theframework has prompted theexploration of the importance of‘what and whose outcome’ might beacross different constituencies. Inhealth and wellbeing partnerships,there are some obvious opportunitiesfor high levels of congruence withoutcomes. Individual health andwellbeing clearly feeds into andimpact upon the health andwellbeing of a family, and community.Other examples of such congruencemight be found in the overallpartnership achieving local andnational service standard targets anda objectives.

6. Implications for PublicSector Management.

There have been significantdevelopments in Urban Regenerationdesigned to support health andwellbeing in local communities.Successful partnerships that embracethe diversity of such activity areessential for communities to flourish.The processes involved in thesepartnerships have rarely beenexplored due to the plethora ofpartnership definitions and the fluidityof Regeneration work. This chapterprovides a framework which may beused to unpick the nuances ofcommunity participation andcohesions within partnerships withparticular attention on the health andwellbeing elements of communitydevelopment.

The common issues that face publicsector managers when determiningregeneration partnerships have thepotential to incite problems in theembryonic stages of partnershipworking. Using the Warnwarth

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Framework can support managers todevelop partnerships which may thenbe later evaluated against the samecriteria by considering the dynamicsof engagement involved at intra, interand extra-interpersonal levels. (Holland, Warne & Howarth 2008)

Conclusion:

As a team, we identified evidencewhich illustrated complexities inherentin developing a conceptualpartnership framework. The term‘framework’ denotes some form ofstructure or construction –paradoxically, such rigidity had thepotential to deter its utility –particularly in relation to partnership‘synergy’. We therefore adopted analternative stance, and designed apartnership conceptual frameworkable to embrace to the need forchange within any givenenvironment. Based on the case siteevaluations, we argue that theflexibility resulting from theWarnwarth framework application inpartnership evaluations enablesaspects of partnership working to berevealed, acknowledged andresponded to in a way previouslydifficult to achieve.

Practical Implications

The Warnwarth framework provides aconceptual anchor for those involvedin undertaking evaluations involvingvarious forms of partnershipsworking. Used in the context ofhealth and social care partnerships,the usefulness of the framework canbe transposed to other settingsinvolving multi-stakeholdercollaborative working.

Originality and Value

Increasingly, the health and wellbeingof a community is being recognisedas a key concern for regenerationactivity. This framework can supportfuture partnership developmentswithin this context.

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Powell, M. Dowling, B. (2006) NewLabours partnerships: Comparingconceptual models with existingforms. Social Policy & Society. 5: 2,305 – 314.

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References

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Chapter 2: Explicating the role of partnerships in Northumberland FISHNETS

Acknowledgements

Undertaking this project would not have been possible without the support and participation of many people. Wewould like to express our thanks to the Older People Partnership Board members, service providers associated withNorthumberland FISHNETS and service users who informed our understanding of the FISHNETS partnership that wasthe subject of investigation in this case study. Without their willingness to participate in discussions about partnershipworking this project would not have been possible. We would also acknowledge the support of the Department ofHealth POPPs programme that funded the development of Northumberland FISHNETS and the HEFCE UrbanRegeneration initiative that funded the case study investigation.

Authors

Glenda Cook, Pam Dawson & Denise Elliott

University of Northumbria at Newcastle

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ContentsSummary

Introduction

Northumberland County

The older population and service provision

Northumberland FISHNETS

FISHNETS task groups

Community involvement

Education and accreditation

Home environment

Physical activity and lifestyle

Intermediate care

Communication and events

Is FISHNETS the good enough partnership?

Good reasons for the partnership

High stakes

Right people

Right leadership

Strong balanced relationships

Trust and respect

Good communication

Formalisation

The difference the Northumberland FISHNETS partnership has

made to Northumberland community

Working in partnership with older people

Transformation of the service culture from treatment to prevention

A whole system response to prevention

Key messages

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Summary

Northumberland FISHNETS is apartnership that was developed inresponse to a government initiativeknown as Partnerships for OlderPeople (POPPs). Within the POPPsprogramme a total of 29 localauthorities, their health and thirdsector partners (voluntary and privatesector organisations) were funded toset up innovative pilot projects thataimed to develop preventativestrategies for older people withinlocalities.

Northumberland FISHNETS aims tokeep older people FIT, INVOLVED,SAFE and HEALTHY, throughinvestment in sustainable communityNETWORKS. The services that havebeen developed under the auspices ofFISHNETS address health, social andenvironmental factors to supportolder people to their maintainindependence and enhance theirquality of life. A key objective of thisinitiative is the promotion of wellbeing through the reduction of fallsand related injury in the olderpopulation. Falls have significantconsequences for older people none-the-less being serious injury, fracture,loss of confidence to participate inusual social activities and loss ofindependence. By reducing falls,serious injury requiring hospitaltreatment and emergency hospitaladmission can be avoided.

A comprehensive falls preventionprogramme is now available acrossNorthumberland County includinguniversal primary prevention andtargeted interventions for those mostat risk of falls. A unique feature ofthese services is the high level ofcollaboration between older peopleand providers in statutory, for-profitand not-for-profit organisations. Thishas resulted in wide ranging provisionincluding campaigns to raise publicawareness of the benefits of exercise

and falls prevention, communityrehabilitation team intervention, fallsprevention exercise programmes inleisure centres, community basedexercise and interest programmes,and home improvement throughhandyman and telecare services. Thegeneral perception of theseinterventions arising throughinterviews with service users is thatthey promote physical well-being,improve social inclusion, make homessafer and foster independence in laterlife.

Northumberland FISHNETS hasachieved success in achieving its aims,which would not have been possiblewithout the commitment andcollaboration of partnershipmembers. There is general agreementacross service commissioners, serviceproviders and older people that theywish to see it continue and expandinto the future. However, issues aboutmedium and long term funding adduncertainty to the future. Whateverthe future, Northumberland FISHNETShas created a legacy of partnershipworking between older people andservice providers, and the knowledgethat preventative approaches to theparticular circumstances of old andadvanced old age have the potentialto improve quality of life.

Introduction

This Chapter focuses on describingthe Northumberland FISHNETSpartnership and articulating theexperience of service planning andchange that has resulted frompartnership working. This is based ondiscussions with partners and adocumentary analysis of minutes,project reports, service agreementsbetween partners and relevant policyand practice literature.

The partnership delivers a countywidepreventative programme, in a localitythat is rich in its diversity. There arelarge areas of rural countryside withsmall villages/hamlets, sea-side townsand semi-urban districts in the SouthEast where more than half of theCounty’s population live. Within theselocalities affluent communitiescontrast with those that fall withinthe 10% most disadvantaged inEngland, as identified through theindex of Multiple Deprivation. Inresponse to the issues which arise inthe deprived areas physical, social andeconomic regeneration programmeshave been developed to revitalisecommunities and meet need.

Diversity is also reflected in healthindices which are marked by contrastacross the County and are indicativeof post-industrial deprivation, ruralisolation and poverty. Added to thisrich tapestry of diversity is health andsocial care service provision whichvaries across the County, with manypeople in rural areas living longdistances from the towns wherebuilding-based services are located.

It is this countywide diversity thatpresented challenges to the successof the FISHNETS partnership toachieve its aims to provide equitableand accessible services across theCounty as well as services that arerelevant to local communities. Thereport therefore commences with adiscussion of Northumberland Countyand its older population, the users ofFISHNETS services, as a back drop tothe main discussion of the FISHNETSpartnership. The report concludeswith an analysis of what theFISHNETS partnership brought to theCounty in its mission, at district level,to take forward holistic area basedregeneration plans to transform thelife experience of all living withinNorthumberland communities.

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Northumberland County

Northumberland is a large ruralcounty in North East England, whichcontains areas of outstanding naturalbeauty, and extensive areas ofcoastline and forest, with the majorityof the population living in urbansettlements. These settlements arediverse and have developed differentroles. There are 12 main towns whichprovide a range of shopping,community and employment facilities.These towns are Alnwick, Amble,Ashington, Bedlington, Berwick uponTweed, Blyth, Cramlington,Haltwhistle, Hexham, Morpeth,Ponteland and Prudhoe. There are11 smaller centres within thecatchments of these larger townswhich have developed as local servicecentres - Allendale, Belford,Bellingham, Hadston, Haydon Bridge,Rothbury, Seahouses, WiddringtonStation, Wooler, Corbridge andSeaton Delaval. Beyond these aremore than 200 villages with fewerthan 500 residents, containing limitedlocal facilities.

More than half of the population ofapproximately 311,300 residents(Nomis Official Market Statistics,2005) live in the urban South East, anarea that covers less than 5% of theCounty’s total land area. Most ofNorthumberland’s large towns arelocated in this area.

Whilst there are some wealthycommunities living in high qualityenvironments in the County, there arealso significant areas of deprivationwhere educational attainment is poorand unemployment is over twice thenational average. Limited jobopportunities, low expectations, poorhousing and health, high levels ofcrime, drug abuse and an invasiveculture of dependency compound thecycle of disadvantage.

These factors contribute toNorthumberland’s populationexperiencing considerably worsehealth than the England and Walesaverage.

National statistics indicate that 14Northumberland wards are in the10% of the most disadvantaged inEngland. Of these, 12 are located inthe South East of the county wherethe worst deprivation, however it ismeasured, occurs.

Councils in the South East areaddressing deprivation issues throughco-ordinated strategic and holisticneighbourhood renewal andcommunity planning. Initiatives suchas Wansbeck LIFE focus on area basedhousing-led regeneration as a leadthat also provide enterprise and workopportunities to local communities(see Appendix 1 for further details ofkey strategy documents).

This approach to regeneration is inkeeping with ‘Better Health, FairerHealth’, the new strategy for 21stcentury health and well being inNorth East England which hasrecently been launched (see Appendix2) to address these issues ofdeprivation and inequality. It sets outa 25 year vision for the North East tohave the best and fairest health andwell-being, and to be recognised forits outstanding and sustainablequality of life. One theme of theStrategy is later life, which the olderpeople of Northumberlandcontributed to through consultationas the Strategy was developed.

The older population and serviceprovision

Forty per cent of the population ofNorthumberland are over the age of50 and this is rapidly changing. It ispredicted that 48.4% of the County’spopulation will be over the age of 50by 2021 (ONS, 2004). Over the sameperiod there will be a sharp increasein the proportion of people aged 85and over, which is expected toincrease from 7,000 to 11,000. Whilstthese demographic changes reflectnational and internationaldemographic trends that are largelydue to an increase in life expectancy,migration to and from the County isalso having a significant effect on thebalance within Northumberland’spopulation. Many young peoplechoose to move away whereas theCounty is a favoured destination forcommuters and for older people whochoose to relocate there as they reachor approach retirement.

Population ageing is unequallydistributed across the County. Insome localities the pace of ageing isadvancing faster than others. It ispredicted that by 2009 Berwick-upon-Tweed and in 2016 Alnwick districtwill have more than 50% of thepopulation aged over 50. Regardlessof the variation witnessed within theCounty other projections indicate thatpopulation ageing across the Countyexceeds that of the English average.Hence, the implications of a changingpopulation will encountered earlier inNorthumberland than in other partsof the country.

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In recognition of this populationchange Northumberland StrategicPartnership (NSP) state that “Publicbodies, community organisations andprivate bodies offering goods andservices used by older people will allneed to adjust to these changes.”(NSP, 2007, p.4). All servicesanticipate that the projecteddemographic changes bring with itchanging expectations of later lifeand advanced old age, and will leadto substantial increases in the numberof older people in need of care.

Expectations of old age change acrossthe life span and this isacknowledged in national policy (seeAppendix 3) and locally by NSP. In theNSP strategy for the older populationdistinction is made between threegroups of older people/phases of laterlife and the public service goals foreach group/phase:

• older workers – people over 50who work or are seeking work. Theprimary goal for this group ofpeople is to ensure that they areable to stay in work for as long asthey wish and if they lose their jobsfor whatever reason they haveopportunities to return toemployment.

• third agers – people who haveretired from work and canreorganise their lives around leisure,family responsibilities, non-vocational education and voluntarywork. The key goals for this groupare to ensure that educational andleisure opportunities exist and thatservices support people to maintaintheir health and fitness to remain inthis phase of later life for as long aspossible.

• older people in need of care –people whose lives are substantiallyaffected by long-term illness ordisability. The key goals for thisgroup are to support people toremain independent and able toparticipate in community life.

These groups are qualitativelydifferent; the differences reflectingthe experience of the individual, nottheir chronological age. Drawing thisdistinction within older population isimportant because it opens up newpossibilities for services to bestructured in such a way that theyenable older people to continue foras long as possible in the first twophases, older workers and third agers,thereby reducing the time that olderpeople live in the final phase, in needof care. This is not suggesting thatproblems associated with ageing,including mobility problems andincreasing dependence for the routinetasks of living in the community, willnot exist, they will, and will continueto do so.

This strategy seeks to delay the finalphase and minimise the time that anindividual lives in that phase. This mayalso delay the time before serviceswitness the predicted significantincrease in older people requiringlong term care.

Fulfilling the public service goalsdescribed above will requireconsiderable change in the way thatservices are configured and deliveredacross the County. Historically,services have focused on treatmentand provision of care. With theagenda detailed by the NSP there willbe an emphasis on preventative andrehabilitative approaches to the needsand problems of old age.

This will require the development ofnew services that foster engagementwith health, fitness and socialinclusion related activities. Thesechanges will need to take account oflocal conditions – in the South andSouth East of the County a significantproportion of older people live on lowfixed incomes and experience all ofthe detrimental effects of financialdeprivation.

Whereas, in rural areas the declining,ageing agricultural workforceexperience all the consequences ofisolation and erosion of rural servicesand amenities such as schools, shops,public houses, banks, post offices.

Historically services have been largelycentralised within urbanconurbations. Rural dwellers in westand northern localities can live longdistances from towns and this canenhance the difficulties that theyexperience in accessing building-based services.

This discussion provides a broadoverview of the challenges of movingto a preventative and rehabilitativeagenda within Northumberland. It iswithin this policy and service planningframework that FISHNETS hasemerged. The complexities that areintegral to such whole systemchange, which is at the heart of thevision that was borne with FISHNETS,is consistent with the strategicdirection of NSP. It is within thiscontext that FISHNETS brings a focusto the issues and concerns of olderpeople living in Northumberland.

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Northumberland FISHNETS

Northumberland FISHNETS wasdeveloped by a partnership that wasled by Northumberland Care Trustwhich comprised of organisationswithin the public, not-for-profit andfor-profit sectors. The key driver thatdrew the partners together was todevelop a proposal for an old agepreventative programme inNorthumberland to respond to theopportunity for funding from agovernment initiative, thePartnerships for Older PeopleProgramme (POPPs). Key partnersincluded District and County Councils,Northumberland Age Concern,RoSPA, Council for Voluntary Services,Independent Sector Providers,Supporting People, HomeImprovement Agency, NorthumbriaUniversity and Newcastle University.

When the bid was successful thepartnership was reorganised toenable the structural arrangementswithin FISHNETS to achieve a balancebetween ongoing development of theFISHNETS vision for NorthumberlandCounty and implementation of theagreed plan of work. Effectively thisresulted in the formation of aPartnership Board (OPPB) thatprovides strategic direction andgovernance for FISHNETS andoperational task groups that developand manage the FISHNETSprogramme of work (see figure 1 onthe next page).

The partners that are represented onOPPB include Northumberland CareTrust (this initially included Director ofSocial Care and County WideServices, Head of Provider services –Older People Services), FISHNETSproject manager and older peoplewho brought with them theexperience of living later life inNorthumberland and a wealth ofskills derived from occupational andvoluntary work throughout their life.

OPPB convenes monthly, providing aforum for Board members to maintainregular communication with eachother, ongoing scrutiny of servicedelivery and decision-making toensure that decision are timely tomeet the ambitious targets that werepredetermined in the FISHNETSproposal to the Department ofHealth.

Operationally, FISHNETS is deliveredthrough six linked task groups. Eachtask group is comprised of partnerorganisations that are committed toachievement of the particular goals ofthat group. For example, the homeimprovement task group includesrepresentatives from Blyth Valley Care(handyperson and telecare serviceproviders), Northumberland Stars(handyperson provider), HomeImprovement Agency, District Councilmembers, Supporting Peoplemanagers and members of OPPB witha particular interest in thedevelopment of home improvementservices.

The wide ranging partnerships thatexist within FISHNETS is representedin figure 1. By structuringpartnerships around operationalimperatives individual task groupmembers are mutuallyinterdependent, working incollaboration to meet service targets.By working together to achieve ashared vision for the older populationby focusing on task group outcomesunifies and commits members to thepartnership. This is particularlyimportant because task groupmembership does change to reflectthe nature of the programme of workthat has to be achieved.


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Figure 1: Partnership arrangements within Northumberland FISHNETS


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The FISHNETS task groups are:

Community involvement

Focus of the task group activities: inaddition to older people membershipof OPPB, community developmentwork focuses on engaging olderpeople in FISHNETS programmes.There is a particular emphasis on‘hard to reach groups’ to reducesocial exclusion and enhanceawareness of and access to the rangeof preventative services across health,social care and housing agencies. Akey strand of this programme ofactivities is the implementation of the‘Community Chest’ which is a fundfor the establishment of communityactivities that promote and enhanceinclusion of the older population insocial and community activities.

Selective outcomes achieved byDecember 2007: Approaching£70,000 has been allocated from theCommunity Chest fund supportinglocal groups such as church hallscommittees and friendship clubs toprovide physical activities and socialengagement programmes.

Education and accreditation

Focus of the task group activities: thisgroup focuses on raising levels ofknowledge of fitness, involvement,safety and health and access tonetworks of support and information,whilst also raising awareness of falls,fractures and osteoporosis throughtargeted training. Different aspects ofthe programme are geared tomeeting the varying requirements ofolder people, their carers and thosewho support or work with them. Akey objective is training older peopleto undertake peer support andmentoring roles within physicalactivities and lifestyle programmes.

Accreditation schemes establish goodpractice across the whole system ofcommunity health services, caremanagement and communitymatrons, housing and supportproviders, care homes, home care andday care and local community groupsin regular contact with older people.

Selective outcomes achieved byDecember 2007: Home care, daycentre, sheltered housing, care homestaff, handyman and rehabilitationofficers across statutory, voluntary,for-profit and not-for-profitorganizations (n = 1,935) haveparticipated in the following trainingprogrammes:

• Falls Prevention

• Low Vision

• Introduction to Dementia

• Dementia Person Centred Care

• Podiatry

• Train the TrainerSeated ArmchairTraining

• NVQ Level 2 in Exercise & Fitness

• Nutrition and Assessment in OlderPeople

• Medication in Older People

• BTEC Level 2 in Dementia

469 older people have completedtraining programmes including FallsPrevention (n = 254) and Low VisionTraining (n = 135).

Currently the numbers of serviceshaving completed or in the process ofaccreditation are as follows:

Care homes with respite 86

Sheltered Housing 76

Home Care organisations 16

Day Centres 42

Total services completing accreditation 220

Home Environment

Focus of the task group activities: theHome Improvement Agencycoordinates a comprehensive homeenvironment assessment service toassess risks, with advice andinterventions linked to fire prevention,crime prevention, fuel economy,heating and insulation, aids andminor work. The existinghandyperson scheme has beenexpanded county wide, and tailoredpackages of equipment and assistivetechnology has been made availableto augment care.

Selective outcomes achieved byDecember 2007: Pre- Fishnets only 3district council areas, Blyth Valley,Berwick and Wansbeck had Handyperson schemes in place. In year 1 ofthe project a contract was awarded,through a limited tendering process,to Northumberland Stars to provideservices in the Alnwick area and itwas also agreed that FISHNETS wouldtake over funding responsibility forthe Berwick contract. In year 2 similarcontracts were awarded to provideStars services in Tynedale and CastleMorpeth. These services have provedextremely popular with the olderpeople of Northumberland andstatistics gathered through therecently developed benchmarking toolindicate an ‘excellent’ satisfactionrating with the services whichalongside the completion of 1484Home safety checks give someindication of the benefit of theseinitiatives.

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Physical activity and lifestyle

Focus of the task group activities:exercise and lifestyle initiatives havebeen implemented to provide a rangeof programmes to enable and sustainpersonally relevant exercise includingTai Chi. Resources are mobilized toassist the most at risk groups of olderpeople to participate in physicalactivity.

Selective outcomes achieved byDecember 2007: Through theinjection of funding from theFISHNETS project the opportunitiesfor older people to access activitieshas increased significantly at all levelsof ability. It is estimated thatapproaching 3000 older people areaccessing activities, ranging fromgentle seated exercise and Tai Chi toline dancing and kick boxing.Although the emphasis has beenplaced on physical activity these newgroups are also benefiting frominformation sharing anddemonstrations of healthimprovement initiatives includinghealthy eating. This substantialincrease in provision has beenfacilitated by the training of 32 newExtend exercise leaders, alongside thesourcing and coordination ofequipment and instructors forvarious other sessions such as kickboxing, salsa dancing and new agekurling.

Intermediate care

Focus of the task group activities:development of integrated casemanagement systems, based on theUnique Care Model has been used toproactively seek out and refer thoseat most risk. CommunityRehabilitation Teams have beenenhanced and expanded to addressthe rehabilitative aspects ofprevention.

Selective outcomes achieved byDecember 2007: The intermediatecare element of this projectconcentrated mainly on thedevelopment of an enhanced andcohesive falls pathway. Prior to theFISHNETS project there had beensegmented and inequitable provisionacross the county, with the ruralnorth and west being disadvantaged.FISHNETS funding has increased thestaffing levels in these 2 areasallowing the development ofspecialist falls services.

The introduction of the 5 questionCryer assessment tool has opened upthe referral system to a wideraudience including ambulance crewsand self referrers.

A new level of intervention has alsobeen introduced into the fallspathway delivering 12 weekprogrammes of specialist fallsprevention classes provided throughappropriately trained leisure centrestaff, which lengthens the time periodfor support available to fallers from10 to 22 weeks, thereby increasingtheir potential to achieve optimumrehabilitation.

Service data indicates that over 1000older people have gone through theFalls Pathway to date with localevaluation data yielding evidence ofimproved functional ability andincrease Falls Efficacy levels.

Communication and events

Focus of the task group activities:communication and events has beenadopted to ensure the projects wholesystem impact and to facilitateawareness of and access toprogrammes across communities. Thishas been achieved through acommunications strategy that involvesuse of multi-media resources, olderpeople’s networks, andintergenerational activities.

Selective outcomes achieved byDecember 2007: To date 11 Young atHeart and 8 Falls Fairs have takenplace with almost 1600 older peopleattending and receiving informationon subjects as diverse as oral hygieneand cavity wall insulation. The FISHNETS website,www.northumberlandfishnets.org hasalso been developed.

Is Northumberland FISHNETS theGood enough partnership?

In the UK, policy rhetoric andguidance has been predicated onconcepts of multi-professionalworking, collaborative, and multi-agency approaches to serviceprovision, greater consumerinvolvement, and in the context ofhealth and social care, statutoryresponsibilities to work in partnership(National Audit Office, 2001; Dowlinget al, 2004; DoH 1997; 1998; 2000a;2000b; 2005; 2006). In line with thisNorthumberland FISHNETS wasdeveloped as a multiagency, multisector, multidisciplinary partnershipthat focused on the core objective ofreducing serious injury in the olderpopulation through prevention offalls. Unlike many other partnershipsin the field of health that fail tocomplete their aims and do notsurvive the first year (Lasker et al,2001), the FISHNETS partnership hascontinued to develop and has metthe majority of the targets that wereestablished in the POPPs proposal.

Though there are many ways ofevaluating the processes thatcontributed to the functioning ofFISHNETS, the Warnwarth partnershipconceptual model (Warne andHowarth, 2009) has been adopted asan analytic framework, as itacknowledges the complexity,interrelatedness and messiness ofpartnership working. All of which arecharacteristic features of the messyreality of the FISHNETS partnership

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that was driven by top-downDepartment of Health policy andguidance, and a local impetus toacquire new funding to supportexisting services and develop newones.

In the Warnwarth framework thenotion of the ‘good enoughpartnership’ sits at the core of theconceptual model; that is ‘isa‘partnership good enough to do thejob and achieve its aim(s)’. In thismodel a partnership is conceived ofas being influenced by eightinterrelated dimensions which are –good reasons for the partnership,high stakes, right people, rightleadership, strong balancedrelationships, trust and respect, goodcommunication and formalisation.Each of these dimensions were usedto interrogate different aspects of theFISHNETS partnership with partners,service providers and service users inorder to shed light on the factors thatled to FISHNETS developing in theway that it has done. The followingdiscussion does not intend toexamine the underpinningassumptions inherent in this model,rather the model is accepted as agiven. The discussion does present asynergy of the discussions about eachof the dimensions of the GoodEnough Partnership.

a. Good reasons for thepartnership

When the Department of Health,Partnerships for Older People (POPPs)programme was announced, thisprovided the impetus for olderpeople, agencies and organisationsacross statutory, voluntary andindependent sectors inNorthumberland to develop apartnership This was a uniqueopportunity for older people,managers and service staff to work ina collaborative partnership to realize a

shared vision of service provision forthe older population ofNorthumberland. This includeddelivering services that all of thestakeholders considered older peopleneeded across all of the County, incontrast to the inequality of serviceprovision that had existed inNorthumberland, and getting theresources and services to older peopleto enhance their quality of life in later life.

Whilst the reason that the partnershipdeveloped was driven by the externalcondition of entering into competitivebidding for new revenue for serviceprovision, this was underpinned bypositive reasons for the partnership,namely, a shared vision, agenda andobjectives. When the partnership wassuccessful in securing funding for theproject, the external drivers that hadestablished the impetus for thepartnership were replaced by aninternal imperative to workcollaboratively to meet therequirements and the conditions ofthe grant.

b. High stakes

The stakes are high within theFishnets partnership in varyingcontexts.

For the Care Trust and Local Authoritysuccess in achieving the aims andobjectives of this project have hadlocal and national implications. Thereputation of these organisations withkey government departments andinspection bodies could have beennegatively affected by failure toachieve service targets or perceivedlack of commitment to a new anddeveloping policy agenda.

Indeed, a case was made in thebidding process for POPPs funding tosupport the development of acountywide falls pathway, which hadthe potential to draw attention toNorthumberland’s health and socialorganisations failure to meet NationalService Framework targets. Therecould have been far rangingramifications of the decision to ‘gopublic’ with this information for thestatutory organisations involved withFISHNETS. There were also potentiallydamaging consequences for thosewith managerial responsibilities forthe relevant adult services. Some keyplayers put their professionalreputations and future prospects onthe line, by championing this projectwithin their own organisation. In onecase, for example, FISHNETS wasviewed as a distraction from corebusiness, and the individual had towork hard to justify the time andresources that were devoted toFISHNETS.

During the operationalisation periodthe financial arrangements of thePOPPs programme involved financialrisks for all partners and requireddiscussions about how the sharing ofthese risks could be managed withinthe larger partnership arrangementfor the Care Trust, under which theNHS organisation was responsible forlarge sums of Council funding, usingSection 31 of the Health Act, 1999.

There were also potentially importantpositive outcomes for health andsocial care organisations that wereinvolved with FISHNETS, none-the-lessbeing the project providing a vehiclefor the delivery of unachievedmilestones and targets in importantolder people’s policy areas includingThe National Service Framework forOlder People ( DoH 2001). As theproject has developed theseorganisations have been able to pointto FISHNETS as an exemplar ofinnovative service development in the

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Comprehensive PerformanceAssessment (CPA). The outcomebeing that FISHNETS has beeninstrumental in supporting theorganisations star ratings.

For voluntary organisations andindependent service providersinvolvement in FISHNETS carried risksof a different kind. Future contractsand work awarded by commissioningarms of the statutory partners mayhave been influenced by theirperformance in this high profileproject. Equally becoming a FISHNETSpartner had the potential to createnew, unplanned opportunities tofurther their work with the growingolder population in Northumberland.

What was unanticipated at the outsetof Northumberland FISHNETS was theextent of the profile of theoverarching POPPs programme at thehighest level of government. Thisrealisation in turn has raised whatwere initially viewed as high stakesacross the whole of the FISHNETSpartnership. The ongoing reporting tothe national project and evaluationteam highlights all areas of activityand this was not initially recognisedbut has through time become moreapparent.

c. Right people

The FISHNETS vision was generatedby individuals who came together asa group in their commitment todeveloping innovative, high qualitypreventative services for older people.These individuals were sufficientlyempowered to make decisions onbehalf of the organisation and theolder Northumberland Countypopulation that they representedwithin the FISHNETS partnership. Thisculminated in a successful bid forDepartment of Health funding. Theirsuccess could be attributed to thediverse perspectives, experience andknowledge of the needs of the older

population that they brought to thepartnership, and their ability to maketimely decisions within this context.

During the initial development ofFISHNETS organisational structureswere developed to facilitate thetranslation of the FISHNETS strategyinto operational processes anddeliverable services. The individualswho had been instrumental indeveloping FISHNETS maintained theircommitment to the project andagreed to take on new roles andresponsibilities within this structure.For example, older people communityrepresentatives became members ofthe Older People’s Partnership Boardwho worked in collaboration withservice partners to undertakegovernance and financialaccountability for the project.Organisational representatives alsoagreed to undertake new roles as taskgroup leads or task group membersto make operational decisions andoversee the day-to-dayimplementation of the project. Thiswas a complex undertaking in asituation where services were beingdelivered across service and sectorboundaries and by staff who did nothave a history of working together.There was a great need for staffdevelopment to enhance theircapacity to fulfil new responsibilities.For example, older people boardmembers completed ‘Stronger Voice’.training to develop skills andknowledge for their expanding rolewithin FISHNETS.

Implementation of the project alsorequired the recruitment of staff tonew posts within the project. Thiswas somewhat problematic in aclimate where there was a freeze onnew appointments within the hostorganisation. At times this led toslippage in meeting predeterminedtargets and frustration within existingstaffing as individuals struggled tomeet the demands of ever increasing

workloads. The implementation ofthe project also highlighted thelimited commitment of somestakeholders, namely GP’s across theCounty, which had the potential tolimit the impact of the project.

Significant changes have occurredthroughout the FISHNETS experiencewith regard to the people involvedwith this initiative. Toward thebeginning of the second year of theproject the host organisation,Northumberland Care Trust and keyexternal partner organisations such asNorthumberland County council,went through a process of structuralreorganisation. These reorganisationsresulted in changes to the peoplewithin the partnership, when keyindividuals were made redundant orrealigned in their organisations withnew responsibilities. This had aconsiderable influence on theleadership and management withinFISHNETS. Whilst this was a time ofconsiderable uncertainty for thosewho remained and worked tomaintain the service and make shortand long term decisions, thesechanges also created the opportunityfor new people to join thepartnership. It is only now that newrelationships are being developedwithin the FISHNETS partnership andit is becoming clear who are the rightpeople with a reasonable degree ofautonomy within the neworganisational structures who shouldbe integrated with FISHNETS tooptimise partnership effectiveness.

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d. Right leadership

Leadership operates at severaldifferent levels within FISHNETS. Atthe National level, the project is oneof 19 first wave pilots in theDepartment of Health POPPsprogramme. It was clear from theinitial prospectus inviting applicationsthat the DoH was looking for localinnovation which it could supportrather than intending to lead theprocess itself. As the projects gotunderway there was increasedperformance management from thecentre with a particular emphasis oneconomic parameters of servicedevelopment. This has sometimesbeen at odds with the localphilosophies of partnership and olderpeople centred care, where quality oflife and service development are keypriorities.

At the local level, strong leadershiphas been apparent in the FISHNETSpartnership. OPPB has a high profileand strong decision making power.Information is fed up to the Boardand decisions are cascaded back tothe task groups through the projectmanager, who is held in high regardand her commitment is referred to ina very positive light. Effectivestrategies, such as devolved taskgroup decision making haveempowered individuals to take thingsforward. People involved in FISHNETShave a high degree of ownership ofthe project and tend to share itsaspirations. Effective communicationchannels have been used to ‘join up’the thinking across and between taskgroups and the strong role andpresence of OPPB has co-ordinatedactivities and provided a point ofreference for all task group activity.

As in any leadership position, thepersonal qualities of the individualleader are pivotal. The projectmanager’s personal strengths andeffective communication skills,therefore, have been crucial informing effective relationships,trouble shooting across the projecttask groups and generally facilitatingthe process of making things happen.FISHNETS has clear aspirations andthe shared vision evident in theinitiative could not have beenachieved without the ‘rightleadership’. As the FISHNETS projectfunding now comes to an end, thecontinuation of effective leadership ismore important than ever to securethe sustainability of the partnershipsand the service developments thathave been achieved.

e. Strong balanced relationships

The partnership was forged in acollective effort that was focused onsecuring the funding for the project.Everyone worked to this commonobjective with less attention beingdevoted to ‘getting to know eachother.’ A consequence of this was thedevelopment of linkages betweenagencies and organisations thatenabled commitment to the FISHNETSvision. These linkages did not alwaystranslate into interdependentoperational processes when theproject moved into theimplementation phases. In somesections of the project, such asdevelopment of handyperson servicesacross the County, independentworking practices within the homeimprovement task group facilitatedservice development and meetingservice targets in a timely manner. Inother sections of the projectorganisational cultures that existedprior to the partnershipovershadowed relationships duringthe initial developments. This resulted

in suspicion between partnersconcerning organisational agendas,and misunderstandings of theimperatives underpinning theFISHNETS project. Working withintask groups enabled the project teamto nurture their relationships andduring the first year ofimplementation differences inorganisational culture and decisionmaking processes were identified andworked through, resulting in avaluing of the different contributionsthat partners brought to the projectand the development of new ways ofworking.

From the commencement of theproject, attention was given toreducing the power differentialbetween the older people boardmembers and professionals. Boardmembers, for example, received anhonorarium for their commitment tothe management and governance ofFISHNETS. Whilst the payment was anattempt to introduce equality into therelationship, in no way did itrepresent the many hours of workthat board members devoted to theproject. An effort to establish equalityin this relationship was also evident inthe way that Board members wereable to influence decisions aboutappointment of the project team andin service planning.

With the reorganisation of the CareTrust came changes in relationshipsbetween the partners. For example,older people members of thePartnership Board had been central todecisions about staff appointmentsand they had considerable autonomyin decisions about the FISHNETSbudget. The reorganisation, whichcoincided with acute pressures on theCare Trust’s budget, resulted in somekey decisions about staffing andresources being taken by servicemanagers as part of the wideragendas and this left the Board

feeling marginalised. Reflection onthis situation stimulated the Board todevelop strategies to forge newrelationships with the external hostorganisation, the Care Trust, to movethe project into a new operationalcontext where Local Area Agreementsand Local Delivery Plans weresignificant to its future. Therelationship changes that have takenplace with the FISHNETS initiativehighlight the temporal nature ofpartnership interactions and the needto continually reflect on and managerelationships that are critical to theeffective working of the partnership.

f. Trust and respect

People with diverse backgrounds havebeen brought together in FISHNETSand professionals from health, socialcare and the third sector have cometogether in a partnership with olderpeople and service users. Trust andrespect has been evident from theearly bid development meetingsthrough to the operation of OPPB.

Respect for each other’s points ofview has been crucial to the successof the visioning of FISHNETS servicedevelopments and the Board does notshy away from the ‘big issues’. Strongvalues are evident in action aschallenges are encountered and dealtwith. Opinions are openly exchangedand, even where compromise isrequired, there is a transparentprocess leading up to final decisionmaking. Most players behave withintegrity, have faith in consensusdecision making and trust eachother’s judgements and we haveobserved and participated in a culturewhere mutual respect is apparent.Learning and development are highpriorities and people are movingforward together in a collaborativemanner. The respect, trust andconfidence between stakeholders has

been a project success but will betested in the outgoing phase ofFISHNETS where sustainability willdepend on maintaining a sharedvision for the future. WhateverFISHNETS becomes beyond theproject funding, the core values andbeliefs that it has fostered will becritical to future success.

g. Good communication

The organisational structure withinFISHNETS provides formal linksbetween older people, servicemanagers and service personnel;partner agencies and organisations;and the commissioner and provider ofservices. This structure provides thefoundation for communicationprocesses that enable the partners toopenly share information that isrequired to make the relationshipwork, including their objectives andgoals, knowledge of statutory andnon-statutory services for olderpeople in Northumberland County,service data, potential areas ofconflicts and changing situations.

Individual members of the partnershipexchange their ideas andcommunicate their concerns withother members through formalstructures (OPPB, task groupmeetings, and supervision sessions)and informal conversations. Face-to-face informal conversations areparticularly valued by members as away of sharing ideas and developingcreative ways to ‘think outside thebox’ in order to move the FISHNETSagenda forward.

Developing open and effectivecommunication structures andprocesses has not always beenstraightforward. For example, somepartners rely heavily on e-mailcommunication as a quick andaccurate method of communication,whereas other partners do not have

access to or do not regularly use e-mail. Hence, methods ofcommunication that were acceptableto everyone in the partnership had tobe developed. Though this challengedthe partnership, the development of aculture where partners felt genuinelysafe and confident to express theirideas and concerns has been moredifficult to sustain. A change in themembership of the partnershipdisrupted relationships, toward thefinal phase of the project, and hashad an impact on communicationflow.

h. Formalisation

From the inception of the FISHNETSproposal OPPB provided a strategicstructure for organisationrepresentatives to maintain regularcommunication with each other andit provided a vehicle for decisionmaking during the implementationphase of the project. Importantly theorganisational representation on theBoard (e.g. Director of Social Careand County Wide Services, Head ofProvider services – Older PeopleServices) ensured that decisionmaking processes could result intimely and effective decisions toenable the project team to meet thedemanding service deliverable targetsthat were predetermined in theFISHNETS project proposal that wascontracted by the Department ofHealth.

From the commencement of theimplementation phase of the projectOPPB linked with middle andoperational managers through 6FISHNETS task groups. In the mainthe leaders of these task groups heldkey roles within their respectiveorganisations; therefore they wereable to translate the FISHNETSstrategy into operational processesand deliverable services.

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This provided a structure for strongvertical linkages within the FISHNETSorganisation and between thepartnership organisations.

With the reorganisation of theNorthumberland Care Trust, duringthe second year of implementation,came a new structure in the FISHNETShost organisation. This resulted in thedevelopment of new posts and newpeople fulfilling the posts. This had amajor impact on FISHNETS becausesome of the individuals who hadchampioned the development andimplementation of FISHNETS withinthe Care trust, including the Directorof Social Care and the Head of OlderPeople’s Services were no longer withthe organisation. There were alsochanges in the staffing of FISHNETS(e.g. the project lead was appointedto a senior manager position in theCare Trust), which resulted in theneed to appoint new staff to theproject.

The combined effect of these changeshas been partners working inrelationships that fall somewherealong a continuum that ischaracterized by ‘permanence’ and‘transition’. At its best periods of‘permanence’ in relationships in thepartnership has facilitated shareddecision making that recognised theauthority, accountability andresponsibilities of individual partnermembers. Whereas phases of‘transition’ disrupted decision makingprocesses and made it harder tosustain mutual understanding thatwas so important to partnershiparrangements. In recognition of thepotential detrimental impact of‘transition’ phases, the FISHNETSproject team sought ways tocontinuously review relationships anddecision making processes, andactively worked to graspopportunities (e.g. new people, newideas, new possibilities for funding)

that arise during periods to change torealise the FISHNETS vision for theCounty.The difference theNorthumberland FISHNETSpartnership has made toNorthumberland community

Partnership working was not anoption for Northumberland FISHNETS,it was an eligibility requirement in theapplication process for POPPsfunding. The successful applicationfor project funding provided a banneraround which all the FISHNETSpartners were able to rally and wasundoubtedly a catalyst in developingthe partnership that now exists. Thepreceding discussion has explored theprocesses and the complexities thathave been inherent in establishingand sustaining the partnership. Thishas not been without its challenges inthe wake of the restructuring ofpartner organisations. Yet thepartnership has been sustained withplans for mainstreaming elements ofFISHNETS to continue to develop thevision for preventative old ageservices beyond the completion of thepilot service in Northumberland.

The discussion now moves ontoexploring whether the ‘partnershiphas been good enough to do the joband achieve its aim’. In its mostsimplistic form the outcomes of theFISHNETS project could be measuredin terms of performance targets.These were explicit from the outset ofthe project and have been regularlymonitored by the national projectteam. Service statistics indicate thatthe FISHNETS partnership has met themajority of the targets and milestonesthat were established in the POPPsproposal (see page 11 - 14 for furtherdetails of service outcomes). On thebasis of this it could be concludedthat FISHNETS has been successful indelivering service outcomes and insome aspects of the project servicedeliverables have exceeded

expectation. Such monitoring isconsistent with the lead given by theNational Audit Office (2001) for themonitoring of performance targets toassess whether partnership initiativeshave achieved their intended benefit.However, this evidence does notencompass all aspects of what theFISHNETS partnership has achieved.There is little doubt that many, if notall of the services developed underthe auspices of FISHNETS would havedeveloped to some degree withoutthe partnership. Service planning wasgrounded in the knowledge ofevidence and best practice for fallsprevention therefore separate serviceswould have individually moved in thedirection that has been achievedunder the auspices of FISHNETS.What this does not capture is the waythat the partnership influenced notnecessarily what was developed buthow the services were developed andtheir outcomes.

Permanent Secretary Sir RichardMottram stated that the ultimate testto be applied with particular rigour, iswhat works: ‘Those keen like me forpartnership working of various kindsand for more freedom of manoeuvrefor those on the ground must showthat it delivers more than thealternative’ (Newman, 2001. p.11).This reflects the emphasis in publicpolicy on outcomes and importantlypoints to the importance ofunderstanding how context andmechanisms interact to produceoutcomes (Dowling et al, 2004). Thefollowing discussion addresses thispoint by examining the outcomesthat were achieved as a consequenceof the partnership and not merelythose that could have been achievedby the various partners workingalone.

The difference theNorthumberland FISHNETSpartnership has made toNorthumberland community

Working in partnership witholder people

Through the FISHNETS partnershipolder people have been brought tothe heart of old age preventativeservice planning and decision makingin Northumberland. Such involvementhas been encouraged in the UK bythe government through recent policydevelopments (for example, DoH1989, 1997, 1998, 1998b, 2000,2001b, 2003 2004, 2006, Blair, 1996;Audit Commission, 2004). Indeed,OPPB provided a vehicle for the CareTrust to meet the requirements ofSection 242, National Health ServiceAct 2006 in the Care Trust. This Actplaced a duty on health careorganisations to make arrangementsto involve and consult patients, carersand the public in:

• Planning: Not just when majorchange is proposed, but in ongoingplanning of services

• Proposal for development / change:Not just in considering proposalsbut in developing them

• Decision making: In any decisionthat may affect the operation ofservices.

Prior to this Act coming into beingthe Care Trust were compliant withthese statutory duties with respect toits POPPs submission, FISHNETS, in2005. Older people were partnersfrom the origin of the FISHNETS ideaand have continued to work inpartnership with organisations instatutory, for-profit and not-for-profitsectors.

It could therefore be argued that the

Care Trust did not merely react tolegislative and policy developments, itwas visionary in aspiring to bringolder people to the centre ofdecision-making structures withinFISHNETS. These were devised at atime when older people generallyfaced exclusion from service planningand policy development, as reportedby the Social Care Institute forExcellence (SCIE):

‘Older people are excluded simplybecause they were old and it wasassumed that they could not performcertain tasks and activities’ (SCIE,2004, p. 5).

Social exclusion has been a widelyrecognized aspect of life for manyolder people, yet the Care Trustimplemented a strategy to overcomethe social and economic mechanismsthat constrained the involvement ofthis population in order to change thesocial conditions of later life inNorthumberland. Older people wereviewed as part of the citizenry, and byproviding supportive approaches thatenabled them to participate indecision making processes, theydeveloped the capacity to getinvolved much more effectively thanpreviously thought possible. Thisstrategy upheld the legitimate right ofolder citizens to have a say indecisions that affected them andprovided opportunities for olderpeople to exercise their moral duty totake part in the construction andmaintenance of their community.

The FISHNETS governancearrangement that is executed throughOPPB ensures the fullest range ofinvolvement of older people indecision-making. This includescommenting on plans, consultation,instigating activities, takingresponsibility for carrying out tasksand leading service planning groups.Wilcox’s (1994) model of involvementstresses the importance of adopting

different levels and types ofparticipation in differentcircumstances, and in keeping withthis the FISHNETS organisationenabled older people Board membersto continue to extend their roles astheir skills and expertise developed.The Care Trust supported this byproviding ongoing training, such asStronger Voice training, to enablethem to increase their capacity toparticipate in service planning.

The ongoing development of Boardmembers has been instrumental inmaintaining the voice of older peoplein Northumberland’s health and socialcare organisations. For example,during the reorganisation of the CareTrust in 2007, OPPB sought ways toinfluence decision-making structuresto ensure that there was a verticallinkage between OPPB and decision-making structures within the neworganisation. They have achievedsuccess in achieving recognition in theTrust that FISHNETS is more than aproject with a time limited beginningand end – it is a pilot to bed thepreventative agenda in the Trust andseek maintenance of this agenda intothe future. There has been aninevitable tension between thisobjective and the financial pressureson the Care Trust. Board membersrecognise that hard decisions must bemade within the Trust about serviceprovision; however they are workinghard to ensure that this is not at theexpense of preventative andrehabilitative services.

As the external, organisationalcontext has continued to evolve andchange since the implementation ofFISHNETS, OPPB has attempted toinfluence the older person’s agenda inrelevant agencies/organisations.Notably, OPPB has sought ways toinfluence the NorthumberlandStrategic Partnership (NSP). Thispartnership was developed in

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response to recent policy that led tothe creation of Local StrategicPartnerships (LSPs) across the country.These partnerships brought togetherat a local level the different parts ofthe public sector as well as theprivate, business, community andvoluntary sectors, so that differentinitiatives and services support eachother and work together. LSP’s areresponsible for developing andimplementing local CommunityStrategies (variously described asCommunity Plans, CommunityInitiatives).

When OPPB members were invited toparticipate in the NSP Older People’sStrategy group (OPSG), thesubpartnership representing olderpeople in Northumberland graspedthis challenge, recognising theimportance of influencing theCommunity Strategy, Local AreaAgreements and Local Delivery Plansthrough Northumberland LSP.Undoubtedly this created newpossibilities to move the olderperson’s agenda forward inNorthumberland, however it alsobrought with it the pressure offulfilling dual roles: OPPB and OPSGmembership. This situation hashighlighted limitations in the capacityof older people who are currentlyinvolved with service planning andpolicy development throughFISHNETS. Whilst this is somewhatrestricted to the members of OPPBand a research group that hasdeveloped under the auspices ofFISHNETS, increasing the participationof older people was envisaged fromthe outset of the project. This,however, has not been realised at thisstage in the development ofFISHNETS.

The future success of involvement ofolder people in service planning andpolicy will depend on developingcapacity from the wider community.

Structures have been developed tosupport involvement and there hasbeen a cultural change inNorthumberland where there is nowa willingness to listen to the voice ofolder people. Across all service sectorsthere is a growing recognition thatwhat older people want is achievableand may require a different way ofdelivering services. Whatever thefuture, Northumberland FISHNETS hascreated a legacy of partnershipworking between older people andservice providers that had notpreviously existed.

Transformation of the serviceculture from treatment toprevention

The FISHNETS partnership has laid thefoundation for an important culturalchange in service provision inNorthumberland whereby themaintenance of good physical andemotional health in later life is nowviewed as important as the treatmentof poor health. This is most starklyevidenced in the NSP strategy for theolder population of Northumberland(NSP, 2007) that seeks to supportolder people to remain in the firsttwo phases/stages of later life – olderworkers and third agers (see p. 7 ofthis chapter for furtherdetails).Traditionally old age healthand social care in Northumberlandreflected service provision elsewherein the UK in being illness-focused,service-led and medically-driven. Thisresulted in an old age service thatfostered dependency in later life andone where little attention was givento developing preventativeapproaches that enable older peopleto be as healthy and independent foras long as possible.

Many factors came together toprepare the ground for the impactthat FISHNETS has had on the

transformation of the service culturein Northumberland. The project wasimplemented at a time when therewas increasing acknowledgement ofchanges or pending change to thedemography of the County.

In some sections of the economy ofcare this was viewed negatively andwas perceived as an impediment toachieving the following targets:

Long Term Conditions PSA target- Toreduce emergency bed days by 5%by 2008.

Older people's PSA target - Toimprove the quality of life andindependence of vulnerable olderpeople by supporting them to live intheir own homes where possible by;

- increasing the proportion of olderpeople being supported to live intheir own home by 1% annually in2007 and 2008; and

- increasing by 2008 the proportionof those supported to live at homeintensively to 34% of the total ofthose being supported to live athome or in residential care.

Significant change had to occur, toenable services to meet these targets.This added to existing concerns acrossold age services that Northumberlandwas falling behind in meeting targetsidentified in the NSF for older people(Department of Health 2001), namelyStandard 6, which specified that olderpeople who have fallen should receiveadvice and intervention fromspecialised falls prevention services.

Other policy developments alsoprovided a clear signal toNorthumberland services that changewas required. The White PaperModernising Social Services (1998c)gave explicit recognition to theimportance of preventive approachesas a response to the needs, problemsand concerns of later life. In keepingwith this policy direction, in January

2006 the DoH published the WhitePaper ’Our health our care our say: anew direction for communityservices.’ This Paper set out a ten yearplan for how health and social careservices would be redesigned to bemore convenient and responsive topeople’s needs in the 21st century.Key to implementation of this planwas development of the evidencebase, which was to be derived fromlearning through a range of pilotsand demonstrators in the early stagesto ensure that roll out of new servicesand methods of service provisionwould work for people and takeservices into the future. The POPPsprogramme was one of these pilots.

The POPPs pilot fell under the sectionof the White Paper relating to HealthyLiving, Prevention and Well-being.This emphasised the need forcontinual improvement in the healthand quality of life of people inEngland. To achieve this there had tobe a move from a culture whichprioritised treatment of illness to onethat considered maintenance of goodhealth as important as the treatmentof poor health. To do this, serviceshad to develop to enable people tolook after their physical andemotional health and to supportindividuals in a way that suited theirlifestyle. The White Paper set outaction to bring about these changes.The POPP pilot was designed to testout radically different ways ofproviding services to older people.

As a POPP pilot, NorthumberlandFISHNETS aimed to supportindependent living of older people inthe community and promote healthyand active ageing. A specific objectiveof FISHNETS being the reduction offalls, and the associated injuriesresulting from falls in the olderpopulation. Through the combineddevelopment of prevention, earlyintervention and changes to the way

services are now provided acrosshealth and social care FISHNETS hasbrought about services andapproaches that:

• support independence andinterdependence in later life

• provide integrated, holistic andflexible packages of care andsupport for the prevention andtreatment of falls in the olderpopulation

• focus on prevention of ill-healthand promotion of well-being toenable older people to live full,healthy and independent lives asthey grow older.

Toward the end of the pilot, theFISHNETS project team is focused onmaintaining the cultural change thathas been achieved and sustaining thisinto the future. There is nowcommitment to the preventativeagenda in the County through NSP,however pressures such as releasingfunds from acute hospital care andreinvesting in prevention are majorchallenges to the sustainability of thecultural change to promotingprevention and wellbeing in later lifethat has so far been achieved. Thereare a number of reasons for optimismthat the key benefits of FISHNETS canbe sustained. The Care Trust is now infinancial balance, and the creation ofa unitary council for Northumberlandwill bring together in oneorganisation lead responsibility for awider range of public services forolder people, including the planningof older people’s housing, grants foradaptations, and some keypreventative services such as leisureservices and community alarmservices.

A whole-system response toprevention

Older people, particularly those of anadvanced old age potentially requiresupport from a number of agenciesacross a number of services, includingprimary/secondary health and socialcare, housing, transport, leisure, andeducation in statutory andindependent sectors to promote wellbeing and prevent the health, socialand personal challenges of later life.However, evidence continues tosuggest that the current organisationof services do not achieve integrationof service provision. Despite policydirectives for joined-up services andwhole-system working, and variousreorganizations to implement thesedirectives, gaps in and betweensystems of service provision cause avariety of problems for older people,providers and commissioners. Theproblems, such as fragmented anddiscontinuous experiences, have beenwell documented and have beenattributed to the following factors:

• demarcation of professionalresponsibilities and the ‘turf wars’that exists in the boundariesbetween services and professionals

• reneging and shunting ofresponsibilities across the boundaryof health, social care, housing andleisure

• weak channels of communicationbetween and within organisations

• a lack of free flowing informationacross the whole service system

• that there are multiple points whereolder people access services with nocentralised systems to co-ordinatewhat/when older people accessservices

• older people are routinely,systematically assessed andreassessed by multiple agencies anddifferent professionals with minimal

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(RCP/RCN/BGS, 2000; McCormack etal 2004; Reed et al 2005, 2007)

Whilst these problems are wellrecognised there have been fewservices implemented across thewhole system of old age serviceprovision. In contrast NorthumberlandFISHNETS was ambitious in its plansfor a whole-system approach to fallsprevention. This required wide spreadchange in FISHNETS partnerorganisations, and involveddeveloping understanding of theircontribution and that of otherpartners to impact on falls prevention;what services they had to offer tofalls prevention; competence of theworkforce to undertake preventativework or be skilled-up to carry out thisactivity; the historical and spatial

influences that enabled or inhibitedpartners working together, patternsof power, authority and hierarchyneeded to be understood; resources,information availability and feedbackprocesses that could be utilized tooperationalize the FISHNETS vision. Allof these factors shaped and havecontinued to reshape FISHNETS as theinitiative has developed.

Partners are clear that the whole-system approach that has beenadopted by FISHNETS has not beeneasy. The difficulties highlighted inthe bullet points above havechallenged everyone who has beeninvolved in the project. Yet partnersbelieve that one of the key outcomesfrom the whole-system approach tothe development of FISHNETS services

has been services that arecomprehensive, joined-up across theeconomy of provision and focused onthe needs and concerns of olderpeople. This is illustrated withreference to the Falls Pathway thatnow exists in the County. A FallsPathway is a schematic diagram ofthe services that are available topeople in a particular locality, who areat risk of falling and those whoexperience falls (see Fig. 2). Theschematic representation portrayshow services link with each other, andprovide a visual illustration of servicesthat users can access followingassessment and referral.

Figure 2: FISHNETS falls pathway

In Northumberland the FISHNETSintermediate task group led thedevelopment of the Falls Pathway(see figure 2). This involvedconsultation with services andprofessional groups across the wholesystem, and importantly the teamnegotiated with relevant services tosecure their commitment to theoperationalisation of the Pathway. Aunique feature of the Pathway is thatleisure, housing, transport, health andsocial care services are represented.This ensures that the Pathway iscomprehensive and includes servicesacross the continuum fromcommunity-based health and well-being interventions to intensivehospital-based interventions. Hence,preventative as well as treatmentinterventions are now available toolder people. This has necessitatedthe development of new services suchas the 12 week leisure-centre basedfalls prevention exercise classes, aswell as linking existing servicestogether, such as CommunityRehabilitation services and handymanservices to make homes safer placesfor people to live.

In addition to the services that arerepresented in the Pathway beingidentified through the consultationprocess, they have been grounded inknowledge of contemporary fallsprevention evidence. For example theemphasis on exercise and physicalactivity in the Falls Pathway is inresponse to the NICE guideline andbuilds on the work of Skelton et al(2005) who demonstrated that abalance and strength retraining groupcombined with a home exerciseprogramme reduced falls in a groupof high risk community dwelling olderwomen. A randomised controlled trialby Barnett et al (2003) tested anintervention programme designed toimprove balance, coordination,aerobic capacity, function and musclestrength coupled with educational

information regarding strategies forfalls prevention. A control groupreceived only the educationalinformation. The intervention groupperformed better in some of thebalance measures and fell 40% lessthan the control group during the 12-month trial period. Day et al (2002)investigated the individual andcombined effects of threeinterventions; home hazardmanagement, vision assessment andgroup exercise on balance, strengthand frequency of falls in people aged70 years and over. The strongesteffect was found in the groupsreceiving a combination of theinterventions, but when analysed inisolation, the group exerciseprogramme demonstrated thegreatest improvement in outcome.

There is little doubt that the whole-system service developments,such as those represented by the FallsPathway, which now exist inNorthumberland provide moreopportunities than ever before forolder people to live full, healthy andindependent lives as they grow older.These developments are fragile, andare dependant on the on-goingcommitment of service partners. Lackof funding to support some aspectsof the preventative services has the potential to damage the whole-system service structure that has beencreated through FISHNETS and withthis there is always the potential thatservices will revert from the wideranging continuum of services to arestricted focus on treating ill-health.

Key messages

Northumberland FISHNETS has beenthe ‘good enough partnership’ torespond to the opportunities thatwere made available for developmentof old age preventative servicesthrough the POPP initiative. It hasachieved its aims, as evidenced bytarget-based criteria. Acomprehensive falls preventionprogramme is now available acrossNorthumberland County includingcampaigns to raise public awarenessof the benefits of exercise and fallsprevention, community rehabilitationteam intervention, falls preventionexercise programmes in leisurecentres, community based exerciseand interest programmes, and homeimprovement through handyman andtelecare services.

There is general agreement acrossservice commissioners, serviceproviders and older people that theywish to see FISHNETS continue andexpand into the future. Whether thepartnership is ‘good enough’ torealize this ambition remains to beseen. There are many challenges forthe partnership includinguncertainties about medium and longterm funding, incompatible priorities,loss of continuity due to changes inkey personnel who championed thepreventative agenda in the Care Trust,changing health and social carepolicy, which together adduncertainty to the future. Whateverthe future Northumberland FISHNETShas created a legacy of partnershipworking between older people andservice providers, and the knowledgethat preventative approaches to theparticular circumstances of old andadvanced old age have the potentialto improve quality of life.

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Newman, J. (2001) Modernisinggovernance: New Labour, Policy andSociety. Sage, Thousand Oaks, CA

Northumberland Strategic Partnership(2007) Older People inNorthumberland - A longer-termview, NSP , Northumberland CountyCouncil.

Reed, J; Cook, G; Childs, S;McCormack, B. (2005) A literaturereview to explore integrated care forolder people. International Journal ofIntegrated Care, vol.5, pp.10.

Reed, J; Childs, S; Cook, G. andMcCormack, B. (2007) Integratedcare for older people: Worldviews onEvidence-Based Nursing Reader inHealth Services Research, Vol 4(2),pp.1-8

Royal College of Physicians, RoyalCollege of Nursing and BritishGeriatric Society (2000) The healthand care of older people in carehomes: a comprehensiveinterdisciplinary approach. RoyalCollege of Physicians.

Nomis Official Market Statistics (2005)Office for National Statistics, London

Social Care Institute for Excellence(2004) Has service user participationmade a difference to social careservices? London: Policy Press

Warne, T. and Howarth, M (2009)Developing the Warnwarthconceptual framework for partnershipevaluation: a review of the literature.Salford University

Wilcox, D. (1994) The guide toeffective participation. Partnershipson-line, Partnership, Brighton .

Appendix

Appendix 1: KeyNorthumberland documents

Northumberland SustainableCommunity Strategy –Northumberland Strategic Partnership,May 2007 (available atwww.northumberlandtogether.org.uk)

Working Together (NorthumberlandLocal Area Agreement), refreshedFebruary 2007 (available atwww.northumberlandtogether.org.uk

A Sub-regional Housing Strategy forNorthumberland, 2007-2011,Northumberland Housing Board, July2007(www.tynedale.gov.uk/residents/showdesc.asp?id=210)

Learning for Life – the 2020 Vision forLearning in Northumberland,Northumberland Strategic Partnershipand Northumberland FACT,September 2007(www.nsp.org.uk/downloaddoc.asp?id=1149)

Northumberland Local Transport Plan2006-2011, Northumberland CountyCouncil 2006(http://pscm.northumberland.gov.uk/pid/90016.htm)

Northumberland Communitytransport strategy, NorthumberlandCounty Council 2008.(www.northumberland.gov.uk)

Community Safety Policy, Strategy andProcedures Manual, NorthumberlandFire and Rescue Service, 2006

Healthy lives, stronger communities, astrategy to improve health and well-being in Northumberland, 2007(available at www.nsp.org.uk)

Northumberland Area TourismManagement Plan, 2006-2009(available at www.nsp.org.uk)

Northumberland Carers Strategy(reviewed 2005, for review 2008 for2008-2011) (available atwww.northumberland.gov.uk/carers)

Appendix 2: Regional documents

Better Health, Fairer Health, Astrategy for 21st century health andwell-being in the North East ofEngland, 2008 (available atwww.gone.gov.uk/gone/public_health/ )

The Region for all Ages: a vision forageing and demographic change inNorth East England – Years Ahead,The North East Regional Forum onAgeing, 2008 (available atwww.yearsahead.org.uk/)

Appendix 3: National policydocuments

The overarching national strategy forolder people is Opportunity Age, thefirst report on which was published in2005 and is available atwww.dwp.gov.uk/opportunity_age/

The 2006 report A Sure Start to LaterLife, published by the Social ExclusionUnit, focuses specifically on olderpeople who are at risk of socialexclusion. It is available atwww.tinyurl.com/37hurh

The Government’s rural strategy,published in 2004, discusses issuesarising because of the ageing of therural population. It is available atwww.defra.gov.uk/rural/strategy/

Key policy and guidance for olderpeople has been published indocuments such as the

• The National Service Framework forOlder People published by theDepartment of Health in 2001.

• The White Paper on communityhealth and social care services: OurHealth, Our Care, Our Say 2006.

• `Everybody’s Business (2005), aboutolder people’s mental healthservices.

These and many other Department ofHealth publications about health andsocial care for older people areavailable on the web atwww.tinyurl.com/2yjn57.

National policy on housing for olderpeople is set out in the February 2008strategy Lifetime Homes, LifetimeNeighbourhoods(www.communities.gov.uk/housing/housingmanagementcare/housingolder/)

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Contents

Chapter 3: Urban Regeneration: Making aDifference? A Case study of a New DealPartnership in action

Executive Summary

Introduction

The Case Study

Background

National Context

Local Context

Research Design and Practice

Methodology

Selection

Research Practice

Analysis and Findings

Workshop

Developing a New Group Focus

Outcomes and Evaluation of the Warnwarth Framework

Discussion

Summary

References

Appendices

Appendix One: The Warnwarth Framework

Appendix Two: Schematic structure of Impact Programme of Delivery Model

Authors

Terry Allen & Melissa Owens, University of Bradford

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Executive Summary

1. Under the auspices of ‘UrbanRegeneration: Making aDifference’, this case study waspart of a project to investigate thefactors which impact onpartnerships being able to worktogether to change the health andwell-being of local communities.

2. The research had two aims:

2.1. To be of tangible benefit to theparticipants, and stimulating to theirpartnership development

2.2. To contribute towards developingan evaluation package forpartnerships (based upon aframework devised by 2 members ofthe project) which could subsequentlybe used on a much wider scale

3. Nine semi-structured interviewswere conducted which were fullytranscribed and analysed usingNVivo 7 software.

4. The case study chosen was theHealth and Social Care SteeringGroup for Impact*, a New Deal forCommunities Programme. As suchit was a partnership without formalstructures where the affiliationsbetween members were quite‘loose’.

5. Because the partnership was in theprocess of changing from a highlyfunded New Deal for Communities(NDC) programme to a socialenterprise the research was timelyand of practical use in shaping itsfuture role

6. Aspects of partnership workingwere encountered which rarelyfeature in the literature but whichare to do with informality,continuity and a commitment toimproving people's lives throughsharing and collaboration. This isan arena some distance from theformal, structured andconventional partnerships uponwhich policy is founded but whichrepresents the day-to-dayexperiences and reality for thoseworking under the regenerationfield.

7. Recommendations were that:

7.1. The role and function of thegroup needed to be clearer, withterms of reference known to all.

7.2. Group membership should bereviewed to reflect its role andfunction and should includesocial services and localgovernment staff as well ascommunity representatives.

7.3. How the group links in – orcould link in – with otherpartnerships needs to beestablished to ensure it meets aneed not provided by otherorganisations.

7.4. The strong leadership of thegroup should be maintained andconsideration given to successionplanning for if, or when, thecurrent leader is no longer in thisrole.

8. Presentation of these outcomes ata workshop with the participantsstimulated future planning andhelped the group considerreconstituting itself to:

8.1. Act as an umbrella organisationfor all health and social welfareprojects operating in the locality.

8.2. Have responsibility for identifyinghealth and social care needs andadvocating these with fundingbodies (PCT, local authority).

8.3 Provide advice and help onaccessing funding.

8.4. Act as a link with, and voice of,community groups andindividuals.

8.5. Reflect the goals and strategy ofthe Local Area Agreement at thelocal level, which is currently avery grey area.

9. The researchers will help the groupcarry this plan forward therebyfulfilling the key aims of the UrbanRegeneration programme inforging an alliance between theUniversity and practitionerorganisations.

10. The Warnwarth frameworkproposed 8 key aspects of the'good enough partnership' whichwere instrumental in designingthe interviews and directing ustowards avenues of enquiry whichmight otherwise not have beenconsidered. This enabled thesubtle relationships within thepartnership to be revealed andthe identification of its strengthsand accomplishments.

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11. Critical examination of some ofthe assumptions of theframework, in the light of theresearch, suggested furtheraspects to consider:

11.1 The importance of thecontinuity and history ofpartnerships.

11.2 Explicitly address ‘sustainability’.

11.3. the local context in whichpartnerships operate.

11.4. the significance of partners’relationships outside thepartnership.

11.5. the complex aspects of the roleof leader and the use of power.

11.6. the ‘networking’ feature inpartnerships.

11.7. informality.

11.8. acknowledging more explicitlythe interdependence of some ofthe framework aspects

11.9. the potential to engage withNewman’s work on thedynamics of partnership.

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Introduction

The Urban Regenerationprogramme has two aims(see The Project Context):

• To address key urban regenerationchallenges in the North of Englandthrough interdisciplinarycollaboration between the partneruniversities and practitionerorganisations, particularly in thepublic and voluntary sectors, and toenhance their collective impact onsociety

• To build a long term strategicalliance between core universitypartners while developing adistinctive form of knowledgetransfer, which is both teaching andresearch driven, in order to meetthe needs of organisations andprofessionals in business and thecommunity.

The Role of Partnerships project wasset within the ‘health’ theme of theprogramme and draws on data from5 case studies of urban partnershipsto determine the effectiveness ofworking practices and the learningneeds required to sustain them.

For the purposes of this research, thespecific research question was:

What factors impact on partnershipsbeing able to work together,effectively, in order to change thehealth and well-being of localcommunities?

Within this framework wereadditional questions:

• What catalytic, prescriptive,informative and supportiveinterventions promote or inhibitpartnership working?

• What factors influence change inthe health and well-being status oflocal communities?

• To develop a 'best practice resourcekit' for assessing partnershipworking in the context of thehealth and wellbeing of urbancommunities.

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The Case Study

This chapter reports on one casestudy, the Health and Social CareGroup, a subgroup of Impact, aNew Deal for Communities(NDC) project.1

Background

The need for health and social careprofessionals to work together,collaboratively, has now long beenaccepted and continues to beregularly emphasised throughGovernment documentation andlegislation, for example the NHS Plan(DoH 2000) and the CommonAssessment Framework for children(DoH 2003). Despite this, therecontinue to be many factors that canimpact1 on partnership workingtaking place effectively:

• Differing agency targets,management practices and

• Accountability

• Time constraints

• Financial constraints

• Professional boundary dilemmas

• Problems in information sharing andmaintaining confidentiality.

(Allen, 2006: 161)

A commitment to partnershipworking however can overcome thesebarriers given:

• Familiarity with each others’ job

• The development of strong personaland professional relationships.

(Sullivan and Skelcher 2002)

How far is this possible and whatactually happens in practice?Reflecting the complexity andmultidimensional nature ofpartnerships, our research is alsocomplex and looks at how far, and inwhat way, the goals of partnership

are delivered ‘on the ground’ througha loosely structured, but task centred,network under the umbrella of aconventional Government directed,and highly structured, partnership –the New Deal for Communities.Evidence from this research will beanalysed using the prototypeWarnwarth framework containing 8ingredients for the 'good enoughpartnership' (see Appendix 1).

In each case we shall scrutinise datafrom in-depth interviews withnetwork members to see how far themodel both explains the dynamics ofthe network and identifies featureswhose presence or absence influencesits successful function.

National Context

Impact is one of 39 New Deal forCommunities (NDC) partnershipprojects planned to run over theperiod 2000 – 2010. Hailed as “oneof the most important area basedinitiatives ever launched”(Neighbourhood Renewal Unit,2003:i), and with a total budget of£2bn, the 'New Deal forCommunities' programme has itsorigins in a cluster of regenerationArea Based Initiatives including - CityChallenge, Estate Action and SingleRegeneration Budget. Interventionsunder the NDC programme have tofocus on 6 key outcomes: communitydevelopment/engagement; improvinghousing and the physicalenvironment, health, and education;reducing worklessness, and fear andexperience of crime. The goal is notonly to improve conditions in eacharea but:

provide an ideal vehicle throughwhich the neighbourhood renewalcommunity as a whole can learn'what works and why' (ibid)

Hence learning from the NDCs wasexpected to influence futureneighbourhood renewal strategy. Incommon with the Government’sapproach to all public service reformsthere was to be an emphasis oncommunity participation within thedelivery and governance of services(Skidmore et al, 2006), and nearly allNDC partnerships have a majority ofelected local representatives on theirboards. The extent to which thecommunity as partners influencedand affected outcomes is a criterionagainst which NDCs must be assessedand hence is an important issue forthis research into the effectiveness ofpartnerships.

Health interventions within NDCsmainly focused on promoting healthylifestyles; enhancing service provision;developing the health workforce; andworking with young people. However,in the evaluation “Health has tendedto be viewed by many Partnerships asa relatively low priority, often beingviewed as a personal rather thancommunity concern” (CRESR,2005:191) and, "in the 4 yearsbeginning 2000/01 about £48 millionof Programme resources was spenton health, less than for any otheroutcome area" (ibid: xix) with onlyminor changes in health indicators.The evaluation identified some clearpolicy implications:

• The need to work in partnershipwith Primary Care Trusts (PCTs) todevelop strategic, long term plans;

• The importance of NDCPartnerships giving health theemphasis it deserves;

• Accepting that outcomes frominterventions will take many yearsto feed through.

(CRESR, 2005: xix)

1 Impact is not its real name

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Local Context

The area in which Impact operates ismulti-ethnic and was, in 2000,particularly deprived on the basis ofmany indicators: “crime was high,educational standards low,community facilities poor and healthbad” (extract from Impact website).Its score on the index of multipledeprivation was somewhat lowerthan the mean of 52 for all the NDCareas and 22 for England as a whole.Impact’s Board of Directors has amajority (12 of the 22) of electedcommunity representatives, incommon with the other schemesnationally.

Like other programmes, Impact’shealth interventions were:

To see that the health, environmentaland social needs of all residents aremet in order to improve their qualityof life.

Table one below identifies ways inwhich Impact is implementinginterventions on these criteria.

Because the NDC philosophy was thatprogrammes should be communitydriven, Impact had the facility to fundpackages of interventions best suitedto meet the needs of their local areas.Under the 'health umbrella’ therewere four broader programmes towhich intervention projects would becontracted and through which theywould be managed. In addition,topic-based steering groups providedadvice and support to the projects(see Appendix 2). One of these is theHealth and Social Care Group and isthe focus of this research.

Although scheduled to run until2010, funding actually terminated onApril 1, 2008 and Impact is intransition from a ‘regenerationprogramme delivery organisation’ intoa ‘social enterprise’ where communityrepresentation, and hence theexperience of partnership working,will be at a different level.

Table 1

• Our projects are aimed atimproving the health of babiesand young children, equippingresidents to improve their diet andlifestyle and equipping residentsto improve their mental andemotional well being

• Impact has set up a healthy livingnetwork at local facilities, soresidents can easily get to theservices they need

• We are providing services thattake account of the needs ofmany different groups of peoplein the area. These include exerciseclasses, advice on diet, cookingclasses, stop smoking clinics, ante-natal advice and improvedchildcare

• We are working to supportparents and families. We areoffering advice and counsellingaimed at reducing stress andisolation, and drugs counsellingand support

• We are creating a cleaner, saferenvironment for all

The Health and Social CareGroup

The health and Social care Group(HSCG) manages around 20projects, with partner agenciesproviding expertise through thegroup by planning joint events,sharing information, managingclients/referrals and setting up asupport system. More recently,professional advisers wereintroduced -- largely from the thenfour Primary Care Trusts. In thisway health projects, or health andsocial care aspects of other projects,were delivered across the whole ofthe Impact area.

There is now a shift in Impactmakeup and governance towards asocial enterprise model, with nocentral funding, which will have ageographical focus on the three'parish' areas within Impact;programmes will therefore becomemuch more localised and locallyaccountable. Communityrepresentation, hitherto by havingborough council members andelected community representativeson the Impact board, will bereplaced by parish council nomineesalthough parish councils currentlydo not exist. Hence ametamorphosis is under way andthe nature of the partnership itselfis bound to change. The transitionis seen by some members of thehealth and social care group as asignificant challenge and there arefears that increased parochialismwill result in an emphasis ontackling 'crime and grime' with the‘improving health’ agenda losingout.

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Research Design and Practice

Methodology

The choice of the HSCG as theresearch object arose for severalreasons. One of the authors wasexperienced in regenerationinitiatives over many years, wasfamiliar with Impact’s work and,through personal contact, wasconfident of access for the research.More importantly, however, itenabled the project to focus on anarea of partnership working wherethe affiliations between memberswere likely to be quite loose andhence, unlike a formal partnership(the Impact board, for example)active membership required a‘payoff’ – there needed to besomething in it for the participantsand their organisations. We wereaware too that members of thegroup consisted of projectmanagers as well as partner agencyrepresentatives and hence thedynamics and power interactionwould be instructive. We alsowanted to see how far the‘community’ imperative, so clearlyenshrined both in the terms ofreference (and the composition) ofthe Impact board, manifested itself‘on the ground’ and how far thehealth and social welfare concernsof the area were both identifiedand addressed through thesemechanisms.

Because our participation in themain project has been exclusivelyfocussed on this case study themethodology itself has been fairlyclosely defined and aimedparticularly at assessing theWarnwarth partnership template.This has enabled us to concentrateon the mechanism of partnershipprocesses through in-depthinterview of the participants andaddressing such fundamentalresearch questions as:

Why is there such a group?

Why are members involved?

What does the partnership do?

When does it function aspartnership i.e. what sort ofpartnership is it?

How effective is it?

Although described as a 'casestudy’ the main empirical sources ofdata are the interviews themselvesanalysed in the context of reportsarising from the National Evaluationof New Deal for Communities.Additional material came from aworkshop conducted with thegroup as it contemplated its newrole as a social enterprise.

The workshop was led by theresearchers and drew uponemerging themes in the research atthat point.

Alongside theoretically drivenquestions set out at the beginningof this chapter, the overarching aimof the Urban Regenerationprogramme is to stimulatecollaborative working throughactive involvement by HigherEducation institutions. Hence wesee the analysis and development ofthis process as part of the researchbecause it tests the dynamics of apartnership in a fundamental wayby challenging its ability to changeand adapt to meet differentchallenges.

Selection

While the ‘cast’ of intervieweeparticipants consisted primarily ofthose involved in the group, wewere aware of changes that hadtaken place over the years, by thenature of projects coming andgoing and hence identified threebroad ‘categories’ of membership:

1. Those who have left thepartnership since 2001

2. Those who are still engaged buthave experienced the transitionand are giving thought to theirown future role

3. Those who will shape futuredevelopment

This basic categorisation hadimplications for the questions wewould explore with them.

In group 1 we asked why they weremembers of the partnership in thefirst place; what it meant for themand their agency's ability to achieveits own goals; perspectives on theprocess and where the power lay;what sustained the partnership;why they withdrew etc.

In group 2 we were aware that notonly would some of the aboveissues arise, but also theirperceptions of the changingdynamics of the partnership.

For group 3 we looked in particularat how the health theme could besustained in the face of the likelyparochial emphasis on quick andvisible outcomes.

The selection of participants for thisstudy, therefore, was purposive.

Research Practice

Research participants were invitedto take part in the interviews on thebasis of the above criteria anddrawing on the current membershipof the HSCG. The initial contactwas by letter followed up bytelephone discussion by one orother of the researchers wheninterview arrangements were made.Formal consent forms were usedand all interviews were tape-recorded. The interviewschedule was designed both toreflect the Warnwarth frameworkcriteria and to facilitate opendiscussion.

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Analysis and Findings

Analysis of the data took placethrough two inter-related processesas follows:

o Analysis of the interviews. Allinterviews were transcribed andanalysed using NVivo software.Template analysis was used inorder to establish preliminarythemes based on the original questions from the semi-structured interviewschedule with additional tree andfree nodes created as newthemes emerged from the data

o Evaluation of workshop.Results were fed-back to theoriginal research participants andmembers of the Health and SocialCare group in a workshopenvironment. The workshop wasled by the researchers andparticipants encouraged toconsider the results of the studyin relation to their group and itseffectiveness as a workingpartnership. Evaluation of theworkshop was then undertakenin order to re-evaluate theanalysis in relation to theinterviews alone

Although interviewees wereselected on the basis of their lengthof time in the group we wereunable to discern any relationshipbetween this categorisation and theviews expressed.

Workshop

We give this 'special mention' herebecause of its unusual place inconventional research. In fulfillingthe goal of stimulating collaborativeworking, and being seen to beuseful to the participants, theresearch outcomes presented at theworkshop were those which wesaw as being of practical use and

drawing upon the experiences ofthe group. The presentation madeby us to stimulate discussion andplanning contained a mixture ofinterview quotations, relevantextracts from research and our owninterpretations.

The presentation was under fourbroad themes that had emergedfrom the data as follows:

• What has been the role andfunction of the group?

• How has this been affected by itscomposition?

• How do you ensure sustainability?

• What are the internal andexternal factors than caninfluence this?

What has been the role andfunction of the group?

It was clear from analysis of theinterviews that the role andfunction of the group had differentmeanings to different people. Forsome it provided a network whichgave them access to other healthand social care professions and forothers it was an opportunity toshare information regardingprojects which were managed andfunded by Impact and in whichparticipants were involved. Forothers the role and function lackedclarity and appeared to havedifferent goals although one broadremit was identified: to promotehealth and wellbeing in the localcommunity.

How has this been affected byits composition?

A key impact on the group’scomposition was that it appearedto have two functions: one being topresent feedback on projectsfunded by Impact and the other toact as an information sharing point:

“The [health and social care] groupitself is quite disparate, lots ofdifferent people involved indifferent projects (...) with somepeople over a short period andsome having quite a long period init” (INT ii)

The impact of the former functionwas that membership was notconsistent. Group membershipcomprised people who were projectleads and key people from the localPrimary Care Trust, who were not.Some of the projects, however,were only short term (for example12 months) in duration and resultedin a quick turnover of somemembers of staff and therefore alack of continuity in groupmembership. Others (such as someof the PCT staff) were not involvedin the actual project managementand therefore found their own roleon the group to be unclear,resulting in a drop in theirattendance over time.

“Yes over a period of timeattendance got less and less andless err and I think that is becauseof how well err it achieved itsfunction people weren’t gettingwhat they wanted so...”(INT vi)

Wilson (2005) has argued that foreffective interprofessionalpartnerships to work there needs tobe a strong sense of personalidentity of individuals making upthat partnership. We did find,however, that the rationale forgroup membership was not alwaysclear and could, therefore, be a


reason for the drop in attendance.Equally, we felt that there were keyorganisations that should berepresented but were not. Therewas, for example, no one identifiedfrom social services on the group,nor from the local authority.

In addition, whilst the remit of thegroup was identified as being toimprove the health and wellbeingof the local community, there wereno community representatives onthe group apart from one ImpactBoard member.

“There are many within thecommunity and in small groupswhich could become part of thesocial enterprise and who we needto reach. And we know who theyare and that they are hungry forthis sort of thing” (INT x)

How do you ensuresustainability?

The withdrawal of Governmentfunding for Impact clearly affectsthe way in which the group willcontinue to function. The changingrole of the PCT, from provider to aprimary commissioner of healthfunding in the area, for example,was also identified as having animpact on this. To ensure that thegroup continued to have a role andfunction, it was recognised thatthey would need to both develop away of working more closely withthe local community members(despite the challenges that thiscauses) as well as with other localservice providers. We alsosuggested that the group wouldneed to find a ‘niche’ and offer aservice not currently provided byothers in the local area. This was re-iterated by a comment from one ofthe interviewees who said:

“They do need to make sure thatthey’ve, they’ve got the mix rightand they’re not, not duplicatingreally” (INT iv)

What are the internal and externalfactors than can influence this?

One key factor considered to be apositive influence on the group wasthe strong leadership from someonewho was committed to maintainingrelationships with group memberseven if they failed to attend themeetings;

“[‘we’ve had] very strongleadership. They kept therelationship up they keptmanaging the relationship eventhough we don’t get tomeetings… [the leader] just keepshanging in there you know she’llcall you and send emails and youknow arrange to meet you just tosort of up-date you” (INT iv)

The downside to this, however, isthat the group has long relied onthe one person whose loss could bevery disruptive to the group’sactivities. Indeed, Robson & Cottrell(2005) emphasise continuity ofmembership as key to effectiveinterprofessional team working. Ifthe current leader were to leave,therefore, this could have anegative impact on the functionalityof the group not only by losing theskills of the leader him/herself, butalso in terms of the formation ofthe group.

Whilst the current strong leadershipwas seen as a positive influence,other factors were considered tohave had a more negative impact.One such example given was thechanging role of Impact and thefeeling that the group had been ina transition phase for a long periodbut with no clear direction as towhat it would end up becoming.

This was felt to be particularlychallenging when recognising thatother organisations or ‘partnerships’with whom they worked were alsochanging so there was never astatic role for any organisation.

Additionally, whilst it was identifiedas important to engage localcommunity members, the difficultyof doing so was recognised as thiswas continually changing too.

“We've had local people involved init and provided that these peopledon't actually ... because what'shappened previously is that localpeople have lived there and assoon as their financialcircumstances have improved theyhave left” (INT ii)

In summary, the key issues wereidentified as follows:

• The role and function of thegroup needed to be clearer, withterms of reference known to all

• Group membership should bereviewed to reflect its role andfunction and should include socialservices and local governmentstaff as well as communityrepresentatives

• How the group links in – or couldlink in – with other partnershipsneeds to be established to ensureit meets a need not provided byother organisations

• That the strong leadership of thegroup be maintained andconsideration given to successionplanning be considered for if, orwhen, the current leader is nolonger in this role

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Developing a New Group Focus

Having provided the group with thefeedback, the remainder of theworkshop involved the groupconsidering how, or if, they wantedto address the issues identified.

The key issues were again discussedby the group and its role andfunction re-considered. It was feltthat the overriding goal of thegroup: to improve the health andwellbeing of the local community,was appropriate and should bemaintained. It was interesting tonote the high level of motivationfrom within the group and itscommitment to seeing it continue.Members present did feel that thegroup could have multiple rolesand, following debate, felt that itshould be expanded to include awider circle of people. This includedlocal General Practitioners (GPs),community members, social andmidwifery services. Considerationwas given as to whether thereshould be two groups: oneoperational and one strategic inplace but this proposal wasdismissed as there was a strongdesire to retain the relationshipsbuilt up over the years and themembers saw benefit in continuingto combine these functions.

Several members of the groupwanted a more pro-active role inimproving local health and well-being than had hitherto beenevident and decided to look at thepossibility of establishing an ImpactHealth and Wellbeing Partnership(working title) which would

• Act as an umbrella organisationfor all health and social welfareprojects operating in the locality

• Have responsibility for identifyinghealth and social care needs andadvocating these with fundingbodies (PCT, local authority [LA])

• Provide advice and help onaccessing funding

• Act as a link with, and voice of,community groups and individuals(one of our suggestions in thepresentation)

• Reflecting the goals and strategyof the LA at the local level, whichis currently a very grey area

We will host and facilitate ameeting in early July to which keystrategic people from the PCT andLA have been invited

Outcomes and Evaluation of theWarnwarth Framework

As we indicated at the beginning ofthis chapter the Impact case study ispart of the Role of Partnershipsproject which draws on data from 5case studies of urban partnershipsto determine the effectiveness ofworking practices and the learningneeds required to sustain them. Wehave already looked at how theresearch has identified issues whichare important for Impact as itmoves into its new phase but wealso need to see how far the datafrom this case study can contributetowards an evaluation model forwider application, a primary focusof the overall project.

As a preliminary to the case studies,two members of the project (TonyWarne and Michelle Howarth)undertook a comprehensive reviewof the 'partnership' literature anddeveloped the Warnwarthframework, a “conceptualpartnership framework that can beused to undertake case studyevaluations on a range of different

current health and well-beingregeneration projects" (Warne andHowarth, 2009:2). The frameworkwas used to develop the interviewschedule used in the Impactresearch and we now consider towhat extent it was of value inidentifying how far the partnershipwas 'good enough'. The conceptof the 'good enough' partnershipinvites the evaluator to consider apartnership not just in terms of howfar it fulfils certain criteria but in thecontext of what it is for andwhether it is adequate for the task.

The 'good enough' partnership(Warne and Howarth, 2009:46)owes its origins to the concept ofthe 'good enough' parent whoserole is to provide, inter alia,stimulation, sustenance andsupport. Hence we consider thepartnership in similar terms -- whatis it that sustains it and helps itthrive and realise its potential?

Warne and Howarth draw on thework of Brown et al (2006) to setout 8 factors which contributetowards sustenance and, asmentioned earlier, upon which ourinterview questions were based.The following is freely adapted fromWarne and Howarth (2009: 47-49).

Right reasons -- having a sharedvision of what might be possiblethrough partnership working andensuring a long-term focus.

It has been evident from the datapresented in Section 4 that afundamental problem in studyingthis group was the lack of clarityover its purpose. Was it a forum forgetting together and sharing ideas;part of the structure wherebyImpact managed its projects; or away of identifying the need forhealth based interventions andresponding to them?

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“It was sharing what washappening, what [Impact] wasdoing and what other agenciesand groups were doing and howsupport and interaction can becreated between them” (INT i)

“It was around promoting health inits very broadest sense for thatparticular community” (INT iii)

“It’s helpful for networking… aforum where partners can cometogether” (INT viii)

“I was never 100% clear what thefunction of the group was” (INT vi)

“It wasn't clear exactly who shouldbe there” (INT vii)

“It was about identifying the needsof the Impact area and monitoringhow programmes were beingdelivered and how that wasimpacting on the health targets inthat area” (INT v)

In many ways it was clearly all 3and seen as such by someparticipants but there were no ofterms of reference or a clearstatement of outcomes.

High stakes -- compelling reasonsfor individual members to ensurethat the partnership is successful(more than it just being ‘a goodthing’). Might involve agreement onprocesses but desired outcomes area crucial aspect.

The Warnwarth framework eschewsbeing 'a good thing' as a legitimaterole of partnership but there seemslittle doubt in the case of this groupthat its mere existence was valuablefor many members who saw loose'networking' as an importantfunction, frequently with positiveoutcomes.

“You think ‘oh yeah they could helpwith that’ or, you know, ‘we couldsupport them with that’. Or‘they’re thinking that way as wellso we could support their projectbecause we do this’” (INT viii)

“I think we shared informationwhich is very important and forthe projects we were involved inwe could say ‘Ah, then you needto make connections with this orthat group, this is somewhere youcould refer people on to if theyhad a good idea about how to dosomething’. So I think that wasprobably a benefit” (INT ix)

In part this was due to mostmembers having contacts outsidethe group and being familiar witheach other. That said, actualinvestment in the group was hardto assess.

“I think it's hard to get people tocommit you know. [The leader] hasinvited, say, senior public healthmanagers who were not regularattenders but maybe that's becauseit's a mixed group of providers sothen people think ‘is this for me?’you know because many of thepeople there are actual communityworkers themselves” (INT v)

And one interviewee was clear thatthere needed to be a clear sense ofpurpose

“People do go to meetings and theyjust 'have the meeting' but there'snot really any clear action… thereare things to be done and peopleneed to take responsibility at alllevels. I think there's this thingabout partnership and it's all kindof lovey-dovey and somehow bysome kind of osmosis we'llunderstand each other but I don'tthink you do. Partnership is aboutmore than having meetings” (INT ix)

Right people -- Have the best andmost appropriate people andsufficiently empower them to havea reasonable degree of autonomy.Issues around appropriate andequitable representativeness needto be addressed.

“The [health and social care] groupitself is quite disparate, lots ofdifferent people involved indifferent projects (...) with somepeople over a short period andsome having quite a long period init” (INT ii)

“…didn't always get consistentattendance to those kinds ofmeetings. There is also a short-term project phenomenon wheresome are only funded for a year orso, so it’s very hard actually to getthings going in that time. So forthe health and social group youlose continuity and it's a bit fluid”(INT ix)

Continuity was to some extent afunction of the short-term nature ofsome projects and there is animplied disadvantage in having bothoperational and strategic peopletogether. However different peoplewith different functions can still bethe ‘right people’ providing thegoals are clear and people knowwhat their roles are:

“I think you have to look at ‘whatdo we want to achieve?’ and thenget the right people there. Nowthat might be a range of people.It might be communityrepresentatives who don't hold alot of strategic power but theycarry the information; it might bepeople who are working in andleading projects, and then it mightinclude people who also carrystrategic power as well. I thinkthat can work as long as everyoneis clear about what their role is”(INT x)

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Such a mixture was seen as apositive advantage in the workshop,referred to in Section Four.

There were some conspicuousomissions; there was no one fromsocial services and communityinvolvement was elusive. While seenby Government as an imperative itis ill-defined and:

"Even the successful partnershipscontinue to struggle with issuessuch as community linkages…andthe challenge of how to ensureongoing community voice andcommunity accountability"(Alexander et al, 2003: 141S and152S)

The usual model just seeksinvolvement from representatives of'community organisations' but oneinterviewee was much more positiveand pro-active:

“There are many within thecommunity and in small groupswhich could become part of thesocial enterprise and who we needto reach and we know who theyare and that they are hungry forthis sort of thing” (INT i)

Again, we find that the situation ismore complex than the frameworkappears to allow because theinformal connections permeatingthe boundaries of even such a loosegroup as this can be very productivein influencing its work.

Right leadership -- Identified innearly all evaluation instrumentsand assessment tools as possibly themost crucial element in achievingeffective working. Need to fosterrespect, trust inclusiveness and beflexible in style and approach.

The leader was explicitly, andincontrovertibly, the representativefrom Impact who organised themeetings and produced theagenda. Everyone saw this asentirely natural largely because the

projects represented on the groupwere all funded through Impact.

“I think [the leader] is a very goodchair… a very good atmosphere, itwas really nice and it was usuallyover lunchtime so we got thereand there was something to eatwhich -- you can't beat it. And weshare communally. And you canhave a bit of a chat at the meetingwhich is well organised with anagenda. I think people felt OK”(INT ix)

“It is difficult for her because weare such a different group ofpeople but that's the skill ofpartnership working I think, ornetworking. It’s to get thecommon interest from the groupof very different people who workat very different levels withinorganisations” (INT vi)

Much depends on the character ofthe leader concerned and therewould have been ample scope herefor things to go wrong. What welearned is that even where theleader comes from the organisationwhich holds all the funding it ispossible to lead the groupeffectively and sensitively.

Strong, balanced relationships --Need to ensure that relationshipsare managed, nurtured andsupported recognising issuesaround imbalances in power whichneed to be addressed sensitivelywith an awareness of differentorganisational cultures representedwithin the partnership.

Again this reflects the character ofthe leader but 'having the power'does not have to be explicit oroppressive without neverthelesshaving a strong influence on theway the group operates. We askedwhether some members got moreout of it than others:

“Yes I suppose coming in, andbeing quite new, I felt verycomfortable that I could speak toeverybody, I could say what Ithought and I think a lot of that isbecause I've known [name ofleader] for quite a long while, afew other members that I knew soI felt quite comfortable in thatsetting” (INT viii)

Relationships built up outside thegroup are frequently influential andthe converse can be the case:

“We didn't have other contact andthat may have been one of thereasons why things were not aseasy as they could have been interms of developing goodpartnership working” (INT iii)

“In the health and social care groupthere isn't any feeling of hierarchy,there is a feeling of relationship afeeling of support and that for meis what partnership work isabout... how else do peopleestablish networks, it is quite hardto do that just by going out andknocking on doors but thatintelligence already exists, a groupof people come together sosomebody will know somebody orwill ask questions and somebodyalready knows the answer so weget that and we get sharing” (INTv)

Trust and respect -- Allcontributions need to be valued andrespected regardless of levels ofresponsibility. This takes time.

Most of the issues here have beenreferred to already, particularlythose to do with valuing allcontributions. This was ascribed tothe commitment of the leader.

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Good communication -- Individualmembers need to ensure withintheir organisations and across thepartnership that communication isopen as possible. It also means thatgroup members should feel able tocommunicate ideas and criticism insafety.

Group members feeling ‘able tocommunicate ideas and criticism insafety’ seems to overlap with ‘goodleadership’ and the ‘trust andrespect’ agenda but there isanother important elementidentified in the framework to dowith communication outside thegroup.

“It would have been good [for me]to have been managed in a waythat said 'Right [name ofrespondent] you're going to gothere and I want a report everymonth because I'm taking this tothe partnership group with thelocal authority and I'm going totake this to the director of theboard of the primary care trust”(INT x)

Formalisation -- Even simplepartnerships required governancestructures which need to beconstantly reviewed to ensure thepartnership can endure and survivebeyond the active participation ofindividual members.

We have already referred to theabsence of terms of reference orexplicit goals beyond the generalone of improving the health andwell-being of the community.Nevertheless there was someeffective working for the reasonsdiscussed above. What came acrossvery strongly was the skills andpersonality of the leader and yet:

“If somebody new were to comeand replace [the leader] tomorrowI think that we would strugglebecause it's someone coming withprobably fresh ideas, looking at itdifferently, and then it's going totake a year or something to themto get up to speed in which caseyou lose momentum” (INT ii)

Although we have focused on theresponses in the context of theframework, and will be discussingthese in more detail later, this was aloosely structured group and wespecifically asked people about howit fitted into their concept ofpartnership. The term ‘networking’frequently appeared, sometimesinterchangeably:

“There is a feeling of relationship, afeeling of support and that for meis what partnership work is about,how else do people establishnetworks” (INT v)

or complementary

“To me it was a network butpartnership working was takingplace within and between theorganisations who met” (INT i).

as a precursor

“… I think partnership is about theoutcome of networking” (INT v)

or operating at a different levelaltogether:

“You have to be clear what you'retrying to achieve from thepartnership and have anexpectation of how thepartnership is going to work. If itis just about networking that's finebut if it is about signing up to, youknow, investment and resourcesthen that's a different sort ofkettle of fish” (INT vi)

One respondent alluded to thegroup being a different sort ofgeneric partnership – community vorganisational

“It was a partnership but acommunity partnership sometimesoperates differently from anorganisational partnership.Community partnerships you canchange -- if something is notgoing well, as time goes along youcan bring new partners in andchange things and you can keep itgoing provided there is someonethere to oversee it all.Organisational partnerships meansyou have to fit in to a bigstructure” (INT ii)

However, popular notions of, andcriteria for, partnership applied,whatever label was attached

“For me partnership working meanscommon commitment tosomething that you're trying to doand that's what we've had withthe group…[which] is a really goodexample of partnership working aspeople are actively involved in thesame thing so everybody'scontributing expertise and theircommitment. They might have adifferent role to play but they'recontributing that to the health andsocial care group. We could all bedoing that individually but thebenefit by coming together isaround delivering services that aremore likely to complement oneanother than being in competitionwith one another” (INT v)

“Partnership working is all abouthaving shared vision and values towhich everybody is signed up… ithelps you as a representative ofyour organisation deliver ontargets” (INT vi)

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Discussion

This research was both conventionalin its evaluative and analytical rolebut also proactive in stimulatingand assisting change. In each casewe drew on similar data but usedthem in a different way. This makesfor a complex report; to meet theaims of the Urban Regenerationprogramme (as set out on page 3)we needed to develop “a distinctiveform of knowledge transfer, whichis both teaching and researchdriven, in order to meet the needsof organisations and professionalsin business and the community.”Hence the research had to be seenas being of practical and tangiblebenefit to the participants, andstimulating to their partnershipdevelopment. However it alsoneeded to contribute towardsdeveloping an evaluation packagefor partnerships, based upon theWarnwarth framework, which couldbe used on a much wider scale.Here too we had different, butcomplementary, aims. While weused the framework to design ourinterview questions and see how farthe group met its criteria, we alsoused material from our research tocritically evaluate the effectivenessof the framework itself inidentifying a 'good enoughpartnership' and to makesuggestions for its furtherimprovement.

In considering the effectiveness ofthe Warnwarth framework, weliked the terminology - ‘goodenough partnership’ - because itrecognises the possibility that apartnership might only satisfy someof the framework criteria to alimited degree and yet be goodenough for the task; i.e. it isassessed in the context of what it istrying to do. Part of the problemwith our case study was that, apartfrom a broader aim to improve

health and well-being, the aims ofthe group were not specified sowhat was it good enough for?

Firstly, it was good enough forgetting together people working inhealth and social care so it did getthe 'right people' with somenotable exceptions such as thesocial services department andmuch in the way of communityinvolvement. Its mix of operational(mostly of projects funded byImpact), and strategic, participantswas seen to be desirable and will beperpetuated in whatever new formthe group takes.

Secondly, it facilitated networking inwhat seemed a very positive sensewhere there was an activecommitment to learning from eachother and offering collaboration.

Thirdly, it provided a support anddevelopment function topractitioners by generating aclimate wherein what were oftensmall-scale, and potentially isolated,projects could share commonprofessional interests and locatethemselves within the broaderobjective and philosophy ofimproving the health and well-being of their local community.

The ability of groups to work in thisless structured way is not unusualand was noted by Molyneux fromthe perspective of aninterdisciplinary team setting:

“Team members clearly felt that thelack of established criteria andguidelines was ultimately helpful,in that staff were able to workcreatively together in devising theirown guidelines and methods ofworking around the needs of thisparticular team” (Molyneux, 2001:32).

Some participants felt that morecould have been done to offerdevelopment advice and support,particularly in accessing fundingbeyond that available from Impactitself and in 'mainstreaming' someof the activities and practices.

Why, therefore, did this partnershipsurvive even though funding wasrunning out and the obviousfinancial benefits of beingassociated with the groupdiminished?

We certainly agreed with theframework on the importance ofleadership and felt that some of theother aspects -- strong, balancedrelationships and a culture of trustand respect -- stemmed from this.We wondered whether theinterdependence of these featuresneeded to be taken more accountof in the framework. The role ofleader here was an interesting onebecause the staff member ofImpact, which convened andmanaged the group as well asfunding the projects representedupon it, was likely to be endowedwith a great deal of power.However none of the respondentswas critical of this, seeing theleadership role as a 'natural' oneand its exercise of power assensitive and even-handed. This isnot an easy task given the mix ofpractitioners and managers, someof whom were well established andrepresented the major ‘players’ inthe locality, while others were fromsmall, often transitory, projects.Robinson and Cottrell (2005: 555)warn “that such ‘minority’members may feel disempowered”,which was clearly not evident in thisgroup.

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There is another element here andthat is the longevity and continuityof the group under the sameleadership. Hence it is important tosee a partnership like this one in itslocal context as part of a long-standing regeneration activitywhere everyone knows everyoneelse and that what goes on outsidethe 'partnership' may be asimportant as what goes on withinit. It was evident from theworkshop, and from the interviews,that there was a reservoir ofgoodwill, expertise andcommitment accumulated overseveral years and sustained throughconsistent and facilitativeleadership.

Alexander et al (2003: 130S)consider that "sustainability is a keyrequirement of partnership successand a major challenge for suchorganisations”. It was an importantstrand in our research because ofthe metamorphosis from NDC to asocial enterprise. The frameworkdoes not specifically addresssustainability, other than byimplication, which we think needsaddressing explicitly. An importantfactor in exploring sustainabilitywith a partnership is determiningwhat it is that will be sustained --whether it is the projects andactivities connected with the groupor its values and tradition. In ourresearch the group is in the processof changing its format, and its task,building upon issues which arose inthe research and upon which weinitiated discussion in theworkshop. The key outcome forthem was to sustain, in the newformat, the habit of collaborationand the personal relationshipsdeveloped in the group.

Where we did have difficulty insatisfying an aim of the research,was in assessing what factors withinthe partnership contributed toimproved health and well-being.There was certainly a general sensethat the associations developedthrough the group, the mutualsupport and advice, together withsharing and developing strategies,contributed to the success of eachproject and therefore to a successfuloutcome. From a methodologicalperspective, the causal processes --what it is within the interventionwhich directly influences health – ishighly complex and trying todeduce the role which thepartnership itself plays in theprocess is equally problematic.However, several intervieweesthought the partnership could haveplayed a more proactive role inidentifying particular areas forhealth improvement interventionand used its accumulated expertiseand cross-agency relationships toattract and coordinate theappropriate resources. This is likelyto be an expectation in the newpartnership which is beingdiscussed.

In many ways this group was anunusual one but, using theframework, we were able toexplore many aspects ofcollaborative working which mightnot have otherwise emerged. Wefound a sophisticated use of apartnership which went beyondsatisfying formal goals but, throughinteraction of the partners,supported, stimulated andfacilitated their activities. Hencethere were ‘layers’ of cooperationwithin the partnership and informalnetworking was one of the layers.The framework does not, in ouropinion, recognise this informal rolein a partnership or that it may be,

in itself, 'a good thing' even whenit is not clearly linked to robustoutcomes and structures. This maybe why there was a preference forthe term ‘network’, becausepartnership, for some, impliedsomething more formal andstructured.

However, network itself was seeneither as coterminous withpartnership, a precursor to it orsomething quite different and morelightweight. Interestingly, the latterdefinition came from one of theprincipal agencies and "big players"in the partnership where preferencefor a more structured andaccountable organisation isunderstandable. In exploring theconcept of networks further wewere attracted to Newman’s workon the dynamics of partnership(Newman, 2001: 114). She appearsto look for tendencies (rather thancriteria) in her four models; towardspragmatism (emphasis on gettingthings done, meeting targets);towards accountability (emphasis onstructures, roles, procedures);towards flexibility (adapting tochanging conditions, expansion);and towards sustainability (fosteringparticipation, building consensus,embedding networks). The Healthand Social Care Group tends, onthese criteria, towards flexibility andsustainability which seemappropriate given the evidence wehave gathered. We think theframework would benefit fromconsidering the above work andfinding some way to incorporate it,or at least its principles; they sharea postmodernist foundation,preferring loose and wide-ranging,rather than rigorous, definition.

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Summary

This research has encounteredaspects of partnership workingwhich rarely feature in the literaturebut which are to do withinformality, continuity and acommitment to improving people'slives through sharing andcollaboration. We believe that this isan arena some distance from theformal, structured and conventionalpartnerships upon which policy isfounded but which represents theday-to-day experiences and realityfor those working in the field ofregeneration.

The research was of practical use tothe participants in helping them tobegin to shape the future role ofthe partnership to meet thechanged circumstances:

• The role and function of thegroup needed to be clearer, withterms of reference known to all

• Group membership should bereviewed to reflect its role andfunction and should include socialservices and local governmentstaff as well as communityrepresentatives

• How the group links in – or couldlink in – with other partnershipsneeds to be established to ensureit meets a need not provided byother organisations

• That the strong leadership of thegroup be maintained andconsideration given to successionplanning for if or when thecurrent leader is no longer in thisrole

As a first step the group proposedreconstituting itself as the ImpactHealth and Wellbeing Partnership(working title) which would

• Act as an umbrella organisationfor all health and social welfareprojects operating in the locality

• Have responsibility for identifyinghealth and social care needs andadvocating these with fundingbodies (PCT, local authority)

• Provide advice and help onaccessing funding

• Act as a link with, and voice of,community groups and individuals(one of our suggestions in thepresentation)

• Reflecting the goals and strategyof the LA at the local level (whichis currently a very grey area)

The Warnwarth framework was avaluable research tool in enablingus to access the subtle relationshipswithin this partnership and identifyits strengths and accomplishments.Learning from the research hasenabled critical examination ofsome of the assumptions of theframework and suggested furtheraspects to consider:

• The importance of the continuityand history of partnerships

• Explicitly address ‘sustainability’

• The local context in whichpartnerships operate

• The significance of partners’relationships outside thepartnership

• The complex aspects of the roleof leader and the use of power

• The ‘networking’ feature inpartnerships

• Informality

• Acknowledge more explicitly theinterdependence of some of theframework aspects

• The potential to engage withNewman’s work on the dynamicsof partnership.

Alexander, J; Weiner, B et al (2003)Sustainability of collaborativecapacity in community healthpartnerships Medical Care Researchand Review 60 (4): 130S-160S

Allen,T (2006) Improving housing --improving health: the need forcollaborative working, BritishJournal of Community Nursing 11(4): 157-161

Brown D, White J, and Leibbrant L.,(2006) Collaborative partnershipsfor nursing faculties and healthservice providers: what can nursinglearn from business literature?Journal of Nursing Management,14: 170–179

Community Participation: WhoBenefits? York: JRF

Neighbourhood Renewal Unit(2003) Research Summary 7.

CRESR (2005) New Deal forCommunities 2001-2005:

An Interim Evaluation, Sheffield:CRESR

Department of Health (2000) TheNHS Plan London, Department ofHealth Publications

Department of Health (2003)Assessing Children’s Needs andCircumstances: the Impact of theAssessment Framework: Summaryand Recommendations London,Department of Health Publications

Molyneux,J (2001) Interprofessionalteamworking: what makes teamswork well? Journal ofInterprofessional Care, 15 (1): 29-35

New Deal for Communities. TheNational Evaluation 2002/03: KeyFindings London: OPDM

Newman, J (2001) ModernisingGovernance: New Labour, Policyand Society, London: Sage

Robinson,M & Cottrell,D (2005)Health professionals in multi-disciplinary and multi-agency teams:changing professional practice.Journal of Interprofessional Care,December, 19 (6): 547-560

Skidmore, P; Lownsbrough, H andBound, K (2006) CommunityParticipation: Who Benefits? York:JRF

Sullivan, H and Skelcher, C (2002)Working Across Boundaries:Collaboration in Public Services,Basingstoke: Palgrave MacMillan

Warne,T & Howarth,M (2009)Developing the WarnwarthConceptual Framework forPartnership Evaluation: a Review ofthe Literature Salford: SalfordCentre for Nursing, Midwifery andCollaborative Research

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References


53

Appendix 1


The ‘Warnwarth’ Framework

(A précis of the principal featuresfrom Warne and Howarth (2009).

Right reasons -- having a sharedvision of what might be possiblethrough partnership working andensuring a long-term focus.

High stakes -- compelling reasonsfor individual members to ensurethat the partnership is successful(more than it just being ‘a goodthing’). Might involve agreement onprocesses but desired outcomes area crucial aspect.

Right people -- Have the best andmost appropriate people andsufficiently empower them to havea reasonable degree of autonomy.Issues around appropriate andequitable representativeness needto be addressed.

Right leadership -- Identified innearly all evaluation instrumentsand assessment tools as possibly themost crucial element in achievingeffective working. Need to fosterrespect, trust, inclusiveness and beflexible in style and approach.

Strong, balanced relationships --Need to ensure that relationshipsare managed, nurtured andsupported, recognizing issuesaround imbalances in power whichneed to be addressed sensitivelywith an awareness of differentorganisational cultures representedwithin the partnership.

Trust and respect -- Allcontributions need to be valued andrespected regardless of levels ofresponsibility. This takes time.

Good communication -- Individualmembers need to ensure withintheir organisations and across thepartnership that communication isas open as possible. It also meansthat group members should feelable to communicate ideas andcriticism in safety.

Formalisation -- Even simplepartnerships require governancestructures which need to beconstantly reviewed to ensure thepartnership can endure and survivebeyond the active participation ofindividual members

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Appendix 2


Schematic Structure of Impact Programme Delivery Model

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Notes


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Contents

Chapter 4 Explicating the role of partnerships in changing the health andwell-being of local communities: A New East Manchester Case Study

Introduction

New East Manchester – A Regeneration Vehicle

Deprivation in East Manchester

New East Manchester and Partnership-working

Methodology

Findings

Differing Discourse on Health and Well-being

Consultation, Engagement and Ownership

Informal Health and Well-being Provision

Conclusion

References

Authors

Ryan Woolrych and Judith Sixsmith, Manchester Metropolitan University

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This case study has adopted aparticipatory action researchframework to understanding the roleof partnership-working throughcollaboration between regenerationprofessionals and local residentswithin an area of regeneration. Thischapter focuses on shared learning,experiences and understandings ofregeneration professionals and localresidents to enable a betterunderstanding of how partnership-working for health andwell-being has been articulated withina regeneration area of the North-West. The work undertakenand data collected through this casestudy constitutes a wider UrbanRegeneration Making a DifferenceGrant entitled : UnderstandingHealth and Well-being: AParticipatory Action ResearchApproach.

This case study is located in theregeneration area of East Manchesterwhich since 1999 has received largeamounts of investment through theUrban Regeneration Company, NewEast Manchester. The funding has ledto significant physical transformationof the area as investment has beenchannelled through key developmentframeworks which have led to theimplementation of a number ofphysical, social and economicregeneration programmes. It isthrough this investment that theurban regeneration company hasintended to improve the health andwell-being of local residents basedupon a number of key performanceindicators aimed at tackling majorhealth determinants. New EastManchester’s strategic vision aims atimproving quality of life for residents,as well as creating a vibrant, liveableplace where people aspire to live andwork through long-term sustainableregeneration. An independentevaluation of the regenerationprogramme revealed that significantprogress has been made to alleviatedeprivation across the area,

“New East Manchester is makinggreat progress… it has alreadydelivered many of its key projectsacross its strategic ambitions and ison course to deliver many more”(EIUA, 2007, p.23).

The evaluation report highlights thatimprovements have been made acrossdiverse range of health and well-being determinants includingcommunity cohesion, housingconditions, educational attainment,and economic prosperity across theregion (EIUA, 2007,). Other research,whilst not focussing on New EastManchester per se, has been morecritical of regeneration initiatives inthe UK as being to focussed onphysical transformation; a focuswhich can have deleterious effects onthe social well-being of localresidents. Here, feelings ofcommunity detachment, exclusionand placelessness can arise (Brown etal, 2003; MacLeod and Ward, 2002;Lees, 2004).

Further debate has centred aroundcollaboration and partnership-working with the local community. Acore objective of the regenerationstrategy has focussed on communityengagement and participationthrough partnership-working whichencourages local people to helpshape and deliver regenerationinitiatives. Here, regeneration policyhas been centred on ‘strengtheningcommunities’ and the need to ensurethat local people have the “skills,knowledge and abilities to effectivelyengage in their area” (New EastManchester, 2001). The documentprioritises the need for communityfacilities which are designed,implemented and sustained by thelocal community. Despite governmentpolicy promoting capacity-buildingwithin the local community (CLG,2006, 2008) the delivery ofregeneration practice across the UK

has achieved mixed results inlegitimising local residents andempowering them through thedecision-making process (Diamond,2004, Dinham, 2006). New EastManchester, considers the“community” to be partners in thedesign and delivery of services in thearea. Consultation, engagement andbuilding skills within the communityhave been a recurring element of theregeneration frameworks for the area(New East Manchester, 2000, 2008).

Using the Warnwarth conceptualmodel for partnership-working(Warne and Howarth, 2009) this casestudy undertakes a participatoryaction research approach tounderstanding the issues which haveemerged from the partnership-working between regenerationprofessionals and local residents. Thiscase study does not analyse a specificformal partnership, rather it providesa critical reflection of the powerimbalances and the differing notionsof health and well-being,engagement and participationbetween the ‘resident’ and‘professional’ communities.

The objectives of the study were to:

• Explore professional and residentconceptualisations of health andwell-being through theregeneration;

• Understand how health and well-being is articulated within theregeneration process;

•Investigate the role of residentparticipation and engagement as aform of partnership-workingbetween the ‘resident’ and‘professional’ community;

• Begin the process of sharedvisioning through an action researchevent aimed at sharing knowledge,learning and experiences aroundpartnership-working and togenerate recommendations forpolicy and practice

Introduction

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The delivery system of regenerationwithin the UK consists ofneighbourhood renewal andregeneration programmes, area-basedinitiatives and EU funding being usedalongside mainstream public servicesand investment from the privatesector with the aim of alleviatingmultiple deprivation in inner cityareas. A key recommendation fromthe “Bringing Britain Together” report(SEU, 1998) and the “Lord RogersUrban Task Force Report” (Urban TaskForce, 1999) was for a singleorganisation (urban regenerationcompanies) to instigate a coherentsingle vision for an entire area andthen co-ordinate and oversee itsimplementation. As a result New EastManchester Urban RegenerationCompany was established with thelead responsibility for delivering along-term strategic holistic vision forphysical, social and economic changewithin that area of the city.

The partnership brought togethernational, regional, and localgovernment to work along side the

local community to ensurecomplimentality, additionality and acoherent approach to both public andprivate sector investment.

As the problems facing EastManchester were predicated uponcomplex socioeconomic andenvironmental factors, acomprehensive and integratedapproach was undertaken, central towhich is the development ofpartnerships with local organisations,the private sector voluntary bodiesand community representatives. NewEast Manchester brings together anumber of the Government’s area-based initiatives, which have beendesigned to address the problems ofurban deprivation.

These, amongst others, haveincluded: Housing Market RenewalProgramme, Surestart Programme;Health, Education and Sport ActionZone initiatives. It also encompassesthe New Deal for Communities (NDC)and Strategic Regeneration Budget(SRB) initiatives otherwise known as‘Beacons for a Brighter Future’ in EastManchester.

Community engagement is a majorfeature of the programme, with anemphasis on community ‘ownership’,the importance of joined-up thinking,partnership working and servicedelivery and the integration ofmainstream activities. The New EastManchester focus is to achieve long-term results, which will narrowthe quality of life gap between EastManchester and the rest of thecountry (New East Manchester, 2001)

Regeneration geography in East Manchester

2. New East Manchester – A Regeneration Vehicle

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The New Deal for Communitiesprogramme has contributedsignificantly to the regeneration ofthe Beswick, Clayton and Openshawareas of East Manchester through acombination of Government,mainstream and private sectorfunding, including the £51 millionNDC and £25 million SRBprogrammes. As a result significantprogress has been achieved acrosskey parameters including crime rates,educational attainment, employmentstatus and measurable health.Additionally, notable improvementshave been made to local housing, asa consequence of the recognition thatmany of the problems associated withdeprived areas, including the qualityof the area and health outcomes, aredirectly linked to housing conditions(ODPM, 2005). Integral to this wasthe need to manage housingtransformation within an areacharacterised by a high proportion ofsocial housing which typically sufferedfrom multiple problems (poor housingconditions, social and economicproblems). The Decent HomesStandard was a result of the HousingGreen Paper published in 2000,which called for “quality and choice:a decent home for all” (DETR, 2000).

A recent evaluation of the New EastManchester regeneration programmehas commended the regenerationarea on achieving improvementsacross a range of health and well-being determinants including reducedlevels of crime, higher educationalattainment and increasedemployment. Furthermore, theregeneration was seen as successfulin establishing partnerships through“extensive collaborative working”across the programme, whilsteffectively engaging and consultingwith the community through theresident liaison team and existingward co-ordination structures (EIUA,2007).

Beacons, supported by the ODPMManchester Housing Market RenewalPathfinder (ODPM, 2003) scheme hasbeen active in regenerating housingstock in the area of East Manchester,integrating: (i) social justice and livingstandards (ii) increased economiccompetitiveness of poor areas andtheir residents and (iii) improved socialcohesion through housingdiversification. The provision of betterhousing quality and management isintended to provide direct quality oflife benefits to local people; stabiliseexisting populations and attract newresidents; reduce stigma and lever inprivate sector investment. This hasalso involved a rigorous programmeof reinvestment in existing stock(repairs, renovation and up-grading)to ensure that all homes now meet

the governments Decent HomesStandard required by 2010. Theintention of the housing marketrenewal scheme was to change thesocial mix of deprived areas as a toolfor achieving improved socialoutcomes (Kleinhans, 2004). Urbanregeneration policy has argued thatmixed tenure is vital to improve socialintegration and sustainneighbourhood facilities in order tocreate regeneration that lasts (DETR,2000). However, some researchsuggests that the principle of housingmarket renewal is predicated upon aprocess of social engineering, whichdemonstrates a shift from sociallyoriented targets towards housingmarket and housing career milestones(Tunstall, 2003). It has beensuggested that such policy lacks aclear operationalised definition ofsocial cohesion and underestimatesthe importance of the ‘community’,which is a place for building socialcapital, woven together by deep-rooted social networks (Forrest andKearns, 1999, 2001).

Furthermore, research indicates thatplace is more intimately connected topeople and that housing policy,through displacement, can disruptcommunity cohesion as it fracturesthe intimate relationships betweenpeople and place (Lees, 2004). Thedynamics between people, place anddeterminants of health and well-being have been well explored(Macintyre et al, 2002), providingevidence to suggest that regenerationpolicy, through physicaltransformation, has a significant partto play in creating ‘places’ which arethe context for improved health andwell-being. Although research hasbeen conducted on linking theconcept of place to the notions ofhealth settings and well-being, littleattempt has been made to situate thiswithin regeneration.

Photographs A and B: NewHousing Stock in EastManchester

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East Manchester was formerly thehub of industrial activity in the region,but started to experience seriouseconomic, social and environmentaldecline in the last quarter of thetwentieth century. Subsequently, thearea suffered physical decay, withmany derelict buildings and largeareas of vacant and degraded landcharacterising the area. Populationnumbers declined as Census resultsevidenced a 13% reduction inpopulation across the New EastManchester/Beacons area between1991-1999, despite the rest ofManchester growing by 3.5% duringthis period (New East Manchester,2001). Vacant housing became a keyproblem in the area, as the value ofhousing stock declined five-fold in tenyears (New East Manchester, 2001).These problems perpetuated in apoorly educated, unskilled workforce,with little or no aspirations for thefuture.

Demography

Analysis of the background datareveals that the householdcomposition of New EastManchester/Beacons area hasrevealed that 16% of a population ofjust under 63,000 are of pensionableage, compared to just under 14% forthe rest of Manchester (ONS 2005,Mid-year estimate). Indeed, thepercentage of the population under16 stood at just under 22%compared with just under 19% forthe rest of Manchester (ONS 2005,Mid-year estimate) revealing a smallerpercentage of the potentiallyeconomically active age group (16-64)and thus possible lower levels ofeconomic activity. The ethnicity ofNew East Manchester/Beacons areademonstrates that as of 2001 90% ofthe population were White British,with small minorities of Asian British,Black British and Chinese.

The ethnicity make-up of the rest ofManchester reveals just over 80% arewhite (Census, 2001).

Health

Extrapolation of the health datareveals that in 2001 over 26% of thepopulation had a limiting long-termillness, exceeding the rest ofManchester (22%) and national levels(18%) (ONS, 2001). Despitecommendable reductions in teenageconception rates, they still remain farin excess of Manchester and the restof England (NEM KPI Report,December 2006). The percentage oflow birthweight babies exceeds 13%in some wards, compared to 9.4% inthe rest of Manchester and 8% inEngland and Wales (ONS BirthExtracts 2001-3; ONS VS1 Table2003; NEM KPI Report, December2006). Furthermore, returned data forthe wards of the New EastManchester/Beacons area reveals amortality rate that is far in excess ofthe rest of Manchester (ONS AnnualDistrict Death Extracts (ADDE) 1998-2002; 2001 Census).

Education Attainment

The educational attainment of theresidents of New EastManchester/Beacons reveals that 51%of the economically active populationhave no qualifications, compared to34% of the rest of Manchester and29% nationally (Census 2001).Unsurprisingly, attendance figures atboth primary and secondary schoollevel are below that recordednationally, albeit showing signs ofsignificant improvement across thewhole of East Manchester (NEM KPIReport, December 2006). Suchfindings suggest that the lowaspirations and stifled ambition of theresidents of New EastManchester/Beacons precipitates tothe younger age groups.

Regeneration projects set up as aresult of the New East Manchestereducation programme have beenaimed specifically at educatingyounger people, including aspects ofaspiration building and raising theself-esteem of younger people.

Employment and BenefitsClaimants

Despite reductions in unemploymentsince the regeneration began,unemployment in New EastManchester/Beacons still stands at6.2%, compared to 3.9% forManchester and 2.8% for the rest ofthe North-West (NEM KPI Report,December 2006). Of the economicallyinactive nearly 30% are permanentlysick or disabled, compared to aManchester percentage of 21.5%and a national figure of 16.5%(Census 2001). Of those employed35.5% are in lower supervisory orroutine occupations, which exceedsthat in the rest of Manchester(25.5%) (Census 2001).Manufacturing still accounts for arelatively large percentage ofemployment in the area, with under-representation in the professionalservices sector. The percentage ofbenefit claimants in New EastManchester/Beacons remainsstubbornly high, with just under 12%of working age residents claimingincapacity benefit, compared to justover 8% for Manchester and 4.5%for England and Wales (NEM KPIReport, December 2006).Nevertheless, a number of projectsand initiatives established as a resultof the regeneration’s economicprogramme have focussed their workon ensuring the long-terminvolvement of residents in educationand long-term employment.

3. Deprivation in East Manchester

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Crime and Housing

East Manchester performs positivelyon available data pertaining to actualcrime. Actual vehicle theft has halvedin New East Manchester since 2000(NEM KPI Report, December 2006)and reported burglary (6.89/1000households) is now lower than therest of Manchester (7.8/1000households). Addressing aspects ofcrime and safety and youthintervention are the initiativesundertaken as part of theregeneration’s crime and communitysafety programme. Housing tenuredata for New EastManchester/Beacons reveals highlevels of social rented properties -38% of existing stock is rented fromthe council, compared with the restof Manchester at 28.5% and justover 13% nationally (NEMImplementation Plan, 2005).Additionally, there are still largeamounts of reported vacant housingstock as whole streets, apart fromone or two properties, stand emptyand abandoned (NEMImplementation Plan, 2005).

Index of MultipleDeprivation

The Index of Multiple Deprivation(IMD 2004) is a composite of sevenseparate domain indices which are:income; employment; health anddisability; education, skills andtraining; barriers to housing andservices; crime and disorder; livingenvironment. The IMD reveals thatthe area of New EastManchester/Beacons performs poorly,with 21 of the 38 super output areasof East Manchester findingthemselves in the bottom 1% of thecountry (Oxford University, 2006).


This study contributes to a key aimoutlined in the New East ManchesterRegeneration Framework for the areawhich emphasised the need forCommunity and Capacity Building,which focuses on ‘strengtheningcommunities’ and the need to ensurethat local people have the “skills,knowledge and abilities to effectivelyengage in their area”. The documentprioritises the need for communityfacilities which are designed,implemented and sustained by thelocal community:

‘The key to ensuring that communityfacilities continue to meet demand ofthe local communities is toencourage community ownershipand maintain long term flexibility inthe context of the core principles interms of provision’ (New EastManchester, 2001).

The recent Strategic RegenerationFramework for the area re-emphasised the need to focus oncreating neighbourhoods and placeswhich are responsive to the needs oflocal people. Working in partnershipwith the local community is seen asintegral to the creation of vibrant,good quality and well used placeswhich are ‘recognisable’ and‘sustainable’ as opposed to“fragmented communities of varyingdegrees of stability” (New EastManchester, 2008, p.72).

New East Manchester’s strategicvision aims at improving quality of lifefor residents, as well as creating avibrant, liveable place where peopleaspire to live and work through long-term sustainable regeneration. Anindependent evaluation of theregeneration programme revealedthat significant progress has beenmade to alleviate deprivation acrossthe area, “New East Manchester ismaking great progress… it hasalready delivered many of its keyprojects across its strategic ambitionsand is on course to deliver manymore” (EIUA, 2007, p.23). Theevaluation report highlights thatimprovements have been made acrossdiverse range of health and well-being determinants includingcommunity cohesion, housingconditions, educational attainment,and economic prosperity across theregion (EIUA, 2007,). Other research,whilst not focussing on New EastManchester per se, has been morecritical of regeneration initiatives inthe UK as being to focussed onphysical transformation; a focuswhich can have deleterious effects onthe social well-being of localresidents. Here, feelings ofcommunity detachment, exclusionand placelessness can arise (Brown etal, 2003; MacLeod and Ward, 2002;Lees, 2004).

Further debate has centred aroundcommunity participation as articulatedwithin regeneration policy and theimpact of participation processes onlocal residents’ health and well-being.Despite government policy promotingcapacity-building within the localcommunity (CLG, 2006, 2008) thedelivery of regeneration practiceacross the UK has achieved mixedresults in legitimising local residentsand empowering them through thedecision-making process (Diamond,2004; Dinham, 2006). Theregeneration company, New EastManchester, considers the“community” to be partners in thedesign and delivery of services in thearea and consultation, engagementand building skills within thecommunity has been a key facet ofthe regeneration frameworks for thearea (New East Manchester, 2001,2008).

Whilst the concepts of communityengagement and well-being arewedded together in urbanregeneration policy, substantialliterature indicates that the conceptsof ‘well-being’ and ‘participation’ areboth complex and multi-faceted(Haworth and Hart, 2007). It hasbeen theorised that “the concepts ofwell-being and participation share anobvious similarity: they are bothhighly contested, internally diverse,umbrella terms” (White and Pettit,2002, p.2).

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4. New East Manchester andPartnership-working

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As such, it is not appropriate toconsider the concepts of in isolationrather there is a direct relationshipbetween the two notions, where it issuggested that “inherent in theconcept and practice ofparticipation… is the assumption thatparticipation will enhance well-being”(White and Pettit, p.2). Participation isseen as crucial to feelings of self-determination, personal fulfilment,and making a positive contribution,which are considered key facets ofindividual development and humanflourishing (Shah and Marks, 2004).

Dinham (2006 p.182) argues that“community participation is the key in laying the foundations for well-being”. Community participationis seen as vital to the long-termsustainability of regenerationprogrammes where continuousservice improvement can only be fullyachieved when local people areengaged in the regeneration processand where regeneration policy issuccessful in putting local people “inthe driving seat” (SEU, 2001, p.5).This requires effective partnership-working between regenerationprofessionals and the localcommunity to facilitate shareddialogue, devolved decision-makingand community empowerment.

This drive towards local co-ordinationand collaboration also necessitates acollective effort between theregeneration company, public sectoragencies and the local community,with the local authority as drivers ofchange. This was embodied withinthe Local Government Act 2000,which called for local authorities toproduce Community Strategies/Plans.These plans gave local authorities thepower to undertake anything which is“likely to promote or improve theeconomic, social or environmentalwell-being of the area” (LocalGovernment Act, 2000, ch 2 pt I)with the engagement andparticipation of local communitiesbeing central to the process. Theeffective engagement of localresidents is seen as vital to creatingplaces which are designed andsustained by the local community,bringing about a sense of identity,familiarity and community belonging(Meegan and Mitchell, 2001).

Resident involvement in the creationof new community places enables theoptimisation of place-basedfunctionality and provides theconditions under which the physicalenvironment can becomepsychologically and sociallymeaningful. Conversely, physicalchange which is sudden or seen asenforced can bring about feelings ofalienation, placelessness andexclusion when local people do notfeel that they are engaged or activelyparticipating in the regenerationprocess (Loukaitou-Sideris, 1995).

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5. Methodology

A mixed-methods approach wasadopted to the data collection phaseof the study consisting of: semi-structured interviews with localresidents (n=15), regenerationprofessionals (n=18) and serviceproviders (n=8) followed by an actionresearch event with local residents,regeneration professionals andacademics. A mixed-methodsapproach was used as it enabled abroad range of research techniques toprovide breadth and depth to theexperiences of both the ‘resident’ and‘professional’ community. Kaplan andDuchon (1988, p.575) suggest that“collecting different kinds of data bydifferent methods from differentsources provides a wider range ofcoverage that may result in a fullerpicture of the research problem… itprovides a richer, contextual basis forinterpreting and validating results”.Semi-structured interviews wereundertaken to explore everydayunderstandings of health, well-beingand regeneration within the contextof engagement, collaboration andpartnership-working from theperspectives of both local residentsand the ‘professional community’.The findings were then used as thebasis for shared dialogue and learningthrough an action research eventconducted with the ‘resident’ and‘professional’ community.

An action research event wasconducted as part of the researchproject, which brought together localresidents (n=12), regenerationprofessionals (n=12), service providers(n=7) and academics (n=13) toengage in a process of sharedlearning and reflection. A knowledgecafé approach was undertaken forthe workshops stage of the event,which engendered an open andcreative atmosphere for the workshopdiscussion. In general, knowledgecafés are useful for generating ideas,sharing knowledge, stimulating deepthought and exploring future ways ofworking (Brown and Isaacs, 2002).The collection of data through theworkshops revealed insights into thehistory of partnership-workingbetween the ‘resident’ and‘professional’ community, as well asproviding a forum for local residentsto engage in active dialogue with theprofessional community.

The data from the semi-structuredinterviews and the action researchevent was transcribed andthematically analysed in NVivo.

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Photographs 1 and 2 juxtapose ‘new’and ‘old’ housing within the EastManchester area. Interviews fromlocal residents indicated that thehousing represented in photograph 2evoked feelings of belonging,attachment and social meaning.Photograph 1 represents ‘new build’housing which aesthetically looksmore pleasing, but did notincorporate the components of placeattachment, being seen by localresidents as devoid of atmosphere,community character and socialintimacy which was fundamental totheir well-being.

Local residents felt that these aspectsof well-being were being impactedupon as a result of the regeneration,where physical transformationfractured their social valuation of thecommunity and their sense of place.Improvements to the quality of thelocal environment are vital toalleviating the problems whichcompound the most disadvantagedareas. Yet initiatives to improve thepublic realm thus far are notconsidered comprehensive enough to

deliver the combination of outcomesthat are necessary for comprehensiveregeneration (Scottish Executive,2006). The experiences of localresidents outlined above suggest thatthe regeneration can haveoverwhelming impacts on the localcommunity, where changes to thephysical infrastructure and design of aplace, can sever social ties, andinfluence local resident’s sense ofbelonging and identity. Intervieweesfelt that the community hadsignificantly changed in eastManchester; places that hadfunctioned formerly as communityhubs had since deteriorated and beenclosed down yet not replaced byother amenities or facilities with thesame sense of place attachment:

“We have always used lots of shops…you could go in and have a cup oftea with the guy who owned thenewsagents…We have lived here allour lives, there have been shops allthe way down. Now everything hasgone.”

“That church coming down has nearlyseen me off… that was the mostimportant thing in my life… it wasthe only thing we had where wecould all gather together.”

“Now they are pulling things downand the precinct is going so there iseven less... it was a place for peopleto meet…it is not intentional thatyou go to meet people… but if itsnot there then you are not going tomeet them are you?”

Well-being defined from a review ofthe academic literature includedindividual, social and communityperspectives, whereby the need forpersonal development and humanflourishing (eudemonic factors) isclosely related to happiness andenjoyment (hedonic factors). Well-being is also viewed throughacademic literature as a processrather than a state of being, includingpersonal growth, achievement andflow. Academically based concepts offlow and individual achievement werenot evident in the experiences of localresidents who prioritised communityand social networking, whilst the

Photograph 1: New Housing Development Photograph 2: Terraced housing undergoingrenewal

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regeneration perspective focussed lesson well-being per se and more on theattainment of objective keyperformance targets concerninghousing, educational andemployment opportunity.

These differing perspectives arerepresented in figure 1 below.

6.2 Consultation,Engagement andOwnership

The local Regeneration Framework forthe area identified the importance ofcommunity capacity building, with anemphasis on ‘strengtheningcommunities’ and the need to ensurethat local people have the “skills,knowledge and abilities to effectivelyengage in their area” where “the keyto ensuring that community facilitiescontinue to meet demand of the localcommunities is to encouragecommunity ownership” (New EastManchester, 2001, p.57). Despite thisbeing highlighted as an achievablegoal, regeneration professionals

revealed that previous attempts atparticipation had rarely developedinto community ownership, capacity-building and long-term engagement.Findings from the research indicatedthat there was no common protocolamongst regeneration professionalsfor defining what constitutes effectiveengagement nor were there anyevaluation mechanisms to ensure thatit happened. As a result there waslittle consensus across regenerationprofessionals about what participationand engagement is for and to whatextent it should operate;

“Effective community engagement isdifficult to achieve. We have oftenconsulted with the local communitywithout really thinking about why itneeds to be done and how we aregoing to do it. I am not sure thatthere is a right answer.”

“We have tried getting theparticipation of local people but theystill report that we have not involvedthem. It’s difficult to reacheverybody when note everybodywant to be engaged.”

Figure 1: Conceptualisations of well-being

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Regeneration professionals andservice providers identified thateffective partnership-working need toensure that local residents are centralto the decision-making processthrough the design andimplementation of community placesin the regeneration:

“It is important to consult localpeople in the design of communityspaces. Whilst time consuming andexpensive it gives people a highersense of ownership over the placethat they are in. It will translate intobetter use of that space and a bettersense of well-being.”

Regeneration professionals andservice providers identified theimportance of accessing theknowledge of the local communityilluminating the integral role of theregeneration in promoting theeffective empowerment of localpeople. The advent of Health Trainersin the local community is a step in theright direction to achieving this (DoH,2004) the success of which has led tothe recruitment of local people in thearea of East Manchester (Devine et al,2007). Regeneration professionalsand interviewees identified theimportance of utilising the skills andknowledge of local people:

“We need to empower disadvantagedcommunities to aspire to goodhealth. Local people are in a betterposition because they have localknowledge and they are familiarwith the local community. We needto makes sure that we work withthem to encourage that after theregeneration ends.”

Furthermore, the evaluation ofregeneration initiatives and services inEast Manchester have, unsurprisingly,revealed that local communityinvolvement in the decision-makingprocess increases the success andsustainability of that regeneration

initiatives in the long-term(Quaternion, 2004). The transferral ofownership of community spaces fromthe ‘professionals’ to ‘local residents’increases the chance of that spacebecoming a well-used, well-maintained community place. Thefollowing regeneration professionalidentified the importance of includinglocal people in the design andownership of community spaces:

“The Community Gardens is aboutgetting members of the community,local residents, to makes use ofpreviously disused space. Ourfindings indicate that workingtogether with local residents helpslocal people achieve their aspirationsof what they want their communityto be. It draws people out of theirhomes and get people sociallyinteracting.”

“Those spaces that are owned bylocal residents are almost entirelyself-sustainable. They are pleasantplaces, are better used and workreally well. If they are resident ledthey require less support from usand are better protected in the long-term. Those spaces which areowned by the local community aremore successful than those that arenot.”

Evidence suggests that partnership-working which emphasisescommunity participation andcommunity ownership has positiveeffects on the health and well-beingof communities as participantsdevelop a sense of life purpose,autonomy and fulfilment (Brock,1999; Narayan, 2000). The need foreffective partnership-workingbetween regeneration professionalsand local residents is now becomingmore critical as the regeneration inEast Manchester enters a period ofsustainability. The subject of‘community ownership’ is integral tothe sustainable communities agenda

(ODPM, 2005) and ‘communityempowerment’ is seen as a priorityarea through the creation of stronger,more prosperous communities (CLG,2006).

Local residents felt that the history ofconsultation and engagementthroughout the regeneration hadfailed to meet their expectationsleaving them feeling disillusioned anddisenchanted with the regenerationprocess. They felt that ‘mild’ forms ofconsultation, such as ‘being invited toa meeting, a local event or tocomplete a survey’ were not effectiveforms of engagement as they oftenfailed to engage them in the decision-making process. Residentsexperiences of consultation whichfailed to meet their expectations orraised false expectations had anegative impact on resident’s well-being and discouraged furtherengagement in future consultations.Residents thought that knowledge-sharing, reciprocal dialogue and activelistening were all important aspects ofany engagement process, but wereabsent from their experiences.Importantly, local residents felt thatactual change as a result of theconsultation process was notinstigated by those responsible,leading to feelings of frustration andsubsequent alienation anddisengagement.

Whilst a diverse range of consultationtechniques have been undertaken,interviewees identified the negativeimpacts that can arise when takingpart in consultation. The commentssuggested that further work can bedone to improve the level ofinformation and awareness of localresidents about their expectationsfrom the consultation process byaddressing more closely whatparticipation is for and to what extentit should operate (Dinham, 2006).The following residents indicated that

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all consultation within theregeneration must be seen as aworthwhile exercise to local residents,a process which keeps them engagedand informed about how theconsultation will ensure their long-term engagement. Local residentsindicated that there was a significantdifference between information‘sharing’ which gave local residentsthe opportunity to have opendialogue and having professionals‘telling’ them which was seen as one-way communication. Moreover, theyneeded to see change as a result ofconsultation with professionals and ifthis failed to happen, they becamedisengaged. Local residents stressedthe importance of being kept fullyinformed in the consultation process,receiving information which was clearand appropriately communicated byprofessionals:

“They just fob us off. They don’t tellus anything. I think they must thinkthat we’re stupid or daft. Its justticking boxes for the regenerationteam. They just sit there and tell uswhat is good for us.”

“I can’t think of one time that wehave been involved as part of theconsultation where they have takenon board what we say and gone anddone something about it. It’s just nothappened.”

“The regeneration are not listening towhat we say. They come in, tell usone thing and then do another. Wesent them a letter detailing ourcomplaints. We know where that is.Its in the bin. I don’t think therelistening to people today.”

“We need to be told what is going tohappen and when. Why is it all soconfusing to find out what ishappening. Its all been decided uponwithout any knowledge from us.”

Whilst consultation is one aspect ofcommunity engagement identified in

the city-wide toolkit, there are manyother elements to communityengagement which are equallyimportant including: continuousinvolvement, supporting communityaction; and devolved decision-making(MCC, 2005). The followingcomments suggests that effectiveengagement should involve thecontinuous involvement of localresidents, tapping into the localknowledge of residents, and ensuringthat their expectations are managedthroughout the process. Being moreinformed and aware of consultationand engagement process possibilitiesi.e. through the fulfilment ofexpectations can ensure that localcommunities feel more involved andincluded in their communiry (Dinham,2006). This process needs to bebalanced sensitively as engagementwith local residents is a complexprocess, which is not alwaysbeneficial as there can be difficultieswhen translating the theory ofcommunity engagement into practice(Wilcox, 1994). Consultation which isinhibitive and not conductedeffectively can lead to feelings offrustration amongst local residents.Local residents need to be engaged ina process of active listening andshared dialogue which is bothparticipative and empowering:

“They don’t know what it means tolive in this area. They just think thatwe are do-gooders. If they could putthemselves in our shoes then theywould realise.”

“The consultation that I have beenpart of has been patronising. Theytalk to you as if you don’t knowwhat you are talking about. Theydon’t actively listen to what you aresaying. “

“It [consultation] means absolutelynothing. I came out of theconsultation feeling flat as if it hadmade no difference whatsoever.”

The literature on communityengagement and consultation has along history and has been stronglyinfluenced by Arnstein’s (1969) ladderof participation. The ladder ofparticipation suggests that trueengagement can only be achievedwhen there is effective partnership-working that encourages delegatedpower [to local residents] and wherethere is a sense of [local] control overthe design and management ofregeneration programmes. Theexperience of local residents suggeststhat attempts at consultation havefailed across a number of thesethemes: there has been a lack ofinformation and awareness aboutregeneration programmes in the area;consultation has failed to incorporateresidents views into regenerationchange, and that previous highlycontrolled attempts at ‘partnership-working’ had dampened localresidents enthusiasm to be engagedin the future.

The experiences of local residentssuggested that effective partnership-working, delegated control at thecommunity-level and citizen controlwere still absent from regenerationparticipatory practice. Indeed, theresearch found little evidence tosuggest that planning and decision-making responsibilities were beingshared between regenerationprofessionals and local residents. As aresult, regeneration initiatives haveemerged which do not include thelocal community in their design andimplementation. In many cases thishas impacted negatively on the well-being of local residents, as it hasthreatened concepts of communityidentity, familiarity and belongingthrough regeneration which fails toincorporate the tacit knowledge oflocal residents.

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6.3 Informal Health and Well-being Providers

Resident disengagement from theregeneration can bring about feelingsof disillusionment anddisenchantment. These feelings canhave negative impacts oncommunities who respond to suchadversity in one of either two ways.The first response is for residents tobecome increasingly disenchantedand disillusioned with theircommunity and the surrounding area.As a result, communities can becomeinward-looking and divided asresidents are less inclined to getinvolved in civic life which hasdeleterious effects on social capital.This impact on communities has beendescribed by the social commentatorRobert Putnam as a symbol ofindividuals ‘hunkering down’(Putnam, 1999) where communitiesbecome introverted as a result ofwhat they perceive to be socialinjustice as described by the followingresidents:

“People around here have turned inon themselves a lot more. Nobodywants to challenge anyone thesedays. They think they can’t doanything. They don’t want to go outof their front doors.”

“The community used to be a lotmore responsive. Now people justoperate within their own homes.You don’t get the active neighbouranymore. Those people that wouldknock on your door when times arebad.”

“Everybody used to come out and dotheir bit for the community. Butnow, people are more isolated andnot as many people bother. I don’tthink people feel that they canchange things as much the used to.”

The second response fromcommunities who feel marginalizedor excluded can be described as oneof solidarity and collective effort,where residents develop strong socialties in times of adversity. This secondresponse was typical of many living inthe deprived communities in eastManchester and was described by thefollowing interviewees who weremembers of ‘communities ofresilience’. Left to effect changethemselves, they had developedstronger, more cohesive communitiesin challenging regeneration initiatives:

“If we didn’t do it, nothing would getdone at all.”

“The community needs to be strongwhen times are tough. People getsick of all the crime and things. Thegangs are the ones that come in andcause all the problems. We were sickof them causing problems in ourcommunity. That is why there is stilla community round here.”

“They don’t do anything for us round‘ere unless they are fighting all thetime.”

“We keep it nice round this area. Wenow that nobody will help us. Itwouldn’t be so bad if they said weare looking into it but we never hearanother thing. They are not going todo it so its left to [residents names]and myself. We work together andwe get things done.”

This data supports findings fromother research conducted indisadvantaged areas where, in timesof need, communities developrelationships based on principles ofsocial justice which can be beneficialto health of both the community andthe individual (see Campbell et al,1999). The importance of social tiesin deprived areas has been previouslyidentified whereby “the poorneighbourhood may have weak andinward looking networks, whichnevertheless offer strong support inadversity” (Kagan et al, 2000, p.2). n

an effort to grasp some ownership ofregeneration in the area, informaltypes of engagement had emerged ascommon practice amongst thedeprived communities in theregeneration area. Formallydisengaged and disenfranchisedmembers of the local communitydeveloped informal methods ofengagement such as generatingneighbourhood campaigns andcommunity gardens. These methodsof informal working were boundtogether by public characters withinthe local community who were seenas informal community well-beingproviders, active in encouragingparticipation and engagement ofother neighbours and communitymembers. The availability and qualityof these groups were integral to thedevelopment of social capital acrosscommunities within the regenerationarea.

“It is one person on a street that doeseverything and takes responsibility. Ithas been like that for years.”

“People like [residents names] give usa place to go if there is a problem. Ifyou need anything then you can goround there. You know that if youare frightened or anything like thatthen you can go round there.”

“If he is going to the precinct they hewill ask us if we want a bit ofshopping, I’ll give him some moneyand he will go and get it for me. If Ineed a prescription, I will fill in theback and he will say right I will goand get it for you and bring it back.

“It’s nice that [resident name] islooking out for you becausesometimes you can feel a bit on yourown.”

“If I tell [resident name] that I amgoing in hospital for a fortnight or aweek then she says right I will keepan eye out on your flat. I haveknown her since I moved in here. I’dbe knackered without her.”

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These local characters were active inaddressing problems within thecommunity and improving the well-being of other residents by providingemotional support for local residentsand encouraging the participation ofother community members in issueswhich directly affected their lives.Moreover, these active members ofthe community, seen as ‘informalwell-being providers’, variouslyexperienced emotional highs (whenachievements were made) and thoseresidents who actively participatedexperienced improved well-beingthrough raised self-esteem, positiveaffect and personal fulfilment.Although these informal networksrepresented a valuable resource tolocal communities, they typically falloutside of the formal partnership-working taking place throughregeneration practice. As a resultthere was no formal support for theinformal well-being providers whoseattempts at garnering participationand problem-solving in the localcommunity had deleterious effects ontheir health and well-being throughmental stress and physical burn-out.Resident interviewees identified thenegative impacts of activeparticipation especially in theregeneration experienced on a dailybasis.

“It gets on top of you. A lot isexpected of you. You are fighting ontwo fronts. The needs and wants oflocal residents and then battling withthe professionals and the serviceproviders. It gets a bit on top of meand I have got bags of patience.”

“Sometimes you take on theproblems of the whole communityand it can weigh you down. If thereare problems and issues in thecommunity then it affects my wholemood. If things are going well, I feelgreat. If they are not going so well, Idon’t feel so great.”

“There are times when you sayenough is enough. You get burnt-out. That’s when I have to take acouple of days off. I go and see myfamily for a couple of times. Then Ican reflect, recuperate, come backand take it all on again.”

“We are stressed. We don’t have anoutlet. We are never away from it.You cannot just walk away frompeople with problems and say ‘You’llbe alright’. They have got no-oneelse. “

Informal health and well-beingproviders are integral to activecommunity involvement in theconsultation process. However, theywould require the necessary supportand the resources at the community-level to facilitate this (including:financial resources; emotionalsupport; and established trust andreciprocity with service providers) assuch activity can be psychologicallystressful (Raschini et al, 2006;Sixsmith and Boneham, 2004).Effective partnership-working withthe local community has been shownas essential to the success ofregeneration initiatives aimed atimproving the health and well-beingof local residents (Scottish Executive,2006). Evidence of partnership-working reveals that communityrepresentatives engaged inpartnership with the regenerationagency can have a positive impact onthe success of regeneration initiatives(Purdue, 2001).

However, further work needs to bedone to manage the expectations ofthe local community in the planning,design and implementation of place-specific regeneration programmeswhich can help deliver effective andlasting regeneration (ODPM, 2005).

These attempts at engaging withlocal residents are identified in thecity-wide engagement toolkit (MCC,2005) but effective consultation andengagement as part of theregeneration needs to enableknowledge sharing, active dialogueand shared decision-making withlocal residents. Furthermore, theyshould sensitively manage andsupport the health and well-beingneeds of community champions orinformal health providers whotypically suffer stress and burn-out asa result of actively participating intheir local community. This needs tocompliment the work undertaken andby the New Deal for Communitiesresident liaison team, which has beenactive in engaging and developingrelationships with residents liaisonteam members/tenants associations.

The action research event organisedwithin the research projecthighlighted the willingness ofregeneration professionals and serviceproviders to work more effectively toengage with these members of thecommunity (see photographs 3 and 4below). This constituted a proactiveeffort to reconcile the sorts ofinformal participation describedabove with the formal processes ofparticipation previously undertaken.

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6. Findings


The findings revealed that there werea number of inter-linked factorswhich influenced the perceivedsuccess of partnership-workingbetween the ‘resident’ and‘professional’ community. Thesethematic indicators were crucial tounderstanding the objectives,processes and achievements of thecollaborative partnership between thelocal residents and regenerationprofessionals. The findings from theproject identified the partnership as acomplex reciprocal process betweenthe ‘resident’ and ‘professional’community governed by a number offactors including: differing discourseson health, well-being, participationand engagement; history of workingtogether; existing decision-makingstructures; information, awarenessand communication; trust, reciprocityand ownership.

6.1 Differing Discourses onHealth and Well-being

When understanding the notions ofhealth and well-being within thecontext of regeneration it wasnecessary to ascertain how theconcepts of ‘health’ and ‘‘well-being’might differ in their interpretationbetween regeneration professionalsand local residents. This interpretationis crucial to the ways in whichregeneration is addressing theconcepts of health and well-being inthe lives of local residents.Regeneration professionals articulatedthe concept of well-being throughthe achievement of measurabletargets and outcomes defined as keyparameters in the regenerationevaluation. These targets weredefined as both health indicators (lifeexpectancy, infant mortality rates) andwider health determinants (such aseducational attainment, housingconditions, crime rates and

employment indices) through whichregeneration professionals hoped thatwell-being would derive.

“We will only improve people’s well-being if we narrow that gapbetween East Manchester and therest of the city. It’s about healthinequalities.”

“We are focussed on the economicside… employment gives peoplemoney… and this naturally lead tobetter well-being and quality of life.”

“The housing market renewal processhas been a fundamental part of theregeneration. Build more houses,attract people into the area and newbusiness. That is what is going tosustain the regeneration in the long-term.”

The experiences of local residentsindicated that well-being was locatedfirmly within their social andcommunity life. Local residentsidentified a number of factors whichthey perceived as important to theirwell-being including: their sense ofplace attachment; feelings ofcommunity identity; their ability todevelop and maintain socialrelationship; and their ownership ofand engagement in communityplaces. Residents felt that havingaccess to strong social ties andnetworks of emotional support wereimportant to the development of theirsense of well-being. These strong tieswere defined in terms of relationshipswith their immediate neighbours andother residents in the local area:

“What’s important to me is beingsurrounded by people that I know,friendly people. If you have yourneighbours, then the problemsaround ‘ere don’t seem half as bad.And the good times better.”

“That social stuff is important in mylife. It is that neighbourliness. It isabout one neighbour going over toanother neighbour when they arepoorly and saying ‘Look, I’m goingto the shops, do you want me topick up some shopping for you?”

Local residents identified theimportance of community ‘hubs’ asplaces for creating, maintaining andaccessing social capital. Here, localresidents identified a strongenvironmental component in buildingsocial capital. Importantly, residentsfelt that such places were central tothe creation of cohesive communities,as they brought different sections ofthe community together in a commonplace which allowed mutualunderstandings to grow andcommunity norms to be transmitted:

“If you’re working all week, how doyou get to meet people? The marketcan be great for that. It’s a meetingplace. A place to go and seeeveryone. Absolutely fantastic.”

“It [community places] is a way foreverybody to get to see each other.They bring the community together.Then everybody looks out for eachother. These places bring everyonetogether.”

“It’s a place for people to go andchat. A place for people to interactand communicate. That is just whatyou want in your community.”

“Its important to have a place to goto where you can mingle with otherresidents in the community. A placewhere you can learn anything aboutthe community that you need tolearn.”

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They recognised that the poor historyof working relationships and theestablished power imbalances need tobe re-dressed before the requiredtrust and reciprocity could begenerated. Once harmonious jointworking with informal communitywell-being providers was established,the capacity of local people toparticipate and to remain engagedafter the regeneration funding ceasescould be enhanced. Importantly, theinclusion of informal well-beingproviders represents an opportunity toshift power dynamics to be morereflective of the experiences of thecommunities being regenerated.

Whilst informal well-being providersrepresent a model to advance theparticipation agenda in regeneratedcommunities, more work needs to bedone to ensure that futureconsultation and engagement isdesigned around the needs of localpeople. Local residents need to beseen as equal in the decision-makingprocess where informal well-beingproviders are legitimised asrepresentatives of the localcommunity.

For this to take place, there needs tobe more work with local communitiesthrough informal modes ofengagement aimed specifically atrelationship-building at thecommunity level. Informalengagement and the networks thatdevelop within them need to beintegrated into the existingpartnership model. Failure to engagewith these networks will result inlocal residents feeling that theattempts of the regeneration todevelop truly effective partnershipsare both disempowering anddisingenuous.

Photographs 3 and 4: Knowledge café workshops bringing together residents, professionals and academics.

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7. Conclusion


Regeneration policy has increasinglydictated an integrated and holisticapproach to alleviating problems ininner city areas. This policy hasidentified the importance of engagingin collaboration with the localcommunity through partnership-working towards a sharedregeneration vision whereregeneration initiatives are shapedaround the priorities of localresidents. That partnership betweenregeneration professionals and localresidents was founded upon the needfor a ‘collaborative model’ based oninformation and awareness,consultation, engagement through toshared decision-making andcommunity ownership. It wasintended that this facilitate physicaltransformation which addresses thesocial and community well-beingneeds of local residents (Mitchell andShortell, 2000). The need to engage,empower and encourage theparticipation of the local communityhas been pushed from centralgovernment i.e. externally, thepartnership can be seen as a policyinstrument, which internally (i.e.through the working practices of‘professionals’ and the ‘livedexperiences’ of local residents) isresource-intensive and does notreconcile with existing engagementstructures and resident liaisonframeworks.. As a result, the researchrevealed that the form of‘partnership’ which has developedbetween the ‘professional’ and‘resident’ community has beenfraught with power imbalances,different discourses and existingstructures which have prevented a‘successful’ or ‘good enough’partnership from being developedbetween the resident and professionalcommunity .

The notion of well-being is aconstruct through which we canunderstand the experiences of peopleand places within the context ofregeneration, physical transformationand social change. Closely allied tothe concept of well-being is thenotion of participation, and forms ofresident engagement andpartnership-working which are seen(through regeneration policy) ascentral to the long-term sustainabilityof regeneration programmes.However, the way in which the twoconcepts are articulated through theimplementation and evaluation ofregeneration practice differs from theexperiential reality of local residents.There needs to exist the opportunitiesand pathways for shared knowledge,experiences and learning betweenregeneration professionals and localresidents to develop shared visionsabout how improved health and well-being can be achieved throughcollaboration and partnership-working. Resident notions of healthand well-being within communityplaces need to be incorporated intospecific urban planning policy, toensure that regeneration practicecreates community places which aresocially and psychological meaningful.This will help towards the creation ofcommunity hubs which help generatehealth and well-being andimportantly in creating sustainablecommunities in the long-term. Fromthe outset New East Manchesteraimed to create these places for thecommunity through ‘communityhubs’ (New East Manchester, 2001),the concept of which was givenrenewed emphasis in the latestStrategic Regeneration Framework forthe area (New East Manchester,2008).

The raised expectations amongst localresidents about what theregeneration will achieve leads tofeelings of frustration, apathy anddisenchantment within thecommunities being regenerated.Attempts at consultation andengagement have been lesssuccessful as the partnership betweenregeneration professionals and localresidents have become fractured.These schisms arise as theparticipation and engagementpracticed by regenerationprofessionals fails to reconcile withthe needs of local residents whichincludes a desire for active listening,partnership-working and equal powerin the regeneration process. Theresilience of local communities has ledto the emergence of informalnetworks of engagement incommunities, driven by activemembers of the community toaddress local issues. Such informalwell-being providers encourage theparticipation and engagement ofother members of the community.Whilst this provides improvedwellbeing through raised self-esteem,positive affect fulfilment for thoseengaging, a lack of availableresources, training andcommunication channels has resultedin some experiences of stress andburnout. Current regenerationpractice suggests that whilst informalyet active groupings remain outsideof the formal engagement process,they will be excluded from theassistance afforded by formalpartnerships.

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If participation and engagementthrough regeneration policy andpractice is to engage the localcommunity in effective partnership-working and relationship-building thenregeneration agencies and serviceproviders need to work towards ashared vision and experience of whatthe notions of (i) well-being and (ii)participation are within the context ofregeneration and partnership-working. Failure to engage andparticipate effectively is unlikely tosustain the interest and long-termsupport of local people. This can havedetrimental impacts not only onphysical and social community placesbut through engendering feelings ofdisillusionment and experiences ofpoor well-being within local residents.Local residents need to be seen asequal in the decision-making processwhere informal well-being providersare legitimised as representatives ofthe local community. For this to takeplace, there needs to be more workwith local communities throughinformal modes of engagementaimed specifically at relationship-building with the community in theirlocal area, in line with the currentnational policy trends towardcommunity empowerment andcapacity building (CLG, 2008).Informal well-being providersrepresent a model to advance theparticipation agenda in regeneratedcommunities. Further work needs tobe done to explore the capacity tosupport informal health and well-being providers within existingformal engagement structures.

An informal engagement agendaneeds to compliment the existingformal engagement which isundertaken through currentregeneration practice. Communityinvolvement which is facilitated byinformal providers within thecommunity will be much reflective ofthe community and is more likely tobe sustained in the long-term.

A key challenge of the regeneration isto re-build effective workingrelationships through partnershipsthat help ‘bridge the divide’ betweenthe ‘resident’ and ‘professional’community. This requires thedevelopment of an engagementframework which facilitates changesto existing decision-making processes,resource allocation and powerrelationships. This is a significantchallenge – although the premise ofcommunity led regeneration was thegrounding for the New Deal forCommunities programme and laterdevelopments have seen establisheddirectives for effective participationthrough Local Strategic Partnerships.Whilst this directive has beenestablished within currentregeneration, the experiences ofregeneration professionals and localresidents operating outside of thissystem (that is the New Deal forCommunities) suggest that, inpractice, these changes are difficult toimplement. Firstly, the uniqueattributes of communities prevent a‘one-size’ fits all approach toaddressing participation in deprivedcommunities yet there is emphasis onhaving a framework for suchengagement.

Secondly, the extent to whichparticipation can be undertakendepends upon the resources allocatedto regeneration professional engagedin that type of work. Thirdly, effectiveengagement with local residentsrequires creativity and imaginationfrom regeneration ‘professionals’, ofwhich there is limited opportunity forwithin some of the current fundingsystems. Fourthly, if capacity-buildingand power sharing are ‘desirable’outcomes, will the ‘professional’community be inclined to relinquishpower and move from a formalpartnership towards an informal,flexible approach where the outcomemaybe unexpected; and where‘outputs and outcomes’ are such anessential aspect of regenerationevaluation and funding.

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Contents

Chapter 5: Swimming in Both Waters: A Case Study of the Manchester Learning Disability Partnership

Authors: Garry Diack and Eileen Fairhurst: Manchester Metropolitan University

Executive Summary

Introduction

How this case study fits into overall HEFCE project

Methodology

Purpose

Policy Context

Manchester Learning Disability Partnership (MLDP)

Inter-organisational Working

A time of innovation and a shared sense of social injustice

Identification of opportunities

Conclusion

References

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Executive Summary

This case study formed part of aHEFCE funded project to examine thenature of partnership working. Inparticular it uses the WarnwarthFramework to examine theManchester Learning DisabilityPartnership (MLDP). The intention of this report is to identify salientfeatures of the development andorganisation of MLDP that may beuseful to new partnerships.

In-depth interviews were conductedwith key members of (MLDP), thetape recorded interviews weretranscribed and a thematic analysis of the transcripts was undertaken.

Both Management Team andPartnership Board meeting minuteswere examined. This enabled thecommunication processes operatingwithin MLDP to be outlined. Keyaspects of MLDP’s communicationprocess are: the open exchange ofinformation, the production ofdetailed minutes and dissemination of information.

Features are identified which accountfor the sustainability and longevity of the partnership over a period of 14 years. The nature of inter-organisational and inter-professional working within the context of the partnership isexamined.

Introduction

Although there is extensive literatureon partnership working, especially inthe realm of health and social care,much of it can be characterised asoffering a ‘pessimistic model’ (Hudson2002) . Typically, differences inorganisational culture between healthand social care institutions and/ordifficulties in inter-professionalworking are identified as ‘barriers’ to‘successful’ partnership working.Hudson (2002: 15) notes ‘…thereis also support for the possibility of a more optimistic view of inter-professionality. Even thoughharmonious relationships may be onlypatchy and partial, the fact that theydo exist suggest that it is time tomove on from an unduly pessimisticview’.

This case study is offered as a counterbalance to this ‘pessimistic view’: the Manchester Learning DisabilityPartnership (MLDP) has been inexistence since 1999. Prior to this aJoint Learning Disability Service, inwhich some of the people currentlyworking in MLDP were employed,operated from 1994 (MLDP, 2008)Some of the participants in this pieceof research have been key players inthe partnership since that time.Internal organisational documents,together with oral histories of keyindividuals who have been closelyinvolved in the establishment andcontinuing development of thepartnership provide the materialsfrom which this case study isconstructed.

A consequence of the NHS &Community Care Act (1990) was thatprofessions had to learn to worktogether in pursuit of their goals.This departure from previous modelsof working was significant andcharacterised by the development ofpartnerships. This makes it aninteresting and relevant case studybecause it is possible to trace the

development of partnership workingover an extended period of time andto understand the elements that havecontributed to the maintenance ofthe partnership.

There are a range of governmentreports which promote theintegration of services and jointworking between health and socialservices departments. (DoH 1997),(DoH 1997a), (DoH 1998), (DoH1998a), (DoH 1998b) Reference ismade in the interviews and the textsof the period that were authored bymembers of the management teamto the policy drivers that shaped thework being undertaken.

Better services for vulnerable people(DoH 1997) laid down therequirement for a JIP (JointInvestment Plan). The developmentof the JIP is described clearly withinthe partnership board meetings ofMLDP.

It will be shown how thesustainability of this partnership hasrested upon both matters of inter-organisational working and inter-professional relationships. Initially, thepurpose and workings of MLDP willbe described. Then the establishmentand development of MLDP will belocated in the policy context. Inter-organisational working will beexamined in terms of seniororganisational ‘sponsors’ andfinancial/operational matters. Theways in which individuals may ‘use’differences in organisational ways ofworking to achieve their purpose linkswith inter-professional working.Exploration of such matters displaysthe crucial nature of being‘innovative’.

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How this case study fits intothe overall HEFCE project

This study is one of five case studiesthat are intended to provideinformation that will inform thedevelopment of a best practiceevaluation framework for theassessment of partnership working inthe context of health and well-beingof communities.

Methodology

Thematic interviews were conductedwith key members of the organisationusing a free ranging interview with aseries of guide questions to initiateconversation. Each interview wasmarkedly different from theinterviews of other interviewees, therich detail presented in each of thetranscripts is illustrative of the natureof service operation at the time whichwas both innovative and risk laden.

Some of the key figures within theorganisation have been a part of theMLDP, and its pre-cursor the jointservice, from its beginnings. This hascontributed significantly to thesuccess of the organisation. Thelongevity of the relationships and thefamiliarity of each member with themanagement team has facilitated aproductive working partnership.

Oral histories are useful tools in theunderstanding of learning disabilitynursing and Mitchell & Rafferty(2005) note that there are variousaccounts both from people withlearning disabilities and from the staffwho supported them. This case studyis in the latter category andconcentrates on managers in theservice.

As is not unusual when using an oralhistory approach, there was littleneed for a comprehensive interviewguide. Interviewee’s accountsdisplayed the features that hadcontributed to the success of thepartnership.

The interview guide questions wereonly loosely adhered to andrespondents were given free reign totake the conversation where theythought it appropriate.

A range of documents wereexamined. These comprisedPartnership Board meeting minutesfrom 1999, management teammeeting minutes from 1994, variousbooks and papers authored bymembers of the partnership team,consultation papers and informationfrom the MLDP web-site.

Purpose

The Warnwarth conceptualframework posits eight elements thatcan be said to contribute to a ‘goodenough’ partnership to enable thedesired work to occur. The case ofMLDP will be examined in the light of the proposed conceptualframework identifying its salience and noting where inter and intra-professional working is successful.

The eight elements of the WarnwarthFramework will be examined inrelation to MLDP. These are asfollows:

Right reasons. The setting conditionsfor the partnership had their originsin the broad cultural changes thatwere influencing services throughoutthe 1980s. The managers in thepartnership had worked in a range ofservices that had particular ways ofworking.

The training of staff was not aswidespread or as effective as it istoday. This contributed to adichotomy between those for whomthe institutional style of serviceprovision was an uncomfortablecompromise and those who workedin the setting without necessarilyquestioning the moral and ethicalissues implicit in the medical model of care. Mitchell & Rafferty (2005)describe nurses who declared adegree of discomfiture with their

previous professional lives and theirparticipation in delivering care in thismanner.

Individuals interviewed noted thesense of dissatisfaction people hadwith the style of care being offeredand their belief that people wereentitled to a far better quality ofservice.

High stakes. The stakes at the timewere very high as the process of de-institutionalisation was not optionalonce the legislative drivers (seebelow) were in place. Theaccountability and responsibility foroutcomes was as much a feature ofthe respective professional status ofthe participants as it was an enforcedaspect of the emerging ‘scheme ofwork’.

Right People. The members of MLDPand its precursor the Joint LearningDisability Service were, viewedthrough the lens of history, highlyappropriate for the task at hand. Theywere empowered to act by therequirement to implement the NHS &Community Care Act, DoH (1990),policy development and theincreasing appeal of the ideasunderpinning the philosophy andservice models of normalisation.

Normalisation is a conceptual termthat has its origins in the work ofScandinavian services in the 1960s.The adoption of the concept byvarious countries inevitably resulted inthe development of a range ofinterpretations of the original term.

In the United Kingdom John O’Briendeveloped an interpretation ofnormalisation that defined a series ofoperational service accomplishments.The term Social Role Valorisation(SRV) was utilised and became one ofmany acronyms to dominate thehealth & social care lexicon.

It could be argued that the adoptionof concepts such as normalisationand SRV served to unify the aims and

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objectives of organisations that werestruggling to work collaboratively. Toally oneself with an emerging,internationally important servicephilosophy had considerable appealand in this sense the partnership wasin the right place at the right time.

The tenets of SRV were echoed in thebasic axioms of the Model DistrictService NWRHA (1983) and anacceptance of, and core belief in,these fundamental ideas is repeatedlyevident in the comments ofinterviewees.

Right Leadership. The leadership ofMLDP has changed hands over time.There is little to suggest that MLDPrequired different styles ofmanagement in response to particularsituations but the different leadersover the duration of the partnershipdo have demonstrably differentapproaches. A key aspect of theMLDP leadership is the long tenure ofmost of the members in a North-Westcare delivery/support setting.

These different approaches do notappear to have hampered the corebusiness of MLDP. It could be arguedthat the presence of a long standingcore membership of personnel, albeitin varying positions over 20 years, hascontributed to a sense of stability. Thekey members were drawn fromlearning disability nursing, social workand psychology fields. Informationfrom individual interviewees revealsthe extent to which informalconsultation/advice occurred betweenpersonnel from the differentprofessions.

Strong, balanced relationships. Inter-organisational partnershiprelationships can be complexparticularly if there are a number ofdifferent partners (Fairhurst 2008) asin the case of MLDP. The complexity,whilst potentially problematic, is alsoa rich source of ideas. Accounts fromindividual interviewees highlightconsiderable investment in thecreativity and innovation of the

members. Ideas were encouraged and different ways of thinking weresupported in order to facilitateprogress.

The identification of organisationaldifferences was an early achievementof the partnership. One intervieweedescribes the methods by whichdifferences were addressed in ordernot so much to eliminate, as to workin tandem with, power differentials.This process was to the mutualadvantage of both partnerorganisations. Taket & White (2000)refer to the pursuit of advantage andcite Huxham’s ( 1996 ) work onsearching for collaborative advantage.

Trust and respect. can be linked withright reasons and right people. Thesocial and cultural setting conditionsfor the evolution of MLDP weresignificant. It could be argued that aconcept of ‘values in action’ was aguiding principle.

According to Lewis et al ( 1995) :‘Positive change in the learningdisability arena can be understood inrelation to the emergence of alliancesthat cohere around key ideologicalpositions’ .. There was a strong focusthrough the 60s, 70s and 80s on thedeveloping consensus that people’srights and opportunities were notbeing served. This is exemplified bythe discussions about the principles ofnormalisation.

There are, however, other morepressing factors that drove the originsof normalisation and these had theirroots in the emerging issue of theconcept of rights. Human rights wereincreasingly the focus of debateduring the early twentieth centuryand the post Second World WarUnited Nations Declaration of HumanRights (1948) served as a launchingpoint for subsequent human rightstreaties that were recognised ininternational law.

The uncomfortable truth that peoplewith learning disabilities were deniedthe rights that were being debatedand enshrined in treaties and policy isperhaps brought into sharp focus bythe reports of the inquiries into SouthOckenden l that clearly showedconsiderable deficits in the standardsof care being delivered.

As the authors of the conceptualframework assert, ‘trust cannot bepurchased, enforced and is unlikely tooccur in the absence of a strongcommitment to shared values’ (Warne & Howarth 2009:43) Theaccounts of the interviewees illustratethe high levels of commitment to ashared value base.

Good communication. The MLDPmembers were, and remain now,particularly adept at communication.There are a number ofcommunication processes embeddedwithin the culture of the organisation,principal amongst these is thecascade approach. In this system theservice manager personally signed allbriefings before they were distributed.The Warnwarth framework suggeststhat individuals need to be confidentin messages being communicated andfeel able to advance ideas andcriticisms.

MLDP operates a culture of openinformation exchange although thereare clear parameters around this witha recognition of, and will to issue,clear statements and direct action inpursuit of the continuingdevelopment of the service. Arguablythis is imperative if an organisation isto avoid the developmental stalemateof endless consultation andindecision.

Harrison et al (2003:35) note thatcommunication processes will changeas relationships mature. They statethat in the formative stages of apartnership assumptions aboutcommunication needs are notpossible. Over a period of time anincreasing knowledge and mutual

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understanding of partners (thematuration process) will enable someassumptions about communication tobe made. Analysis of meetingminutes and interview transcriptsprovides evidence of maturation;there is tacit understanding of ideasand concepts.

Communication is both effective andof a high quality. This is evidenced bya clear direction within thepartnership. Partnership boardmeetings are always well attended,actions to be completed are allocatedto a range of people which securesinterest, participation and adeveloping knowledge-base amongstthe partnership members. Within themanagement team meetings work isundertaken by the most appropriateperson and actions are recorded,work is reviewed and outcomes aredisseminated. This iterative processcan thus be seen to be producingclear outcomes that are the result ofa coherent communication system.

Formalisation. The MLDP formalisedthe process of work at an early stageand had clear reporting structures.The principal protagonists in thesenew arrangements were socialservices and health staff who wereco-operating to a degree notpreviously seen. Currently thepartnership reports to parentorganisations such as the PrimaryCare Trust, Social Services and theStrategic Health Authority.

Issues of authority, accountability,confidentiality and responsibility areperhaps less problematic than theywould be for a nascent organisation.The length of time over which thepartnership has operated has enabledMLDP to refine its formal processes.

Policy Context

It is important to understand therange of policies that were providinga steer for the partnership at thetime. As with all services the strategicdirection and operational decisionsarise from the prevailing policyimperatives.

Policy making can be conceptualisedin terms of either a top-downapproach or a bottom-up approach.

Arguably the Community Care Act(1990) was the first coherent attemptto create a way of working that wastruly multi-disciplinary. The issues ofensuring an effective multi-disciplinaryapproach to delivering care hasalways been problematic and theLaming Report (2003) serves as aharsh reminder of the work yet to bedone to achieve a seamless service.

Baker (2000) points out that asignificant barrier to integratedservice provision is the politicalboundary between social services andthe NHS. The former is run by localgovernment and the latter is run bycentral government. There ispotential for dissonance if, forexample, the local government is ledby an opposition party which takes adiffering view of priorities from theparty in power at Downing Street.

The structure and organisation of theNHS has been subject to change sinceits beginning in 1948. This continualprocess of examining the structureand organisation is an importantfactor to be understood in thecontext of the development andmaintenance of the partnership.

The NHS operates its own websitewww.sdo.nihr.ac.uk/ to guidemanagers through the complexities ofthe management of change. Theemergence of the internet and itsattendant proliferation of electronicdocumentation has arguablyincreased the knowledge base ofhealth and social care managers.

This is a recent innovation, the paceof change was somewhat slower inthe 1980s and the availability of suchguidance, be it in the form of keytexts or research papers, wasrelatively sparse. This was the case forMLDP, they came into operation at atime when information technologywas not as advanced as it is currently.

The organisations in a partnershiphave a shared view of the principalneed that informs the existence ofthe service being provided. However,the varying interpretations of ‘need’as understood by differentprofessional bodies have oftenresulted in tensions that have beendifficult to surmount. This situation isreflected in a key point of debatewithin learning disability services ( DH1985;, Mitchell ,2003; Mitchell 2004;Northway et al, 2006; Clark &Diack2007)) namely that is there arequirement for learning disabilitynurses to provide services that couldperhaps be provided by social carestaff.

The origins of this debate can betraced back to the Jay Report (1979).The ensuing debates arising from ithave never been satisfactorilyconcluded. There have beensubsequent calls for a rationalisationof learning disability services thatarguably contribute to a considerabledegree of instability.

One of the key features in asuccessful partnership as elucidatedby the Health Education Board forScotland (1979) is the ability ofdifferent members of the partnershipto offer “contrasting contributions toan agreed common goal” (Whitelaw& Wimbush, 1979:2). In this respectthe, at times, diverse perspectives ofhealth and social services seem ideallyplaced to fulfil this feature.Potentially problematic in this regardis the debate described previouslywithin which a social care focus hasassumed some degree of dominance.

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There is a developing discourse aboutthe ‘loss’ of a health focus in learningdisabilities which has been initiatedby a somewhat tardy recognition ofthe numerous health deficitsexperienced by people with alearning disability.( Turnbull 2004;Hardy et al 2006; Clark & Griffiths2008)

The provision of community careservices had to be tailored to localneeds given the disparate nature ofservices around the country.Deeming (2004:57) notes that theNHS is considered to be over-centralised and local services may notalways reflect the tone ofgovernment policy announcements.This is perhaps understandable whenpolicy is generated from London,albeit in the wake of consultation,and an appreciation of regionalnuance may be constrained. TheMLDP management team were ableto operate across local boundariesand were actively engaged withregional and national authorities.

An example of this cross-boundaryworking is given by Interviewee A inwhich he describes a conference thatwas held in Manchester:

The Secretary of State of the timewas a guy called Stephen Dorrell andour response to that as a region, thethen implementation team of theRegional Health Authority organisedbrilliantly a conference on what wewere doing and why we were doingit and why it mattered and the wayforward. We got Stephen Dorrell tospeak at it and that was at theBritannia Hotel in Northenden thatwas a tremendous event and includeda lot of people who had beensuccessfully resettled from hospitalsto come to that, to say howeverbriefly, how it was. I remember PeterClarke saying that one of theoutcomes of that would be a form ofwords that said that the Northwestwas committed to a range of optionsfor people resettling from hospital

without stating what they were and ifyou were pressed you would pointout that there were flats and therewere houses and there werebungalows and all sorts of ways ofsupporting people in their ownhomes, short of saying hostels andcontinuing life for hospitals.

Kellaway and Ruane (1998) describethe biggest challenge as being howto start, what they refer to as the bigbang approach (1998:103). Theydescribe some of the many challengesfacing the team at the time. One ofthe major problems was how tofinance two essentially separateoperations. This is a bridging matter,whereby the existing service (theexisting hospital site and its services)needs to be maintained as well asdevelop the new resettlementscheme.

This financial double running requiredconsiderable financial investment anda great deal of negotiation in order tofacilitate the process.

I guess we began working towardsdeveloping a joint service because wewere getting a bit of a push fromgovernment at the time. There was apush to go for joint services and webegan working together more andmore closely. In the time we weredoing it in 1994 (but really the buildup to that the previous eight/ tenyears I suppose from 1984), we hadto work together to resettle peoplefrom the big institutions; from your(interviewer) old institution Cranageand Calderstones and Mary Dendyand all the other ones. I think wisely,the Northwest Regional HealthAuthority (NRHA) who had themoney and the resources at the timewere committed to partnershipworking. They believed that the localauthority and health had to talktogether before they’d agree totransfer the resources to thecommunity so they had to worktogether. That was a big incentivereally. That was one of the political

elements, I certainly think the factthat NRHA said that ‘if you want themoney that’s attached to resettledpeople then you have to worktogether’.

A consequence dual fundingidentified by the managers of MLDPis that risks were inevitably takenbecause of under funding, particularlywithin the hospitals and the hostels.

The Audit Commission review of1992 described the changing balanceof care. At this early stage there wasa recognition that costs werespiralling and as the report says theindependent sector and voluntaryagencies were “growing insignificance”. The Audit Commissionreview was entitled ‘Managing theCascade of Change’. There was adesire to, as the report says, “ensurevalue for people and value formoney”. (Audit Commission, 1992:1)

Community care was predicated onthe notion that care for people with alearning disability, a vulnerable groupin society, could be provided at acheaper cost than institutional modelsof care.

There was a strong focus on the wayservices were commissioned andmanaged, and a requirement for arobust multi-disciplinary approach.One of the tenets of the CommunityCare Act (1990) was the developmentof a clear purchaser/provider split andfor this to be effective services had towork collaboratively. It is importantto recognise that at the end of the80s a somewhat separatist culturepredominated in which individualprofessional cultures had not yethomogenized to any degree.

The accounts of interviewees indicatethat some services at the time of theNHS & Community Care Act (1990)assumed that the dowry monies wereakin to a revenue budget whichwould continue. This was not in factthe case and members of MLDP hadanticipated future changes in


funding. One of the intervieweesdescribes the ability to ‘horizon scan’.

The 1990 NHS & Community CareAct was seen as a way of addressingsome of the difficulties with thismulti-agency, multi-funded approachand a way to rationalise services. TheAudit Commission review emphasises“consultation and collaboration” withthe opportunity for local services tobe “restructured and re-orientatedtowards serving the real problems ofpeople”. (Audit Commission 1992:1)

The process of implementation wasconsidered to be potentiallyproblematic because “the process ofimplementation inevitably generatesnew difficulties which in turn triggerfurther adjustments in an ever-increasing cascade of change” (AuditCommission 1992:1)

Authorities could be justified infeeling intimidated by the process butit is quite clear that MLDP did not infact feel intimidated and respondedto the various challenges that policydirectives presented to them.

Manchester LearningDisability Partnership (MLDP)

Manchester Learning DisabilityPartnership evolved from theManchester Joint Learning DisabilityService. At the time of the publicationof Valuing People ( DoH, 2001) thelearning disability population whichwas known to services wasapproximately 16,000 people. (seeTable 1)

Table 1: The Learning Disability population

At the beginning of the partnership in 1994 a key issue was to developintegrated working practices. TheJoint Investment Plan (JIP) wasproduced in the light of 1992guidance on the development ofhealth and social services for peoplewith a learning disability. (HSG 1992:42).

The JIP identified that Manchester’spopulation was increasing from430,000. This followed several yearsof population decrease that was mostlikely linked to a decline in localindustries. Within the city 1200learning disabled people at any one

time received a service, with1500people receiving a service over thecourse of a year.

Research undertaken in 2001 tosupport the development of the JIPindicated the need to increaseprovision by 15 % for people withsevere disabilities and by 7% forpeople with less severe disabilities.This prediction was based over a 10year period with an average 1%growth in demand each year. It wasnoted that there were 22% ofchildren under 18 from ethnicminority communities mainly southAsian compared to 2.7% of thegeneral population. Minutes fromboth the Partnership Board and themanagement team demonstrate thatthere was a clear focus on the needto address the particular issues of aminority ethnic population.

Wall and Owen (2002:75) describeorganisational culture as a “collectionof ideas, values, norms andassumptions”. This is seen asimportant because there will be animpact on the behaviour ofparticipants within that particularorganisation. Consistency andcoherence are also described asimportant features, MLDPinterviewees talk about notions ofsinging from the same song sheetand having the same set of corevalues and beliefs.

One interviewee commented onanother interviewee’s strong valuebase and described how he woulddisseminate and reaffirm those ideasthrough the various communicationmedia used by the organisation.

Wall and Owen (2002) describe arange of changes which have affectedhealth care and suggest that this haspresented a particular dichotomybetween professional culture, in termsof professional identity, and theactual practice of deliveringcommunity services. This has beenclearly recognised by MLDP althoughnot necessarily voiced in such terms. 84

Provision

Domiciliary care

Adult placement

24 hour supported accommodation

Support with less than24 hours

Out of borough placements

Hospital beds for offenders

Respite care

Day care

Employment services

Care management

Numbers

155

50

410

43

26

36

167

397

35

784

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Inter-organisational working

Kellaway and Ruane (1998:105)identify a minimum range of peoplewho need to be involved in apartnership as a tripartite list:

1. People with a learning disability intheir family

2. Staff

3. The community and its localrepresentatives

It is evident from current and pastMLDP minutes that individuals fromeach of these groups attend boardmeetings on a regular basis. MLDPtailor their ways of working fordifferent audiences. The PartnershipBoard has a clear set of guidelines forpeople who are giving presentations.The target audience is identified as:

1. Self advocates, family membersand carers

2. Councillors and senior health andsocial care staff

3. Representatives from partnerorganisations who may not have familiarity with learning disabilityservices.

4. Representatives from charities

5. Representatives from thecommissioning service and from providers.

Burton & Kagan (2000:3) describewhat is known as the edge effect, a phenomenon whereby there is anotion of enrichment betweendifferent organisations “when anedge is actually created we notice anincrease in energy, excitement andcommitment”.

The interviewees describe theexcitement and high energy that werepresent at the beginning of thepartnership. Burton & Kagan ( 2000 )identify that where people areworking across traditional and

established organisational boundaries,the utilisation of the strategy ofmaximising the edge results in“energy efficiency and a highlikelihood of leading to sustainableand co-ordinated change.”

An interesting aspect of thedevelopment of the partnership wasthe co-location of nurses, alliedhealth professionals and socialservices staff in the same base. Thisenabled joint working by dint of thefact that people were workingalongside each other. The co-locationof staff also removed physical barriersand the communication process wasless constrained than it might havebeen if teams were dispersed.

One issue that was talked about waswhat one of the interviewees referredto as the “fear factor” in terms ofprofessional identities. This is theassumption, however erroneous, thatprofessional identity may becompromised by working in a jointservice. This is a theme that isrecurrent throughout learningdisability services.

There was a drive to have integratedways of working and one of theinterviewees did comment that hehad been waiting for a meeting oneday and had been musing upon thefact that the service was so integratedthat the respective professionalidentities, whilst not forgotten, hadbeen displaced as an important issue.

He felt that people knew theirprofessional identities but viewedthemselves as part of an integratedwhole. E-mail communications withinthe UK Health and Learning DisabilityNetwork bulletins provide indicationsof the continuing struggle of someservices to achieve integration.

One of the interviewees talks aboutthe breaking down of professionalbarriers in order to achieve aneffective partnership and he saw that

as one of the key issues in the earlydays of the partnership. He felt that ifstaff were based in the same officewith desks next to each other it wasvery difficult to maintain a sense ofbeing separate. He described thisremoval of physical barriers as:

“… taking a quantum leap to actuallybasing people in the same office”

He felt that there was a great deal ofdissatisfaction in terms of discreteprofessional identities. People wereunclear about their priorities and co-locating staff in the same officehelped to alleviate this issue. Therewas an encouragement from an early stage, actively supported bymanagers, in encouraging people toview themselves as a partnershiprather than as members of theirdiscrete professional organisations.

Burton & Kagan (2000) identify theneed to respect the uniqueness ofeach community in a collaborativearrangement. The accounts ofinterviewees describe the respect forthe unique qualities of each of thepartner organisations; eachorganisation had a great deal to offer.

Interviewee A described the situation:

“Yeh. I think… I think you have to,you know…. when you’re on theedge of two organisations for a longtime at the Community Trust and thelocal authority… it was a good placeto be in that we were our ownmasters and mistresses really and wecould play a little bit off against theother. We’d say ‘well the localauthority are doing this’ or we’d say’you know what the trust are doing,they’re doing this, you know.’ Andwe could bring the best of both tothe other party and we could live onthe edge of it. Of course it did… itcould make you vulnerable if theywere looking to get rid… to cut awhole service…


you could just cut us at the edge. Soyou had to get yourself well in nestwith the other party so it was a …youwanted a degree of separateness butyou also wanted to make sure youwere meshed in because you couldn’tafford to be completely separate”.

Successful inter-organisationalworking rests upon the relationshipbetween individuals, Meads andAshcroft (2005) outline fivepreconditions for an effectiverelationship to develop:

Directness is seen as influencing thequality of the communicationbetween partners within therelationship. Face to facecommunication facilitates a deeperunderstanding than that which couldbe achieved through telephone callsor written reports. Face to facecontact allows for the non verbalinformation to be developed and thiscan create a better understanding.MLDP established co-location of staffat an early stage in the partnership.

Continuity of relationships is seen asimportant for the development of arapport between individuals. Giventhat some of the people within thepartnership have been workingtogether for a number of years the.development of a rapport can beexpected. The accounts of theinterviewees illustrate the extent ofthe rapport between individualmembers of MLDP’s managementteam. Individual respondents spokewith a degree of warmth that isindicative of a long standingrelationship, for example IntervieweeA said:

Right I can give you a couple ofanalogies around that, I said earlieron about one of the driving forces interms of developing the partnershipand moving us as far as we havedone was (name of individual A) buta lot of the problems with him and

(name of individual B) is that theyoften conflicted quite a lot in terms ofbeing very similar in wanting thedegree of power and autonomy so(name of individual A) was fantasticbut sometimes a little confrontational.What we have got with (name ofindividual A) is being a differentperspective so we have had a changeof lead in terms of the driving force.(name of individual C) is very differentand where we have got a lot ofstrength in him is, his ability to beable to argue the point and wherejust for example, in some of the jointmanagement teams especially thepooled budget which is the onewhere we get the greatest amount ofpressure to either under-spend orbreak even, definitely not overspend,where in the past you could get to asituation in where it became heated,(name of individual A) would take hisglasses off and be challenging. .(name of individual C)’s way ofnegotiating is a lot more differentand a lot more subtle but no lesseffective so we have got differentstrengths from the different needsthat we have had over the past and .(name of individual C) has really beenable to build on the very positive.

Meads & Ashcroft ( 2005 ) considermultiplicity is the third pre-conditionof an effective relationship. Theysuggest that mutual understanding oforganisations will be greater if there isan appreciation of individualcontributions. This is particularlyrelevant in the case of individualprofessional roles. If respectivepartners within the organisation areable to appreciate and understandthe roles and functions of otherpeople then it is felt that therelationship will be strengthened.This strength will support themanagement of relationships. Theaccounts of the interviewees give astrong indication of the degree to

which individual contributions werevalued by other members of theteam.

Parity is seen as the recognition thatdifferent parties within thepartnership relationship need to havesome notion of power within therelationship. If there isn’t parity thiswill lead to a lack of participation andas such “strategic objectives are notowned, may reduce morale and stifleinnovation”, (Meads & Ashcroft2005:21) Interviewee accountsindicate that members of themanagement team of MLDP arecomfortable with their respectivepositions in the partnership andparticipate fully in the strategicdirection of the partnership.

Commonality is seen as the pursuit ofa way of working together towardsshared goals. If there is a commongoal or objective there is morelikelihood of the organisation workingwell, a shared culture will minimisethe possibility of differentunderstandings. MLDP was a newdeparture, it moved away from anidentifiable social services or anidentifiable health services trust andbecame a learning disabilitypartnership and the shared cultureemerged from that move to a neworganisation.

In 1999 a series of regional seminarswere conducted by the Health &Social Care Unit at the Department ofHealth to examine the nature of jointworking between health and socialservices organisations. A number ofthemes emerged from the report.Relevant to this discussion is theorganisational and policy context.

It was determined that there wasadded value from having a jointworking approach to improvinghealth. The possibility of widening theperspective of respective professionalgroups by working in a collaborative

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way was identified. It is howeverworth noting that there were stillpotential conflicts in terms oforganisations maintaining somedegree of separation e.g. “I have toconvince my councillors that my PCGinvolvement is worthwhile” (SSrepresentative), (DoH 1999:6).

The interview accounts give examplesof some of the complex negotiationsbetween members of themanagement team and local andnational politicians.

A time of innovation and ashared sense of socialinjustice

The period in which the NHS Act(1990) came into force wascharacterised by an emerging senseof social injustice. Learning DisabilityServices moved from institutional tocommunity care in the wake of the1990 Community Care Act. Thismove followed a number of pivotalpieces of legislation that arguablyfailed to achieve the required seachange in standards of care. A keyexample is ‘Better Services for theMentally Handicapped’ DHSS,(1971)which outlined the need to addressthe very clear deficits in care,associated with an institutionalsystem of care. In addition to thelegal drivers there were increasingconcerns resulting from a raising ofawareness amongst the public aboutthe standards of care in ‘mentalhandicap’ hospitals. Inquiries such asNormansfield (1979), Ely (1978) andSouth Ockenden (1978) alsoproduced distressing accounts ofinstitutional care and contributed to agrowing sense of unease.

The screening of ‘Silent Minority’ inJune 1981 on ITV was a catalyst forthe production of the Green paper‘Care in the Community’.

Key texts from the period, Ryan &Thomas(1987) and Collins (1993)described the conditions in thehospitals and provided a rationale forchange.

There were parallels with otherservices which were undergoingsignificant change. The Mental HealthNursing Review Team identified“considerable advances in the re-provision of services against abackground of growing public andmedia concern about people withmental illness in the community”(DoH 1994:30)

MLDP gained recognition for thequality of the new service they hadinitiated, as Interviewee C explains:

Certainly when I… after it happenedpeople kept…. you know, we won aprize in the health service journalmate, we were inundated withpeople wanting to come and talk tous and things and we ended upsetting up a few days with variousorganisations [that] came and clearlywe were one of the first onesbringing together such big services. Itwasn’t just that we were comingtogether but there was a singlemanagement model so that if youwere local authority or health youmanaged the other side without aquestion but we had a shared visionand purpose. That we were runningboth soft services, field work services,community nursing, social work etc,as well as hard services in residentialservice and domiciliary and day care.Very few people were doing that andeven now a lot of people have cometogether in joint services and whatthey’ve brought together iscommunity learning disability teams.They haven’t brought togethercommunity learning disability nurseswith expertise in behaviouralchallenge and mental health andpeople with serious physical health

conditions, haven’t brought themtogether with residential social workstaff to work in long term supportsituations.

Another interviewee talks abouthaving to spend a lot of energy inprotecting the partnership throughthe various changes that occurred.

A significant change was thereorganisation of the threeManchester District Health Authorities(DHAs) and the development ofcommunity trusts. The initial Head ofthe Service does talk during hisinterview about the need tocontinually demonstrate value formoney in terms of the organisation.He spoke of a premium for theprovision of a quality service becauseof the development of mixedeconomies of care and the so calledpurchaser/provider split. There wassignificant pressure from privateorganisations/providers to tender forservices. Therefore the PCT and socialservices partnership had todemonstrate that they were providinga good quality of care.

The issue of quality is a featurethroughout the history of MLDP, as itis in all services, and work was doneto address the challenges of providinga quality service. This included theproduction of a training resource, (Burton 1992).

A significant point which may explainthe success and longevity of thepartnership was their ability tooperationalise policy in their ownterms.

In the late 80s early 90s there was aclear imperative from Whitehall to rundown/close the long stay institutions.MLDP made it very clear that theywere going to prioritise theestablishment of viable communitybased services in order to, asInterviewee D says:

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“ensure that districts would beproperly prepared to receive peoplefrom discharging hospitals”.

He goes on to state that he was quitesatisfied that, when people did comeout from the long stay hospitals, theydid go into a properly preparedcommunity provision.

A comment made by Interviewee Cwas that:

“a key driver was in fact money in theguise of dowry monies which cameattached to each person who wasdischarged from the hospital”.

This money and its appropriateapportionment between differentaspects of the service was, as he putsit,

“a source of quite a bit of tensionand very healthy debate”.

It is perhaps worth noting that at the time of the community carelegislation being implemented there never appeared to be anunderstanding that the money wouldbe a finite resource. It was receivedwisdom that the sale of theproperties and the subsequentmonies accrued would be more thanenough to provide a very good levelof service for the foreseeable future.With the benefit of hindsight, wenow know that the monies did not infact last forever. Currently learningdisability provision faces a wholerange of financing challenges. Thisremains an issue for all services to thepresent day.

“…but we know where we want tobe and how we can get there buttrying to do it within budgetaryconstraints is difficult no matterwhat political party…”

An interesting element of thefinancial problem was that there wasan anticipation that people would dieat the same rate and at the same ageas they did within the hospitals. Oneof the many positive outcomes from

the discharge from hospital-basedcare was that people’s quality of lifeimproved significantly and with thattheir life expectancy. This has beenreinforced by the increasing emphasison health.

An important theme is that of peoplebeing, as was described byinterviewee B, ‘champions’:

“A younger man was recruited; a realchampion for this work and hedrove stuff through the associationof directors and social services.”

It was felt this particular individualwas able, with his communicationskills and his commitment to learningdisability, to drive things throughparticularly at regional meetings ofDirectors of Social Services. Thenature of the move from hospital-based care to community provisionwas highly controversial at the timeand proponents of the move facedconsiderable resistance. The presenceof champions is seen as essential tothe success of change, especially onsuch a large scale as that which wasprompted by the NHS & CommunityCare Act (1990).

Interviewee A talks of political will,having support from central and localgovernment, as being an essentialingredient of successful partnershipworking:

“you can’t do it if a few politiciansdon’t agree, so you have got to getthem in your pocket”

In the early days of the partnershipthere was a degree of resistance fromlocal people and some parents andthey sought support from variousplaces. In one instance a local MPinitiated an adjournment motion thatquestioned the way in which theRegional Health Authority wasproceeding with its resettlement. This meant that the partnership hadto respond:

“You use strong rhetoric to promotewhat you are doing and you mustexpect people to exaggerate in theother direction”

He also describes notions of“confidence and trust” between thepeople from different parentorganisations and the need to have ashared value base.

Interviewee D describes a ‘groundbreaking and innovative’management team. The team wasground-breaking in terms of settingup a multi-professional service andinnovative in the ways that theymanaged the change from hospital-based to community-based care.There was a significant changemanagement task to move from themodels of care that were dominant,at the time, to a community basedmodel which people were learningabout as they developed the services.Pioneering work was beingundertaken by Wolfensberger (1984)in terms of the process ofnormalisation or Social RoleValorisation and the idea that corevalues such as community presenceand community participation werevery important.

The MLDP worked hard inimplementing the ideas and conceptsof normalisation. An example of thisis their assertion that they would notresettle anyone until the communityplacement was ready.

The team moved to a functionalmanagement system whereby eachperson had a defined area which wastheir responsibility. The team wereable to maintain a general perspectivethrough regular city-wide meetings toensure that everybody was focusedon the main objectives of thepartnership.

One of the key questions asked ofinterviewees was whether they feltthe partnership was effective. Therewas a unanimous view that the

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partnership was effective and to alarge extent this was considered to bebecause of, clarity of and agreementabout, their purpose. This consensuscontributed to the longevity of thepartnership as there were no majordisagreements about philosophy andservice direction.

As mentioned in the Continuitysection (P.18) the key members of thepartnership had a long history ofworking, primarily within the NorthWest region, so they had grown uptogether professionally. There wastherefore a sense of familiarity and asense of shared understanding.

Interestingly there were perceiveddifferences in terms of drivers. Oneof the participants felt that at timeshe thought that other people wouldhave liked him to be pushing hardertowards the goal of effectivepartnership working and progress.

A key challenge in the early days ofthe partnership was the process ofnegotiation between the parents andfamilies of people with a learningdisability and the members of theMLDP.

When the concept of hospitalresettlement was developed,following changes in policy direction,families were being told that theirfamily members were coming homeor coming back to the area. Therewas a lot of apprehension about this.One of the interviewees talked aboutan 80 year old lady being very upsetabout the thought that she wasgoing to have to care for her, nowmiddle aged, daughter after 20 yearsin the institution. In the light of thissituation a key role of one of theinterviewees was to negotiate withthe families and explain to them howthe process of re-settlement was totake place. Another intervieweedescribed how MLDP liaised withfamilies and helped them negotiate

their way through what may haveseemed like quite dauntingprocedures.

The parents experienced variousdegrees of upset and may well haveassumed that the process wouldimpact on their lives quite negativelyso the art of negotiating with parentsand families was crucial to thesuccess of the resettlementprogramme.

Many of the parents of people whowere to be discharged from thehospitals had experienced the verynegative and highly traumaticexperiences of having their respectivesons or daughters taken into care,sometimes under the auspices of theMental Health Act (1959). Familieshad endured a very harsh experienceand were faced with anotherpotentially difficult time in havingtheir children (now adult) resettled.

MLDP’s ability to successfully liaisewith families was very important andthe continuing participation ofparents on the Partnership Board, forexample, is an indicator of thesuccess of this process.

A great deal of work was done bysenior members of the team toconvince other staff of the value andpotential for success of thepartnership; the process of selling theconcept of the service to staffmembers. A clear strength of thepartnership was a commitment to‘the cause’ amongst the participants.The cause in question was to facilitatea quality service for people who arearguably amongst the mostvulnerable in society. The intervieweestalked very positively and passionatelyabout people with learning disabilitiesand about the need to provide aservice that was of the very bestpossible quality. Respondents all hada broad range of experience withinservices and were able to bring this to

bear on their management of thepartnership.

One of the members of the team wasdescribed by one of the intervieweesas being very good at selling thecommitment to the cause in the faceof what was and arguably stillremains limited financial recompense.His absolute commitment to the livesof people with learning disabilitiescame through in terms of the way hesold the service to people. Anotherinterviewee comments on staffmembers remaining in the service fora number of years. This longevity ofnot only the senior managementteam, but also, more junior staff is anindicator of the success of MLDP.

Interviewees were asked if theyactively sought specific types ofpeople who are able to cross thetraditional boundaries of differentdisciplines in order to work effectivelyin the partnership. One intervieweewas clear that people become thepeople they are through working inparticular environments. Intervieweesfelt that managers and staff were nodifferent than other people but therewas something about the situationthat helped to develop the person.The support, training anddevelopment that people were givenresulted in a staff team that wasequipped to deliver the service.

Identification of opportunities

Burton & Kellaway (1998) describethe opportunities afforded by theemergence of a new joint serviceconfiguration. Policy formulationbetween agencies enabled the jointservice to develop interagency workand to operate outside of the ways ofworking that were accepted at thetime.

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The ability to ‘horizon scan’ is animportant aspect of the partnershipand participants were able to citeexamples of their clear vision of theway services should be. They werealso able to develop this vision withinthe constraints of policy direction:

Interviewee C:

I think you needed to keep your eyeon the ball at all times so a goodexample would be …not reallypolitics but it’s about policy…theybrought out a vulnerable adults policynationally in 2000, I think. We’d hada policy since 1996. They wereconsulting on this when …thewoman who’s an MP now but shewas a law commissioner at theUniversity….can’t remember hername now….she wasconcerned…because I went and hada chat with her a few times…aboutthis, about how we protectvulnerable people so we knew it wascoming. The consultation as a jointservice. We’d written a long responseto the consultation document. Webegan a vulnerable adults policy fouryears before we had to. The localauthority thought this was excellentand they were saying to us ‘We mustdo this for mental health and elderlypeople too.’ We never got around toit until government told them theyhad to. So if we were talking abouthorizons scanning, it’s being aware ofthe shifts. Maybe a better example interms of politics would be the shiftaround funding from where…Iremember when we went fromhostels and hospitals to networkhouses…we maximised people’sbenefits and we did not…we did notcall them care homes. The reason wedid not call them care homes wasbecause it would have restricted howmuch money each individual personhad. It would have meant all thecharge fell on the local authority, itwould have meant the houses would

have had to been compliant with carehome legislation. It was normal. Itwasn’t ordinary. We were going forordinary life and it wasn’t ordinarylife to live in a three bedroom housethat was kitted out like an oldpeoples’ home.

Interviewee A:

Right. Well the partnership thatManchester Learning DisabilityPartnership started in about wheneverand prior to that I was chair of aregional health authority committeecalled the Mental Handicap Advisorygroup. This arose because in the verylate seventies the then regional health authority was called theManchester Regional Board, then itwas called the North WesternRegional Health Authority, which wasthe Northwest (except for Mersey)and it charged this group withcoming up with a policy forcommunity care in mental handicap,as it was called in those days. Therehad been a lot of movementnationally towards community mentalhandicap teams and greater inclusionof people with what we now calllearning disability and so on.

A further example of this ability tothink ahead was the ability toanticipate service directions. Oneexample that is given is pre-emptingthe introduction of the LDAF trainingand getting staff in the serviceenrolled on NVQ courses. This wasinitiated several years ago inanticipation of there being anexpectation that the workforce wouldneed to be qualified.

The investment in training of staff didnot just have the immediate benefitsof a more competent and committedstaff team but also the partnershipforged, what have proved to be,enduring links with ManchesterMetropolitan University and as oneperson put it:

“we were able to examine some ofthe stuff we hadn’t examined beforeso we were able to embark onestablishing a reasonable standard ofresearch”

The partnership maintained a focuson was what they called ‘maintainingthe momentum’:

‘setting things up was the easy bit, itis about maintaining the momentum ,about ensuring that things continue’

In order to keep people motivated heused a team brief which is not aparticularly innovative conceptnowadays; but this has custom andpractice since 1994. An interestingaspect of the training anddevelopment of staff was one of themethods used to keep the emphasison refining the quality of service.Money was used to send members ofstaff abroad to get a sense of whatservices were doing in different partsof the world.

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Conclusion


The MLDP is a partnership that hasexisted over a fourteen year periodand has evolved against abackground of significant changes inpolicy. The partnership has been ableto maintain its focus and continue todeliver a quality service to peoplewith a learning disability inManchester.

The multi-professional context inwhich key members of thepartnership operated requiredconsiderable risk taking strategies andinnovative ways of addressingproblems.

The maintenance of relationships wasachieved through continuingaffirmation of the guiding principlesand a demonstrable belief in thevalue of what they were trying toachieve.

The time of the early years of thepartnership’s existence wascharacterised by the need tochallenge prior assumptions. Themembers of the team were willingand able to overcome barriersassociated with organisationalboundaries and develop innovativeways of working.

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Wolfensberger, W. (1984) Areconceptualization of normalizationas social role valorization. MentalRetardation. 34(2), pp 22-29

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Contents

Chapter 6: Case Study: PartnershipWorking in Therapeutic Services

Introduction

Manchester

Therapeutic Services

Partnerships and Therapeutic Services: A Good Enough Partnership

Partnership within Therapeutic Services

Within Organisation Partnership

Outside Organisation Partnership

Local Primary Care Trust

University of Salford

Discussion and Conclusions

REFERENCES

APPENDIX ONE Interview Schedule

APPENDIX TWO Report for Therapeutic Services

Authors: Claire Hulme & Paula Ormandy: University of Salford

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Introduction

The focus of this report is thepartnership working of TherapeuticServices (an arm of the Big Life Groupbased within the Kath Locke Centrein Hulme, Manchester).

Aim

The aim was to explore partnershipworking from the perspective ofTherapeutic Services.

The study uses the WarnwarthConceptual Framework forPartnership Evaluation and the idea ofthe ‘good enough partnership’(Warne and Howarth, 2009) todescribe, unpick and evaluate theintricacies of working in partnershipboth between and withinorganisations. The context withinwhich Therapeutic Services works isfirst described, highlighting thegeographical area and businessstructure within which the Serviceoperates.

Manchester

Manchester, located in the NorthWest of England, is a denselypopulated city with around 39.1people per hectare compared to 3.9for England as a whole1. The 2001consensus estimates a populationunder Manchester local authority ofjust under 400,0002 but more recentestimates put that figure at over450,000 equating it in populationsize to Liverpool (which has a similardensity)3. By gender, under the 2001consensus, approximately 49% of thepopulation were male; 21% wereunder the age of sixteen and 13%aged 65 or over.

Manchester fares badly in terms ofeconomic deprivation whencompared both to the North West asa whole and to England.

As the table As 1 below illustratesseconomic activity and employmentrates are lower whilst unemploymentrates, the proportions of thepopulation claiming a key benefit, jobseekers and those on capacitybenefits are higher4.

Indicators of Economic Deprivation Manchester North West England

Economic Activity Rate (Persons, Apr06-Mar07) 4 5 1

Employment Rate (Persons, Apr06-Mar07) 4 5 1

Unemployment Rate (Persons, Apr06-Mar07) 4 5 1

All People of Working Age Claiming a Key Benefit

(Persons, Aug05) 3 2 6

Job Seekers (Persons, Aug05) 3 2 6

Incapacity Benefits (Persons, Aug05) 3 2 6

%

%

%

%

%

%

69.9

65.6

7.1

23

3

12

76.6

72.4

5.5

18

2

10

78.6

74.3

5.5

14

2

7

Table 1 : Indicators of Economic DeprivationTaken fromhttp://www.neighbourhood.statistics.gov.uk/dissemination/LeadKeyFigures.do?a=3&b=276778&c=Manchester&d=13&e=4&g=351271&i=1001x1003x1004&m=0&r=1&s=1213876507695&enc=1

1 http://www.manchester.gov.uk/downloads/A22_2006MYE_Wards_Density.pdf2 http://neighbourhood.statistics.gov.uk/dissemination/LeadKeyFigures.do?a=3&b=276778&c=manchester&d=13&e=16&g=351271&i=1001x1003x1004&m=0&r=1&s=1213881257390&enc=13 http://www.manchester.gov.uk/downloads/A22_2006MYE_Wards_Density.pdf4 http://www.neighbourhood.statistics.gov.uk/dissemination/LeadKeyFigures.do?a=3&b=276778&c=Manchester&d=13&e=4&g=351271&i=1001x1003x1004&m=0&r=1&s=1213876507695&enc=1

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Figures from the 2001 census alsoshow Greater Manchester has ahigher proportion of the populationwith limiting long term illness thanthe England and Wales average(20.4% and 18.2% respectively), ahigher proportion of peoplepermanently sick or disabled (7.8%,5.5%), a higher proportion of peoplewith no qualifications (32.7%,29.1%) and a lower proportion ofpeople with qualifications at degreelevel or higher (17%, 19.8%)5.

It is important to note that evenwithin these figures differences areapparent between wards. WithinManchester the averageunemployment rate in April 2008 wasestimated at 3.5%. However, in theaffluent wards of Didsbury West andDidsbury East this is 1.3 and 1.4%respectively where as in Bradford therate is 6.4%6.

The focus of this report is thepartnership working of TherapeuticServices based within the Kath LockeCentre. The Centre lies in theManchester Ward of Hulme whichborders the City centre, Ardwick andMoss Side.

In 1990 Hulme was given the dubioushonour of being said by thegovernment to have the worsthousing estate in Europe. Since thattime both Hulme and Moss Side havebeen undergoing extensiveregeneration.

Indeed it’s estimated that there hasbeen over £400m of public andprivate investment in both wardssince 19977. Despite size and scale ofthe regeneration project, of the thirtytwo wards that make up Manchesterlocal authority, Hulme, Moss Side andArdwick have amongst the highestunemployment rates (4.6%, 5.7%and 5.2%)8.

Indeed all three feature in the top 1%of most deprived locations in Englandusing an index that takes intoaccount income, employment, healthand disability, education skills andtraining, crime, barriers to housingand services and living environment9.

5 http://www.statistics.gov.uk/census2001/profiles/2A-A.asp6 http://www.manchester.gov.uk/downloads/H1_Unemp_April_08.pdf7 http://www.manchester.gov.uk/downloads/Hulme_10_years_on.pdf8 http://www.manchester.gov.uk/downloads/H1_Unemp_April_08.pdf9 http://www.manchester.gov.uk/downloads/F1_IMD04.pdf

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Therapeutic Services

Therapeutic Services is situated nderthe umbrella of Big Life Services,which itself is situated under theumbrella of The Big Life Group, asocial enterprise. Recent estimatessuggest there are over 55,000 socialenterprises across the UK. Socialenterprises account for 5% of allbusinesses with employees, have acombined turnover of £27bn and areestimated to contribute £8.4billion peryear to the UK economy10. TheGovernment, within its 2002 Strategyfor Social Enterprise, defines a socialenterprise as:

‘…businesses with primarily socialobjectives whose surpluses areprincipally reinvested for that purposein the business or community, ratherthan being driven by the need tomaximise profit for shareholders andowners.’ (DTI, 2002)

The Big Life Group consists of a groupof social businesses and charitieswhose stated mission is:

‘To bring about social justice for themost excluded in society -to create anew way of working and a new wayof living. A world where people canmake mistakes and be helped tomove on and change. A world whereeveryone has the opportunity toimprove themselves and develop theirpotential. Where people’s needs aremet, and their talents and assetsutilised. Not a world divided into theneedy and the sorted11.

The Big Life Company, launched in2002, came about as a merger of BigIssue in the North and DiverseResources with roots going back overalmost two decades (DiverseResources was set up in 1991)12. It isbased across the North West and inYorkshire. Big Life Services, a limitedcompany and registered charity withinthe Big Life Group, aims to identify

gaps in services and meet the needsof local people13 by providing andpromoting services to improve thehealth and well-being of people whohave been excluded from mainstreamsociety. Following a self-help anddevelopmental approach, it focuseson the power of opportunity tochange people’s lives. Servicescurrently offered include Self-help andTherapeutic Services acrossManchester, Leeds and Liverpool andtheir surrounding areas. The servicesprovided don’t attempt to duplicateexisting services but rather to identifygaps and work either alone or withlocal partners to meet local need14. Indeed they reiterate their belief inand support of partnership working.

The following diagram illustrates thestructure of Big Life Services:

Structure of Big Life Services

10 http://www.socialenterprise.org.uk/page.aspx?SP=134511(http://www.thebiglifegroup.com/home/index.asp12 http://www.socialenterprise.org.uk/Page.aspx?SP=198713 http://www.thebiglifegroup.com/charities/big_life_services.asp14 http://www.thebiglifegroup.com/charities/big_life_services.asp

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Big Life Services has, for over adecade, provided free and reducedfee access to selected complementaryand alternative medicine (CAM)therapies in the Manchester areathrough their Therapeutic Servicesdivision. The services provided includecounselling, homeopathy, Reiki andmassage. The sessions are provided ona volunteer basis by trained andaccredited practitioners. In addition anumber of sessions are commissionedby the local Primary Care Trust (PCT).

Sessions are targeted towards personsat the margin of society eitherthrough homelessness, chronic longterm unemployment or (mental) ill-health, or through theirmembership of particular minorityethnic groups.

Figures taken from the 2006/7 Big LifeGroup Annual Report15 show theservice received 306 referrals forcounselling from GPs and undertook1758 counselling sessions with 345people over the period. Sessions werecarried out at the Kath Locke Centre,Zion Community Resource centre andin GP’s surgeries across theManchester area. In the same period64 people accessed complementarytherapies (homeopathy, massage,reflexology and Reiki) with plans inplace to expand these therapies at theKath Locke Centre and that they arerolled out to other centres.

The Kath Locke Centre, managed bythe Big Life Group, opened over adecade ago and is based in Hulme,Manchester.

The Centre was the first NHS primarycare facility in England to be managedby the independent sector. The Centreprovides or hosts primary care servicesthat include chiropodists, dentists,audiologists and opticians. Servicesare provided by Big Life, the PCT,Local Authority, Mental Health Trustand the voluntary sector16. In linewith the ethos of the Big Life Groupthe Centre offers a holistic healthapproach to well-being, offeringtraditional health care servicesalongside complementary therapies17.

The services are available to the wholecommunity giving everyone theopportunity to take control of theirhealth18.

Figures from the Big Life Groupwebsite report that over 32,000people visited the centre last year.

15 http://www.thebiglifegroup.com/Uploads/230107biglifeannrpt0607.pdf16 http://www.thebiglifegroup.com/Uploads/klc%20evaluation.pdf17 http://www.thebiglifegroup.com/charities/kath_locke.asp18 http://www.thebiglifegroup.com/charities/kath_locke.asp

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Partnerships and TherapeuticServices: A Good EnoughPartnership

Using the Warnwarth ConceptualFramework for Partnership Evaluationand the idea of the ‘good enoughpartnership’ (Warne and Howarth,2009) this section of the reportattempts to describe, unpick andevaluate the intricacies of working inpartnership both between and withinorganisations. Focus lies onTherapeutic Services and theirperceptions of partnership working;drawing on interviews with peopleworking within the Service anddocumentary analysis.

Interviews were carried out with fivepeople within therapeutic services inDecember 2007. Intervieweesincluded service leaders and providers;paid workers and volunteers. Theinterviews were semi-structured;interview schedules (Appendix 1) andanalysis were based on the initialWarnwarth Framework.

The documents included in thedocumentary analysis included Big LifeGroup annual reports and evaluationreports.

All documents were freely accessiblefrom the relevant websites.

Therapeutic Services organisationalpartners come from both within andwithout the Big Life Group andinclude Big Life Services, the KathLocke Centre, and the local PCT (whoprovide funding for the service). Atthe level of the individual, TherapeuticServices partners include thosedelivering the services and thosereferring to the service (for example,the mental health team or local GPs).

Partnership within TherapeuticServices

The Therapeutic Services team ismade up of paid staff and volunteers,some of whom work full time, otherspart time.

Practitioners of CAM are oftenemployed elsewhere in addition totheir roles within Therapeutic Services.This means that for this group thereare competing demands on their time.Turnover within the team hashistorically been low but this is setagainst the uncertainty associatedwith continued funding of the Service.During the research period there werea relatively high number of newpractitioners but many existingpractitioners had been with theService for over two years.

This part of the report explores thepartnership working withinTherapeutic Services. Initially therewere no plans to analyse thispartnership, but rather to focus onthe organisational partnerships at thelevel of the organisation and theindividual.

However, when asked aboutpartnership working, three of thoseinterviewed initially assumed thisrelated to the working withinTherapeutic Services and focus ofmuch of the interviews lay here. Thisled the authors to the assumptionthat, for these people, this partnershipis the most important, most relevant,or at least the most visible within theirworking environment.

Many of the people working inTherapeutic Services come fromwithin, or have roots in, the localcommunity, and in this sense thepartnership within TherapeuticServices includes partnership withlocal community. As one intervieweenoted:

It’s very much a partnership with thecommunity and a sense that peopleare saying, this is something theywant and we’ve found a way ofhelping them deliver it. And it’s, youknow, members of the community aredelivering themselves in the sense thatpeople are volunteering their time andare or are training and wanting theexperience. And so it’s people whoare in the community and are helpingto deliver the service that’s veryimportant. (5)

Another interviewee noted:

When we have events service usersattend, we also have informal helperswho are service users that want togive something back to thecommunity (1)

An important characteristic of CAM isthe involvement of the service user intheir treatment – of activeparticipation in their treatment ratherthan of being ‘done to’. Thoseinterviewed talked about thepartnership with the patient to theextent that the therapy requiresengagement by the patient:

..you need them to feel part of theteam that’s healing them, no to beentirely passive in the process becauseit’s their body’s ability to heal itselfthat I’m trying to stimulate. I’m nottrying to impose something that’swholly external to the body (3).

The culture in therapeutic services isabout increasing clients selfawareness, and getting them to helpthemselves,but being a guide andsupport at the same time (4).


Right Reasons

The Warnwarth framework suggeststhat there needs to be the rightreasons for creating a partnership andthat those reasons lie in a sharedvision and collaborative partnershipworking. Interviewees had a sharedvision for, and a sharedunderstanding of the function of,Therapeutic Services that included selfhelp and improved quality of life.

As one interviewee noted:

We are hoping to make a differenceto people's quality of life in terms ofhealth and well being…..givingpeople tools that they can use athome to continue to improve theirhealth and quality of life, as well asreceiving treatments in the clinic.(1)

Within the UK CAM services aretypically provided privately on a feepaying basis. The services are thusrationed by ability to pay; access toCAM linked to affordability washighlighted by all those interviewed:

…on the therapeutic services side weall have the same vision to provide aholistic service and give choice to

service users, and to those people outthere who are on a low income andbenefits to access our service to helpthem to reduce their stress.(4)

The function is to serve low incomepatients, and patients that have beenreferred from doctors. I think thefunction is to give a good service thatsome people would not otherwise beable to afford. (2)

Therapeutic Services, as a whole, Iunderstand is that they offer a rangeof complementary and alternativeservices that people would nototherwise be able to access becauseof income or other sorts ofcircumstances. (3)

However, the latter interviewee goeson to say I’ve got a very limited graspof the rest of the service to be honest(3).

Whilst the focus of the vision for theService lies in the beneficial effects forthose accessing it; it was apparentthat service providers also benefitedfrom the role they played in theService. Reasons for this include afeeling of personal satisfaction fromhelping in a community in which theyhad roots, to the opportunity to see avaried group of service users outsidethe narrow range typically accessingCAM.

High Stakes

Clearly the benefits to those workingin Therapeutic Services describedabove provide, as suggested in theWarnwarth framework, compellingreasons to work towards a successfulpartnership; this was thought to beespecially pertinent for volunteers.

I would say that the volunteers thatcome in here for the body therapiesare coming here to get experience.Their intention is to get experience ofworking in a community setting andworking with your basic everydayperson, working with a cross culturalclient group, because they don’t getthat in training. So it is mutuallybeneficial, and they also get thesupport and guidance for managingthe clinical and day to day stuff. Sothat is a good partnership becausewe win and they win (4).

In general there was an expression ofpersonal satisfaction and enjoymentin the roles interviewees performedwithin Therapeutic Services based onthe shared vision:

I love being in the community andwhat we do, we really do make adifference to people’s lives. (1)

Right People

Involving the best and mostappropriate people was alluded to bya couple of the interviewees whospoke of similarities based on CAMculture:

The culture in therapeutic services isabout increasing clients selfawareness, and getting them to helpthemselves, but being a guide andsupport at the same time. I think theculture here reinforces that becausewe all have that same calling, and thesame aim. (4)

Conversely, differences between teammembers were also highlighted as astrength giving breadth to thepartnership.

For example, two interviewees spokeof the benefit that their localknowledge and understanding of thecommunity brought to their role.Another spoke of the multi-ethnicityand multi-linguality of those workingwithin Therapeutic Services reflectingthe community around us (1).

Right Leadership

Leadership within TherapeuticServices was thought to be botheffective and supportive with clearline management, clear expectationsof what they can expect and what isexpected from them. (2) Anotherinterviewee spoke of a goodrelationship and rapport with theservice leader that meant:

if you have a problem or disagree……(the leader) will take yourcomments on board. So I think it isbalanced, and we all work as a solidteam. (4)

Only one interviewee felt they werenot clear who led the service.

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Strong Balanced Relationships,Trust and Respect

Relationship building within anorganisation is likely to be difficultwhen a service is characterised by alarge proportion of part-time workerswho often have little physical contactwith each other in as much as theywork at different times on differentdays. However, despite thiscomplexity relationships appeared tobe strong, the people withinTherapeutic Services worked welltogether and felt a valued part of theservice. Whilst the relationship in thepartnership wasn’t balanced in asmuch as one interviewee noted

I don’t think I have a say in therunning of it they went to on say Ithink that I am noticed and valued(2).

Another interviewee echoed thisview:

I really feel valued by ’TS’ and by themanagement (4).

These feelings of being valued weretempered by another intervieweewho perceived that:

I think if I make a fuss something willhappen….But if I don’t make a fussthen it may or may not (3)

Feelings of being trusted andrespected were demonstrated byautonomy in the workplace

…when I come here I just get on withit and there’s no-one telling me whatto do all the time (2)

Good Communication

Good communication was seen to bea vital component of effectiveleadership and thought to beenhanced by the nature or culture ofCAM. As one interviewee noted:

Because of the work… the team haveto be really grounded and centred,and I think we communicate reallywell (1)

Regular team meetings and clinicalsupervision provide opportunities fordiscussion that was thought to beenhanced by the small numbers inthe team. However, for volunteersteam meetings could be perceived tobe an unnecessary draw on theirtime. Opposing views were given bytwo interviewees. One highlightedthe positive aspect of communication,especially for those working part-timeand of feeling part of a team;

another wasn’t interested in beingpart of a team (3).

This interviewee went on to say thatcommunication can work fine but it’sa bit erratic and it may well be thatthe service is highly understaffed.

Both service leaders and practitionerstalked about having the freedom todiscuss and challenging ideas.

Formalisation

Therapeutic services has its ownmission statement that outlines theaim of improving the quality ofpeople’s lives, health and well-beingand reaching people that othersmight not (1).

Within the managerial structure theCAM manager is responsible forleading the team and within the teama clinical supervisor is responsible foroverseeing the team’s client and workloads and sharing skills withintherapy. Both volunteers and

paid staff have formal contracts;although as one interviewee noted:

I very often ignore those hours (3).

One particular difficulty articulated bya part time volunteer was the lack ofclarity in respect of the roles of othersin the organisation and the demandson their time. This related particularlyadministrative help.

Within OrganisationPartnerships

The history, structure and context ofthe Big Life Group have beendescribed earlier.

This part of the report attempts toexplicate some of the relationshipsbetween these separate but partnerorganisations under the umbrella ofthe Big Life Group.

Right Reasons and High Stakes

The documentary analysis revealed ashared vision at an organisationallevel between Therapeutic Services,the Kath Locke Centre, Big LifeServices and the Big Life Group. Thevision for Therapeutic Services, in linewith the Big Life Group ethos wasoutlined eloquently by oneinterviewee:

We are hoping to make a differenceto people's quality of life in terms ofhealth and well being…..givingpeople tools that they can use athome to continue to improve theirhealth and quality of life, as well asreceiving treatments in the clinic.

Despite this shared vision, there wasfor the CAM practitioners intervieweda feeling of detachment from thewider organisation (the Big Life Groupand Big Life Services). For thesepeople Therapeutic Services, and tosome extent the Kath Locke Centre,was the boundary of their work.


This is understandable given theirimmediate contact, and indeedcontract, is with Therapeutic Services.As one interviewee noted I’m notinvolved with Big Life Services or theBig Life Group (2).

Another that, sometimes I wonderabout the bigger picture of Big Life(4).

For this group focus lies not in theorganisational structure but in thebenefits to the community andindividual service users and in thistheir individual visions mirror that ofthe organisation.

Feelings of detachment are, in part,borne from the organisation’ssignificance to their every dayworking.

One interviewee articulated theirdetachment in terms of whathappens at the ‘coal face’:

I have worked within organisationslike this and I’ve fund raised a lot fororganisations like this. And rarelydoes it seem to me that the statedaims appear to have any significanceat all.

But there may be sort of generalstatement of intention, but actuallywhat’s significant is the service deliveron the ground to people and whetherpeople find that useful and beneficialin their everyday life.

And that’s the only bit of this servicethat I am interested in. (3)

Strong Balanced Relationships,Trust and Respect, GoodCommunication andFormalisation

For the interviewees in managementroles there was close alignment withand to the overall organisation.

They had a clear picture of theorganisational structure and howboth they as individuals andTherapeutic Services as anorganisation fitted within thisstructure. As one intervieweeexplained:

….there is a senior managementteam. We have the company goalsand targets, then they set our targetsin line with theirs, and they managethe budgets. They have the overallresponsibility of the contract, but theday to day running of it is left to thetherapeutic services (1).

Whilst Therapeutic Services do not actautonomously, the relationship isstrong and balanced in as much aspower is devolved through formalisedprocesses. The relationship is definedby working with, rather than workingfor:

We have the same aims andobjectives, but we influence how weare going to reach our target. Onetarget is "making a difference topeople's lives". The company havetheir own has their own targets andTherapeutic Services set their own inline with the company’s (1).

The relationship between the KathLocke Centre and TherapeuticServices was described as supportive.

The Centre was seen to share theirvision and work in partnership withTherapeutic Services.

The Centre provides use of theirpremises and support events held byTherapeutic Services:

…. the Kath Locke centre pays thetherapeutic services from their budgetto projects in the community.

They also give us the use of theirrooms for free, and support us whenwe hold events, so I think there is acommitment there.

The chief executive has been aroundfor 12 years and is keen to make adifference and change people's lives(1).

Another noted that it’s a lovely place,and the people were so helpful whenI first started (2)

Outside OrganisationPartnerships

Therapeutic Services work inpartnership with many organisationsoutside the Big Life Group in both thestatutory and voluntary sectors.However, the focus of this part of thereport is their partnerships with thelocal Primary Care Trust (PCT) andwith the University of Salford. Choiceof organisations for this part of thereport was informed by historical andcurrent context.

Local Primary Care Trust (PCT)

The Big Life Group has been linkedwith the National Health Service, andin particular primary care services forover a decade; the Kath LockeCentre, the primary base ofTherapeutic Services, was the firstNHS primary care facility in Englandto be managed by the independentsector19.

19 http://www.thebiglifegroup.com/Uploads/klc%20evaluation.pdf

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103



Documentary analysis shows that atthe level of the organisation, thevision or aim of Manchester PCT alignto those of the Big Life Group:

….to ensure modern, high qualityNHS services that are easily accessiblefor all residents in the city.

We are committed to working withpatients, carers and the public toensure that our services meet andrespond to the needs of the diversecommunities across the city20.

The PCT also demonstrate theirwillingness to enter into productivepartnerships in order to achieve thisvision:

We will work closely with localpartner agencies, particularlyManchester City Council, healthprofessionals such as GPs anddentists, voluntary and communityorganisations as well as our own staffto achieve this21.

Therapeutic Services work inpartnership with Manchester PCT andhave received funding annually fromthem for over 10 years.

The bulk of this funding applies tothe provision of counselling but asmall part is allocated for CAMservices.

Primary care providers including GPsand the mental health team referindividuals to Therapeutic Services.

However, within Therapeutic Servicesthere is concern over whether theirtender to the PCT for funding for theCAM part of the Service will besuccessful in the medium to longterm. The primary reasons forconcern, and thus threats to thepartnership, are exogenous to thepartnership lying in the perceivedweak evidence base in CAM andguidelines set down by the National

Institute of Health and ClinicalExcellence (NICE). As one intervieweenoted:

…there’s so much there’s so muchresearch done on the effectiveness ofcomplementary therapies and yetNICE are still saying that there isn’tevidence sufficient enough that it isworth investment and I think thatthen impacts on everyone’s view.And most medicine in this country isgiven in a very western medicalmodel and treats the actual illnessrather than the person as a whole.So, and most of the professionals aretrained in that framework, so it’s theodd one that thinks differently. So,you know, we’ve had things likehealth visitors not knowing whether itwould be right to refer to theHomeopathy Service, for instance,because they were saying, well we’regiving it some credence and we’regiving it recognition in the fact that itis going to be effective if we’rereferring people (5).

Therapeutic Services concern is thatthese factors, together with negativemedia coverage of the effectivenessof CAM, may result in their tender forfunding from the PCT beingunsuccessful for the CAM element ofthe Service (excluding counsellingservices which they perceived will befunded).

Right People, Right Leadership,Strong Balanced Relationships,Good Communication

From the perspective of the workingrelationship between the PCT andTherapeutic Services was viewed byone interviewee as good at anorganisational level but at anindividual level the partnership washampered by people moving aroundin jobs.

As one interviewee noted:

There is probably one person who haskey relationships for funding with thePCT. In terms of the City Council wehave built a really good relationshipwith them. We regularly havemeetings (2-3 times a year) There is aconsistency within the council as thesame person has been in the role for3 years now (1).

The balance of power in thepartnership was thought by oneinterviewee to be in favour of the PCTin as much as they decided whetheror not to fund the service:

I think the power lies in the PCT, myperception of it, I don’t know if I’mright but they can open doors tofunding for us or not, and originallywhen they came to replace theHealth Authority their main remit wasabout providing the community withthe things that they want andmassage was one of them, but…their remits have changed, but ourshasn’t (4).

However, Therapeutic Services aretaking a proactive stance in order tosecure future funding in thetendering process by working withthe University to provide a morerobust body of evidence andproviding for example, courses thatpeople can take skills away from, aswe felt this would give us a strongerposition for funding next year(1).

For one interviewee

there was the feeling of constantlystruggling to provide evidence (4).This was despite having really highdemand for all the complementaryservices that we deliver (5).

20 http://www.manchesterpct.nhs.uk/pct/about/21 http://www.manchesterpct.nhs.uk/pct/about/

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Formalisation

The partnership is formalised in partthrough the contractual process. Thecontract has strict criteria to workwith specific groups and work inpartnership with other agencies (1).

University of Salford

The University and TherapeuticServices have worked in partnershiptogether in the past. This work hasincluded students from the Universitycarrying out research as part of theirstudies within the Service and, mostrecently, working in partnership todevelop research to evaluate theeffectiveness of the CAM servicesprovided.


The University of Salford fashionsitself as an enterprising Universitywith an excellent reputation forresearch and business partnerships22.Their aim is to strengthen these links,developing ideas and encouraginginnovation23.

The vision goes on to say:

What marks us out in national andinternational arenas is ourengagement with local and regionalcommunities – this will remain core toour values as a University24 ( Universityof Salford 2008)

The vision of engagement with localcommunities and a research focus onsolving real world problems25 canclearly be seen to align itself with thatof the Big Life Group and TherapeuticServices. Indeed overall thoseinterviewed within TherapeuticServices perceived partnerships withhigher education institutions asbeneficial:

I think generally we’ve had lots ofgood partnerships, particularly SalfordUniversity and there’s the integratedcomplimentary therapy course andthings like that. So all the waythrough the years, you know, and I’vebeen in Salford today and the HealthCentres there are talking about takingstudents on. I think there is a verygood relationship generally.

I think we’ve worked over a numberof years to try and find funding tomeasure effectiveness and we’llcontinue to look to that kind ofpartnership because I think that’sbeen useful to us (5).

Not all the experiences were positiveparticularly in respect of the mixedquality of work produced by studentsand the paperwork required. Oneinterviewee noted:

We have had student placements inthe past, but stopped as it becametoo time consuming chasing uppaperwork, but I think it is somethingwe would be open to trying again (1).

The reason for the current phase ofthe partnership, to produce robustevidence of the effectiveness of CAM,was clear from the outset. Prior tothis current project, TherapeuticServices and the University hadworked together to develop aresearch proposal to evaluate theeffectiveness of the CAM servicesthey provided. Unfortunately, theproposal was unsuccessful and wasnot pursued further at that time dueto a change in staff both at theUniversity and at Therapeutic Services.However, dialogue continuedbetween the University andTherapeutic Services to explore waysin which to develop a co-ordinatedand systematic outcomes monitoringsystem in collaboration with

practitioners to facilitate the on-goingevaluation of the effectiveness ofCAM services by Therapeutic Services.This was thought by both theUniversity and Therapeutic Services tobe important for two reasons. WhileCAM is enjoying increasing popularityand acceptability in the UK existingdata on the benefits is basedpredominantly on the experiences offee for service clients who come fromtypically non-marginalised, higherincome target groups. There istherefore a need for evidence on theireffectiveness for disadvantagedgroups who access free or low costCAM therapies to guide service usersin selecting treatments, serviceproviders in developing appropriateCAM services and commissioners infunding the delivery of such services.

It was anticipated that the resultswould provide evidence with which tosupport funding for the service.

It was this need for evidence in orderto help secure funding for the Servicethat was paramount and provided apowerful reason for the partnershipfor both those working in TherapeuticServices and for the Universityresearchers; that a co-ordinated andsystematic outcomes monitoringsystem would help provide evidencethat would together with other workbeing carried out by the Service helpsecure funding:

Commissioners are impressed by acertain body, which is why beinginvolved with the University could bebeneficial.

As this area is the university’sexpertise it will be taken moreseriously. I think it could be a goodongoing process/ relationship (1).

22 http://www.vision.salford.ac.uk/page/our_aims23 http://www.vision.salford.ac.uk/page/our_aims24 http://www.vision.salford.ac.uk/page/our_aims25 http://www.salford.ac.uk/about/

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Right People, Right Leadership,Strong Balanced Relationships,Good Communication

The Service managers believed thatthe project undertaken with theUniversity was carried out inpartnership.

Communication of the project topractitioners was initially undertakenby the University through a series ofworkshops that provided a forum fordiscussion of the outcome measurethat would be used within thetherapists’ everyday practice.

The workshops led to a number ofadditional questions to be added tothe measure in line with the outcomeof the discussions.

Once the outcome measure wasintroduced, ongoing data collectionwas overseen by the TherapeuticServices Manager.

Regular contact between the Serviceand the University, at this time, wastypically by either e-mail ortelephone.

Communication about the use of themeasure across the Service was goodin as much as whilst one practitionerwas new to the service and was notaware of the partnership with theUniversity the practitioner said that:

the forms will show the case studiesof each person, and show that theclients are getting better (2).

Similarly another noted, in respect ofthe outcome measure:

I think they’re quite good. I meanthey don’t always work, you know,they don’t always work in practice.

Theoretically I think they’re fine. Ihave no objection to filling them in atall. I am perfectly happy to do thatuseful exercise, collection ofinformation (3).

This interviewee went on to say that

sometimes it doesn’t work andthere’s a variety of reasons why itdoesn’t work… I might just actuallyforget….. I think the scales are quiteuseful but, and I will always ask, I willquite often ask patients to markthings anyway. But the scales arequite useful so they can add to myunderstanding.

Reflections from the Author (CH)

Unlike in the previous subsection, theperspective of the ‘other’ partner canbe explored in as much as it is theauthor’s reflections on the partnership– as such I will write in the firstperson for this section. Overall I thinkthe partnership was successful in asmuch as there was a small body ofevidence available for TherapeuticServices to use at the end.

The relationship appeared to be bothstrong and balanced. Each of thepartners, both at an organisationaland individual level, was aware oftheir roles and worked to theirstrengths and expertise. I did notperceive any imbalances of powerbetween myself and the Servicemanager (with whom I had mostcontact). We were both were workingtowards the same goal, and thehistory of working with TherapeuticServices in the past also helped makethis a positive experience for me, asthe interviewees comments suggestedit was for them.

The interviews with people within theService were carried out by thesecond author (PO ) who was notinvolved in the case study in anattempt to minimise bias but, despitethe positive comments made by theinterviewees of the partnership, I feltthat there were some aspects of thepartnership that could have beenimproved upon.

To set this in context soon afterbeginning the project I moved jobs,going to a different University. Thismeant that I was geographicallyremote from Therapeutic Services inManchester and that I no longer hadthe time allocated to the project Iwould have had had I stayed in theprevious job. Whilst this did notdamage the partnership per se itmeant that communication wascarried out primarily through e-mail,which was not ideal; I think by beingphysically present at TherapeuticServices, for example at teammeetings, would have increased thenumbers of outcome measurescompleted and thus the success ofthe project. It also meant that whilst agood working relationship with theService Manager had been developedthis really didn’t develop any furtheras it would perhaps have done withmore face to face contact.

My final note is regardingformalisation of the partnership. Thehistory of working with TherapeuticServices meant that, in my mind atleast, trust was established prior tothis current project. Whilst thepartnership was relatively fluid(especially given my job move) I feltthat there was clear lines ofresponsibility and accountabilitywhich I don’t think waivered over thelife of the project. On reflection thiswas in part due to setting out rolesand responsibilities right at thebeginning (what could be achievedand by whom) and as a result of thehigh stakes (to obtain funding for theservice).

Further details of the project areincluded in the project reportcontained in Appendix 2.

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Discussion and Conclusions


The Warnwarth Framework was auseful tool for evaluating thepartnership relationships facilitatingexploration of both organisationaland individual partnerships. However,this should be tempered by sayingthat there were difficulties in beingable to evaluate concepts such astrust and respect from interview dataand documentary analysis alone.There is also a danger that in tryingto separate out different conceptsthat the holistic evaluation of thepartnership is lost. However, this didnot appear to be the case as theconcepts within the framework werenot mutually exclusive and ofteneither merged or informed oneanother to provide that holistic view;the framework allowed evaluation ofimportant factors without losing sightof the partnership as a whole. Ofparticular importance when using theframework were the explanations ofthe concepts. The authors found theneed to refer back to theseexplanations frequently during theanalysis.

The framework was used to explorethe partnership within and betweenorganisations. The within organisationanalysis shows clear differencesbetween those interviewed inmanagerial roles and those who areat what was described by one personinterviewed as ‘the coal face’ (themicro, meso, macro analogydescribed by Warne and Howarth).These differences are likely to havebeen compounded by both part timeworking and that some participantswere volunteers holding down jobselsewhere in addition to their workwithin Therapeutic Services. For thesepeople the strategic aims of theService and the umbrella organisationheld little interest although theirvision and aims of the service alignedcompletely with both.

It is also of note that intervieweesmentioned the importance of theirpartnership with the local communityand whilst it was not possible toexplore this in detail within this reportit is clearly integral to the Service andtheir umbrella organisation.

Overall partnership at the level of theindividual within the Service workswell. The culture is one of inclusivityrather than exclusivity and theenvironment nurturing. Thoseinterviewed attributed this to goodleadership and, importantly, to theculture within CAM itself (which wasseen as seen to attract people whowere nurturing and goodcommunicators). Whilst somedissatisfaction was expressed this wasprimarily associated withunderstaffing and linked to fundingof the Service and clarity of roles inadministration. Difficulties in this areawere exacerbated by the complexityand logistic difficulties of a staffingmix of volunteers, paid staff, full andpart-time contracts. However, themajority of those interviewed felt thatclarity of role and goodcommunication was facilitated by theright people, right leadership andsystems in place.

The evaluation of the organisationalpartnerships was hampered to someextent by inclusion of the perspectiveof only those in Therapeutic Services.Whilst this makes some of theconclusions relatively uni-dimensionalit was possible to explicate thedynamics of the partnerships anddraw some conclusions about thepartnerships relative success. For theorganisations within the Big LifeGroup the documentary analysisprovided, perhaps unsurprisingly, aclear alignment of their visions; of ashared vision and clear structure.Whilst this was echoed by thoseinterviewed who were in managerialroles, as mentioned previously for the

people working at the ‘coal face’ theorganisations above TherapeuticServices in the hierarchical structureheld little interest and this wasvocalised by one interviewee as afeeling of being detached. For thisgroup, especially those who workedpart time, there was little reason tocome into contact with theseorganisations (other than the KathLocke Centre) in their work.

There has been a long and successfulpartnership between the local PCTand Therapeutic Services at anorganisational level evidenced by overa decade of funding from the PCTwhich, together with funding fromother sources, has allowed the Serviceto be sustained and expanded overtime. Whilst the on-goingcommissioning of counselling servicesdo not appear to be of concern,some of those interviewed fromTherapeutic Services voiced concernover funding for CAM services, inparticular massage, despite high levelsof demand. The asymmetry ofknowledge regarding funding meansthat there is a power imbalance in thepartnership in favour of the PCT thatis typical in any partnership thatinvolves tendering for funding asorganisations priorities and remitsevolve over time. However,Therapeutic Services have beenproactive in addressing this, as oneinterviewee noted:

At a local level all we can do isdemonstrate the effectiveness of theservice…I think we’ve got to make astrong case for why they should keepit in (5).

At the level of the individual,movement of staff within the PCTmeant relationship building wasdifficult.

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Details of the partnership with theUniversity given by the intervieweeswere relatively brief but the reasonfor the partnership was clear (asdemonstrated in the above quote);the interviewees were vocal about thebenefits based on the potential forthe outcome measure to provideevidence of effectiveness (andpotentially help secure funding forthe Service) and to aid practice. Thepaucity of interview data, or indeedopinions regarding the partnershipwith the University relative to theother partners may be due to the lackof physical presence within theService workplace. Communication,once the workshops had beencompleted was typically by e-mail andtelephone between the author andthe Service manager. However,despite the lack of physical presencethe study was successfully completeand each person interviewed wasclear about their role in the collectionof data and the reasoning behindthat collecting it.

108

References


* Note for the purpose of this reportall information retrieved fromwebsites have been included asfootnotes attached to the relevanttext

DTI (2002). Social Enterprises, AStrategy for Success, Department ofTrade and Industry, London.

Warne, T., Howarth M (2009).Developing the WarnwarthConceptual Framework forPartnership Evaluation: A review ofthe Literature. Salford Centre forNursing, Midwifery and CollaborativeResearch, University of Salford.

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APPENDIX ONE


In considering this, can you tell me what you think the phrase 'partnershipworking' means in relation to your involvement with the CAM service?

Would you describe the service as being a partnership?

If so, what sort (formal, network, loose arrangement, steeringgroup, talking shop etc)?

What partnerships exist?

Who are the commissioners? How does this work? Their level ofinvolvement/engagement?

Higher education partnership?

3 RR (but mighttouch on all of

them!)

QWarnwarthReference

Could you begin by explaining what see the function of the CAM service tobe?

Promoting health and well-being?

What does that mean to you?

What should the service be doing?

How well do you think the service fulfils its function?

Can you give examples of anything the service has achieved inimproving health and well-being?

Reasons?

Are there things that it set out to achieve that have failed?

Reasons?

1 RR

2 HS

(outcomes)

I want to talk to you because you’re a key person concerned with the CAMservice

As you know, the aim of this study is to determine the way in whichpartnership working impacts upon the health and well-being of localcommunities.

Urban Regeneration - Interview schedule:

Researchers: Claire Hulme and Paula Ormandy

Service Leaders/providers:

110


QWarnwarthReference

What made you get involved in the CAM service?

Personal interest? - Role

As agency representative?

How is leadership of the service decided?

Was everyone content with this process / clear process

Do you feel the leadership is effective -- if so how?

How do the practitioners relate to the leader?

4 RR, HS, RP

Is there a formal agreement on the purpose of the service?

If so, was it used, was it influential?

If not, should there be/have been one?

5 F

6 RL, SBR

Did you have professional dealings with the service funders/ in other forumsand settings prior to setting up the service?

If so, do you think it influenced your role and behaviour in theservice?

History of working together?

7 SBR, TR

What is your role in the service?

Has this changed since it was first conceived?

If so how, why etc?

8 RR, HS, RP, TR(?)

What are communications like?

Within the practitioners/team?

Within the organisation with regard to the service?

With the commissioners?

9 GC, F

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QWarnwarthReference

What is it like being a member of the CAM service team?

Do you think your opinions are valued and listened to?

Is there trust and respect between team members/practitioners?

What are relationships like?

Are there some practitioners who get more benefit from being involved inthe service than others?

Or less?

Or where the purpose of their involvement is unclear to you

10 RP, RL,SBR,TR

11 RR, HS, RP

Is there a commitment to the service? If so from who?

Within the organisation

From the funder’s/commissioners

within the team

from users

12 RR, HS

How does culture impact on the service?

culture within the organisation (power, politics,

culture within the community (access, recognition of service, competing agendas/ pressures in society)

13 HS, RP, RR

Where does the power lie within deciding the future of the service?

Who will be involved?

How will this be achieved?

What influence will the team have?

14 HS, RP, RR, RL,SBR, (TR)?

Does the service have the appropriate resources?

Sufficient resources to meet the demand? (skills within the team,number of available practitioners)

Financial constraints?

15 F, RP

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QWarnwarthReference

What is the future vision for the service and the community?

How will this be realised?

What partnerships are required to enable this to happen?

16 RR, RP, SBR

Are there things which we have not covered but which are important inenabling partnerships to promote health and well-being in the community?

17

The questions I have asked you have inevitably focused on our own principalconcerns

RR Right reasons

HS High stakes

RP Right people

RL Right leadership

SBR Strong, balanced relationships

TR Trust and respect

GC Good communication

F Formalisation

Key - Factors which influence successful partnership working, taken from the ‘WarnworthConceptual Framework’, pp 46-9 (Warne and Howarth, 2007):

113

APPENDIX TWO


Dr Claire Hulme26

Report prepared on behalf of Big Life Therapeutic Services as part of Urban Regeneration:Making a Difference Project, Supported by HEFCE (Strategic Development Fund)

February 2008

Acknowledgements

This report was prepared on behalf of Big Life Therapeutic Services as part of UrbanRegeneration: Making a Difference Project, Supported by Higher Education FundingCouncil for England (HEFCE) (Strategic Development Fund). Thanks to all the staff atTherapeutic Services.

26 Formerly Salford Centre for Nursing, Midwifery and Collaborative Research, Institute of Health and Social Care, University of Salford

114

Report for Therapeutic Services


Background

Big Life Services provides andpromotes services to improve thewell-being of people who have beenexcluded from mainstream society.Following a self-help anddevelopmental approach, it focuseson the power of opportunity tochange people’s lives. Theorganisation has, for over a decade,provided free and reduced fee accessto selected complementary andalternative medicine (CAM) therapiesin the Manchester area. The sessionsare provided on a volunteer basis bytrained and accredited practitioners.In addition a number of sessions arecommissioned. Sessions are targetedtowards persons at the margin ofsociety either through homelessness,chronic long term unemployment or(mental) ill-health, or through theirmembership of particular minorityethnic groups.

While complementary and alternativemedicine (CAM) is enjoying increasingpopularity and acceptability in the UKexisting data on the benefits is basedpredominantly on the experiences offee for service clients who come fromtypically non-marginalised, higherincome target groups. There istherefore a need for evidence on theireffectiveness for disadvantagedgroups who access free or low costCAM therapies to guide service usersin selecting treatments, serviceproviders in developing appropriateCAM services and commissioners infunding the delivery of such services.

Aim

The aim of this case study is toevaluate the effectiveness of CAMservices provided the Big Life Services.

The purpose of this report is todescribe and report on the evaluationof CAM services provided the Big LifeServices.

Methods

The research was undertaken withinthe CAM service delivered at the KathLocke Centre, Hulme, Manchesterusing a before and after type studydesign in which service users wereasked to complete a questionnaire atthree points in time. Thequestionnaire was an adaptation ofan outcome measurement toolappropriate to CAM interventionswith disadvantaged groups, MYMOP27

(Measure Your Medical OutcomeProfile). This was used together withexisting assessment paperwork(developed via consultation with theComplementary Therapy Manager).The practitioners/therapists weregiven advice/support in order thatthey may administer thequestionnaires to their service users.The outcome measures wereadministered at three points in time(at the first treatment session (initialconsultation), one month after thefirst treatment and three months afterthe first treatment) to measure shortand longer term effects ofengagement with CAM.

• At the first treatment session thequestionnaire was administered bythe practitioner.

• Where possible the practitioneradministered the questionnaire atthe one month follow up. If theclient had finished his/her treatmenteither a follow up questionnairewas sent by post and included astamped addressed envelop forreturn or the questionnaire wascompleted over the telephone.

• Where possible the practitioneradministered the questionnaire atthe three month follow up. If theclient has finished his/her treatmenteither a follow up questionnairewas sent by post and included astamped addressed envelop forreturn or the questionnaire wascompleted over the telephone.

The time frame of the case study was9 months. Data collection began inJune 2007. Recruitment took placeover a 6 months period beginning inJune 2007.

The practitioners were responsible fordata collection as part of theirpractice and were supported by theresearchers from the University ofSalford. All completed questionnaireswere held by the service. Any datapassed to the University of Salford foranalysis was anonymised. Ethicapproval for the evaluation wasobtained from the University ofSalford Ethics Committee.

27 http://www.pms.ac.uk/mymop/index.php?c=welcome

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Findings

Sample: Baseline

Overall 32 people completed at leastone of the questionnaires; five hadreceived homeopathic services andthe remainder massage. Of thepeople who had receivedhomeopathic services only one hadcompleted a questionnaire at all threetime periods. Thus the focus of thisreport lies upon those in the lattergroup, massage services.

Twenty seven people who had hadsome form of massage completed atleast one questionnaire; eighteen ofthose completed questionnaires in allthree time periods. The massageservices received by those in thesample were described by thepractitioners as: massage,aromatherapy massage, reflexologyand acupressure. The massage areasincluded back, neck, leg, face,shoulder and feet.

The majority of those receivingmassage were female (n=23, 85.2%).Age ranged from 34 years to 82 yearswith a mean of 57.4 years. Eachperson was asked to choose one ortwo symptoms which bothered themthe most. For the purpose of thisanalysis the first symptom has beenclassified as the primary symptom andthe second as the secondarysymptom.

Almost half of those in the sample(n=13, 48.1%) presented primarysymptoms related to muscle or jointpain. Other primary symptomsincluded tension/stress (n=6),emotional issues (n=2), lowenergy/fatigue (n=5) and period pain(n=1). Participants rated the severityof the symptoms over the past week(0 as good as it could be; 6 as bad asit could be). The mean rating for theirprimary symptom was 4.2 (range 0-6). Almost half (n=6; 46.2%) of thosepresenting with muscle or joint pain

rated their symptom at either 5 or 6.Twenty people gave details of howlong they had had the symptom(either all the time or on and off).Sixty percent (n=12) had had theproblem for over one year.

Secondary presenting symptoms weregiven by 20 people and theseincluded muscle or joint pain (n=10),tension/stress (n=5), emotional issues(n=1) and other (n=4). This lattercategory included bladder and bowelsymptoms and circulatory problems.The mean rating of the secondarysymptoms was 3.9 (range 0-6). Thelower mean rating suggests thatthese symptoms did not botherparticipants as much as the primarysymptoms and, indeed the differencebetween the primary and secondarysymptoms rating was statisticallysignificant (p=0.012). Of the 20participants who gave details of twosymptoms 11 gave the secondsymptom the same rating as the first,just one gave it a higher rating(indicating that it was worse).

Only eight people said they weretaking medication for the symptomsthey had described; four of these saidthat cutting down this medicationwas important. A further six said thatavoiding medication for their problemwas important to them.

Participants were asked to give detailsof an activity that was important tothem and that their symptom makesdifficult or prevents them doing.Nineteen people answered thisquestion. Of these, two people saidthat it did not prevent them doinganything, six said sport or exercise,five outlined activities of daily living(including getting out the bath orchair) and two referred to socialactivities. The four other responsesdescribed activities using physicalstrength, sleeping and hobbies. Againthey were asked to rate how good orbad this was; the mean score was 4.2

(range 2-6).

Participants were asked to rate theirgeneral feeling of well-being over thelast week; again this was on a scaleof 0 (as good as it can be) to 6 (asbad as it can be). The twenty fourpeople who answered this questiongave a mean rating of 3.4 (range 0-6).

Baseline of Those CompletingQuestionnaires at all ThreeTime-points

Nineteen people completedquestionnaires at all time-points (theinitial consultation, one month andthree months after the initialconsultation). The mean age of these19 was only slightly higher than forthe sample as a whole (59.5 years);17 were female (89.5%). The primarysymptom for 57.9% (n=11) wasmuscle or joint pain; four people citedtension or stress, one emotionalissues and three low energy orfatigue. Participants’ rating of theseverity of their symptoms over thelast week was 4.2. This mirrored therating of the overall sample. Justunder half of the participants (n=8)rated these symptoms at either five orsix (where six represents as bad as itcan be). These ratings were acrosssymptom categories (n=5 muscle andjoint problems, n=1 tension or stressand n=2 low energy or fatigue).Fourteen people gave details of theduration of their primary symptom.Ten had had the symptom on or offfor over a year, one for between3months and a year and theremainder for less than three months.Six participants who had had theirprimary symptom for over a yearpresented with muscle or jointproblems. Seven participantsindicated that they were takingmedication for their primarysymptoms.

Secondary symptoms, when included(n=13), were muscle or joint pain(n=9), tension or stress (n=3) andcirculatory difficulties (n=1). The meanrating for these symptoms was 3.8 (0-6). All those who rated theirsymptoms as bad as it could beduring the last week (n=3) presentedwith muscle or joint problems. Eightparticipants gave their secondarysymptom the same rating as theirprimary symptom; five gave a lowerrating indicating that the problemshad not been as bad over the lastweek as the primary problem.

Participants were asked to chooseone activity (physical, social ormental) that is important to them andthat their problem makes difficult todo or prevents them doing. They thenrated this activity (0=as good as itcould be; 6=as bad as it could be). Ofthe 14 people who completed thisquestion two people said that it didnot prevent them doing anything,four said sport or exercise, fiveoutlined activities of daily living(including getting out the bath orchair) and two referred to socialactivities. The three other responsesdescribed activities using physicalstrength, sleeping and hobbies. Againthey were asked to rate how good orbad this was; the mean score was 4.6(range 2-6).

Finally participants were asked to ratetheir general feeling of well-beingover the last week. Seventeen peopleanswered this question and thereresponses gave a mean rating of 3.1(range 0-6).

Overall it should be noted that thissub-sample of participants did notdiffer from the sample as a whole.

One Month after the FirstConsultation

In the second questionnaireparticipants again rated theirsymptoms over the last week. Themean rating of the primary symptomshowed an improvement compared tothe same participants previous rating(a decrease from a mean value of 4.2to a mean value of 3.4). Thisimprovement was statisticallysignificant (p=0.012) and was madeup of ten participants whose ratingimproved, six gave the same ratingand two gave a worse rating (oneparticipant did not give a score).Similarly the mean rating of thesecondary symptoms decreased from3.8 to 3.3 (range 1-6) indicating animprovement. This was not howeverstatistically significant and comprisedof 13 participants three of whomrated their symptoms worse thanpreviously, four the same and siximproved.

In respect of activities thatparticipants felt their problem madedifficult to do or even stopped themdoing, again the change in rating forthis group of participants representedan improvement (4.9 initially to 3.63).Nine participants completed both thisquestion at both time points (fiveratings improved, three remained thesame and one worsened).

Participants’ ratings of their owngeneral well-being over the last weeksaw a slight improvement from 3.1 to2.9 over the two time periods. Of the14 people who completed thequestion at both points, five ratedtheir well-being better, six the sameand three worse. In additionparticipants were asked how theywould describe their general feelingof well-being over the last weekwhen compared to when they startedwith the programme.

Fifteen people completed thisquestion: six indicated they felt muchbetter than at that time, sixsomewhat better, two about thesame and one worse.

Three Months after the FirstConsultation

The 19 people who completed boththe first questionnaire and secondquestionnaires also completed afurther questionnaire three monthsafter their initial consultation. In thisthird questionnaire participants againrated their symptoms over the lastweek. Again the mean rating of theprimary symptom showed animprovement compared to the sameparticipants previous rating (adecrease from a mean value of 3.4 toa mean value of 2.9). Thisimprovement was statisticallysignificant (p=0.028) as was theimprovement between baseline andthree months (p=0.06). Between onemonth and three months after theinitial consultation two participantsrated their primary symptom worse(i.e. a higher rating), seven the sameand nine better (one person didn’tcomplete this question). Similarly, thedifference in ratings between baselineand three months showed one worserating, six the same and eleven better(again one person didn’t completethis question. The mean rating for thesecondary symptom was 2.2 (range0-4). This represented animprovement in symptoms from bothone month after initial consultation(mean 3.8) and from baseline (mean3.3).

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Seventeen people rated their general-well being over the last week; thisgave a mean rating of 2.4, again animprovement when compared to boththe previous time periods. This isfurther corroborated by participants’classification of their general feelingof well-being over the last weekwhen compared to when they startedwith the programme. Of thefourteen people who completed thisquestion seven indicated much better,four somewhat better and three thesame. Twelve of these participantshad also given the duration of theirprimary symptoms. Of the eight whohad had their symptom for a year ormore, six reported that their generalfeeling of well-being over the lastweek when compared to when theystarted with the programme much orsomewhat better and two about thesame.

Participants were also asked if theyhad any other comments that theywould like to make about theirgeneral feeling of well-being sincestarting the treatment. Whilst fewadded anything the five who did allhighlighted, either explicitly orimplicitly, a feeling of relaxation:

Client says that she sleeps rightthrough following reflexology (clientpresented with sleep disturbance)

Relaxed (client presented with painand stiffness)

Client thinks the treatment is verygood and relaxing; felt relaxed andable to deal with issues better; andsleeping at night (client presentedwith stress)

I feel much more relaxed and notmuch tension around my neck andshoulders thanks to the treatment. Ifeel much better in general comparedto when I first started the treatment –I would strongly recommend massage(client presented with tension in neckand shoulder)

Conclusion

Overall the questionnaires show thatthose using the service perceive thatthere has been a positiveimprovement over time in theirsymptoms and general feeling ofwell-being. Whilst this cannot bedirectly attributed to the treatmentreceived, it is important to note thatsome participants who had presentedsymptoms of long standing reportedan improved feeling of general well-being.

Despite the small sample size, whichmeans that statistical significanceshould be treated with caution, thereported findings to individualquestions corroborate each other inas much as reported improvements insymptoms are accompanied byreported improvements in activity andgeneral well-being. In addition theimprovements were evident both atone month after the initialconsultation and at three monthsafter the initial consultation.

Of particular concern to thepractitioners during the planningstages of the evaluation was theperception that numbers on scales didnot reflect the service users realfeeling of well-being – thatwords/qualitative data would give atruer picture (particularly the clients’own words). To address this inaddition to the scale for well-being acategorical general well-beingquestion was added (much better,somewhat better, about the same,somewhat worse and much worse).The two questions were placed ondifferent pages within thequestionnaires. The responses to thequestions reflected each other whichsuggest the scales were lessproblematic than anticipated.

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This section outlines limitations of theevaluation and presentsrecommendations in respect of howthese may be addressed in the on-going evaluation of the service.

Limitations

The small sample numbers mean thatthe findings reported for this sub-sample they are unlikely to begeneralisable. In addition furtherdetail in respect of the number andnature of treatment sessions eachparticipant received is needed.Although differences between somesub-groups are outlined, again theseare only indicative.

Whilst the majority of participantsreported an improved feeling of well-being and improved symptomslittle data is available to illuminate thefindings. The qualitative commentsgiven by a small number ofparticipants are indicative of feelingmore relaxed which for oneparticipant meant improved sleep andfor another participant less tension intheir neck and shoulders.

A further limitation was the missingdata on the questionnaires whichmeant for some responses there waslittle data to report. This particularlyrelated to medication. Unfortunatelythe data for the medication questionswas sparse and as such has not beenreported in any detail.

Recommendations

This initial report and the databaseprovide a sound basis for on-goingdata collection and evaluation forTherapeutic Services which is a creditto the hard work of both the servicemanager and practitioners within theservice. The main limitation of theevaluation is the small samplenumber but this will be rectified overtime as the sample numbers increase.

This part of the report makes anumber of recommendations in orderto improve the evidence provided, tomake the evidence more robust andthus increase generalisability; and tobuild on the work already carried outwithin the service. Therecommendations made take intoaccount the burden placed on theservice, practitioners and users.

Data Collection Forms

Include the following within the datacollection forms:

• Details of the total number andfrequency of treatment sessions.This will enable comparisonbetween the effectiveness oftherapy based on number andfrequency (for example, are weeklysessions for three to four weeksmore effective than the samenumber of sessions carried outfortnightly?)

• More details of the type of therapy.Within this report it was not alwayspossible to distinguish satisfactorilybetween, for example reflexology orback massage. This may beimportant, for example, in terms ofthe effectiveness of treatingdifferent symptoms

• Further demographic detail will bevaluable (include for example,employment status and ethnicity29).This will allow analysis in respect ofwhich demographic groups aretaking up the service and aidlonger-term planning in targetingthe service to particular groups

• Details of whether the service userhas had CAM before

Practitioner Training

Missing data, in the form ofunanswered questions, wasproblematic. Given the difficultiesassociated with staff turnover withinthe evaluation period further trainingin administration of the questionnaireis likely to be beneficial and willaddress this. In additionreinforcement of the importance ofevaluating the service is vital for bothfor the practitioners own continuingprofessional development (providingevidence of the effect of the therapythey provide) and for commissioningpurposes.

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Summary: Key factors to ensure successful partnerships

Authors: Karen Holland, University of Salford

As noted by Holland, Warne & Howarth (2008: 25) there are key factors to ensuring successful partnerships, all of which have been identified in the Case Studies through both evaluation of theWarnwarth Conceptual Framework , the literature and the experience of the project team members:

• Establishing the right reason for setting up the partnership initially

• Ensuring the partnership is the right size to enable effective working and collaboration

• Developing a shared vision of what the partnership is trying to achieve and the benfits involved

• Agreeing the contribution of each partner to achieving the aims of the partnership

• Assembling the right people in the partnership - not only from the right organisations but people who are able

to contribute appropriate knowledge and experience, have sufficient autonomy to represent the views of their

community or organisation and can communicate ideas effectively

• Ensuring you have the right leadership -in terms of being effective and having strong interpersonal skills that

foster respect, trust, inclusiveness and openness among partnership members

• Developing a shared understanding of what each partner brings and also agreed ground rules from the outset

about how the partnership will work and manage its task(s). The latter is very much dependent on the

partnership lead and their ways of working

• Making sure all contributions to the partnership should be valued and respected

• Effective communication is essential, both in relation to direct partnership working at meetings but also

between meetings and how partners communicate the work of the partnership to others

• Ensuring, as part of setting the ground rules for ways of working, that issues such as how the

partnership is managed and conducted, and to whom it is accountable, are transparent to all involved

Reference

Holland K, Warne T & Howarth M (2008) is 'good enough' good enough? Learning Curve, New Start,3rd October, 2008, 24-25.

Acknowledgements:

Our thanks go to John Thornton and his team for their patience andperseverance in supporting us with the final preparation of this report and fortheir excellent design which reflects our project team collaboration as well as thefocus to the actual project itself.

Without him and his team this report would not have been completed and weare grateful for his professionalism in completing this work.

Education Development UnitUniversity of SalfordSalford, Greater ManchesterM5 4WTUnited Kingdom

T +44 (0)161 295 2331F +44 (0)161 295 2332

www.edu.salford.ac.uk the design team

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