Partnership Working in Public Policy Provision: A Framework for Evaluation

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Original ArticlePartnership Working in Public Provision: A Framework for EvaluationSheena Asthana, Sue Richardson and Joyce Halliday

Partnership Working in Public Policy Provision: A Framework for Evaluation

Sheena Asthana, Sue Richardson and Joyce Halliday

Abstract

Partnership working has emerged as a key feature of New Labour’s approach to social policy.However, although the theoretical benefits of partnership have been well rehearsed, agencies chargedwith fostering partnerships lack “evidence” about how best to proceed in bringing about organ-izational change. This paper describes the development and implementation of a practical approachto capturing the strategies that can be used to establish, strengthen and sustain local partnerships.To this end, it presents a conceptual framework for the evaluation of partnership working anddemonstrates the application of the framework to an investigation of partnership working inCornwall and Isles of Scilly, and Plymouth Health action zones.

Keywords

Partnership working; Health action zones; Evaluation

Introduction

Partnership working has emerged as a key feature of New Labour’s approachto social policy. The main thrust of attempts to promote better multi-agencyworking has been through a series of area-based initiatives such as Employ-ment Zones, Education Action Zones, Health Action Zones, New Deal forCommunities and Sure Start. Targeted at areas of high deprivation, the ideathat problems that are connected to social exclusion require joined-up solu-tions has contributed to the value placed on partnership (Amery

;Painter and Clarence

).Expectations of partnership working are not confined, however, to those

statutory, voluntary and private agencies working in deprived areas. Forexample, it is significant that the geographical areas targeted for healthaction zone (HAZ) status have not been localized pockets of high depriva-tion, but can be whole health authorities. HAZs were established to find new

Address for correspondence:

Dr Sheena Asthana, Department of Social Policy and SocialWork, University of Plymouth, Drake Circus, Plymouth, PL

AA. E-mail: [email protected]

SPOL_285.fm Page 780 Friday, November 1, 2002 11:49 AM


ways of tackling health inequalities and modernizing services, particularlythrough partnership, innovation and the participation and empowerment ofhealth and related staff and local people. Technically based in the “

areasof greatest deprivation and poor health”, they cover

million people inEngland, representing over a third of the total population (Bauld

et al

.

).This focus on large organizational units rather than the worst local areas hasled some to question whether the HAZs’ real agenda is less concerned withtackling inequalities than issues of service organization and management(Powell and Moon

).The development of Local Strategic Partnerships (LSPs) suggests that the

establishment of action zones and similar initiatives has indeed been the firstphase of a far broader political project. The first LSPs to be accredited willbe in the

deprived areas targeted for the local neighbourhood renewalstrategy. However, they are expected to develop across the country and playa key strategic role in developing community strategies; in bringing together,and looking at ways to rationalize, partnership and planning arrangements;and in developing and delivering on local public service agreements (DETR

).LSPs are thus designed to consolidate earlier attempts to improve partner-

ship working on the understanding that services that are coherent, cost-effective and responsive to their users are more likely to be achieved byagencies working together than by agencies working in parallel. A “collabor-ative discourse” lies at the heart of the government’s strategy for moderniz-ing public services (Clarence and Painter

) with areas that have receivedzone status seen as “trail-blazers” for ways of working that are expected tobecome the norm for the country as a whole.

For a concept so central to current public policy provision in the UK,remarkably little is known about how to translate the rhetoric of partnershipworking into practical reality (Glendinning and Clarke

). The theoret-ical benefits of partnership have been well rehearsed (Painter and Clarence

). In practice, however, agencies charged with fostering partnerships lack“evidence” about how best to proceed in bringing about organizationalchange. Policy statements tend to be rather normative, partnership beingtaken to be a “good thing”. However, little substantive guidance is givenabout what is even meant by partnership, let alone the conditions or factorsthat increase the probability of effective partnerships emerging.

Having been established as “learning enterprises” (Bauld

et al

.

), ini-tiatives such as health action zones offer significant practical experienceabout the process of partnership working, the tensions that can arise and theways that such tensions may be resolved. The development and implemen-tation of a practical approach to evaluating partnership processes has beenan important aim of the research, commissioned by Cornwall and Isles ofScilly (CIoS) and Plymouth HAZs. The overall goal of the research is to raiselocal stakeholders’ awareness about key components of partnership workingand to provide practical guidelines about the strategies that can be used toestablish, strengthen and sustain local partnerships. An important aim is toproduce concepts, methods and findings that are not only of local but ofgeneral relevance.



In this paper, we present the conceptual framework that has guided thisevaluation and provide some emerging findings to illustrate its application.

Methodology

A key aim of the evaluation strategy has been to increase stakeholders’awareness and recognition of the full spectrum of issues that influence andcharacterize partnership working. The development of a conceptual frame-work that not only provided a frame of reference for the collection andanalysis of data, but could also act as a summary tool for discussions withlocal stakeholders was thus an important goal. Emphasis was placed oncreating a framework that was sufficiently

comprehensive

to accommodate thecomplexity of issues that arise in the building of partnerships and was

intelli-gible

to all stakeholders (i.e. that had a practical rather than a theoreticalbasis). At the same time, the framework had to be

rigorous

enough to allowfor comparative analysis between the two health action zones participatingin the research and between their composite programmes and projects.

As a first step towards the framework’s development, theoretical andempirical literature on partnership working, inter-agency working, collabora-tion, etc., was reviewed. Common themes were identified and then synthe-sized into a set of analytical components. Like other studies that have soughtto identify key characteristics of partnership working, the objective of thisexercise was to produce a realistic framework rather than a “grand theory”of partnership working (Hudson

et al

.

:

).The framework provided a conceptual “coat hanger” that was used initially

to engage stakeholders and to help them understand the nature and purposeof the evaluation. It also provided a consistent frame of reference for resear-chers working in both health action zones and has guided the collection andanalysis of data. A variety of data collection methods has been used, both formaland informal. Semi-structured interviews have been conducted with repre-sentatives from statutory, voluntary and private organizations. Represent-atives of agencies have also completed a self-administered questionnaire basedon the Nuffield Institute of Health’s Partnership Assessment Tool and theWorld Health Organization’s Verona Benchmark. Documentary evidencehas been analysed and meetings have been closely observed. Data have alsobeen collected through other evaluative activities such as facilitation ofprojects and partnerships. Throughout the data collection the framework hasacted both as a checklist to ensure that each aspect is adequately covered andas a tool to investigate relationships between different components.

A Framework for Evaluating Partnership Working

There is a growing body of literature that describes attempts to foster collab-oration in the planning and delivery of public services, comments on thefactors that enable or constrain inter-agency working, and seeks to identifygeneric aspects of the process (Challis

et al

.

; Holtom

; Ansari

et al

.

; Glendinning

). The Nuffield Institute of Health in Leeds hasmade significant progress in developing frameworks that capture the key



ingredients of partnership working (Hudson

et al

.

,

). Indeed, anadaptation of its Partnership Assessment Tool (Hardy

et al

.

) has beenused to evaluate specific dimensions of partnership working in this research.

For all of its merits, however, the Nuffield Tool does not provide a com-prehensive framework. Nor does it make explicit distinction between inputs,processes and outcomes of successful collaboration. This may in part reflectan understanding that many of the key aspects of partnership working areiterative and cumulative (Hudson

et al

.

:

). For example, the devel-opment and maintenance of trust can be seen as an input, a process and anoutcome of successful partnerships. Against this, making a distinctionbetween the investments (tangible and intangible) that organizations canmake to facilitate partnerships, the strategies that can be used in the processof partnership-building and the kinds of indicators that characterize success-ful partnerships can be enormously useful for local stakeholders themselves.It is for this reason that we have explicitly identified inputs, processes, out-comes and impacts as key analytical components of the conceptual frame-work (see figure

). The importance of context is also emphasized in theframework, as is the notion that interrelationships between different stake-holders are underpinned by principles of access, representation and power.

A second feature of the framework is the emphasis placed on level ofanalysis, in terms of both organizational level (strategic, operational, etc.) andstage of the partnership life cycle (Lowndes and Skelcher

). It is wellknown that the transition from joined-up decision-making to joined-upimplementation can be difficult (Hudson

). However, when agencies areencountering bottlenecks in translating strategy into action, it is helpful todistinguish between the stages involved in moving towards goals such as jointcommissioning and joint provision and to acknowledge that partnership maybe easier to achieve in some of these stages than in others.

In seeking to define the key components of the framework, we have drawnupon the extensive literature that exists on the difficulties of developingcollaborative relationships, particularly between health and social services.However, the framework also shares some common ground with models thatdo not relate specifically to partnership working, such as the theory-basedapproach to evaluation (Weiss

) and the production of welfare model(Davies and Knapp

; Davies

).Having described the framework in general terms, the remainder of this

paper demonstrates its application to an evaluation of partnership workingin Cornwall and Isles of Scilly and Plymouth HAZs. The framework itself isused as a reporting structure to illustrate some of the main themes that haveemerged from the research. We focus here just on the strategic level of theHAZs rather than individual programmes or projects.

The Context of Partnership Working

The geographical context

The importance of geographical context has been acknowledged in literatureon partnership working (Hudson

et al

.

; Maddock

), primarily



through an interest in the significance of coterminosity (Exworthy and Peck-ham

; Painter and Clarence

). The fact that Plymouth HAZ iscoterminous with the local unitary authority, the primary care trust (PCT)and a number of other area-based initiatives in the city is seen as a definite

Figure

A framework for examining partnership working



benefit by local stakeholders. The city also has a long history of communitydevelopment investment and well-established networks fostered by a range ofprevious partnership initiatives.

Cornwall and the Isles of Scilly HAZ, by contrast, covers an area admin-istered by one county council (of which the local educational authority andsocial services department are part), six district councils, one unitary author-ity and three primary care trusts (which have recently merged from fiveprimary care organizations). Distance in Cornwall has compounded theproblem of non-coterminosity by inhibiting networking and heighteningterritorialism; while, as a rural county, Cornwall has been further disad-vantaged by the long-standing urban bias in community developmentinvestment.

A difficult geographical context is not an insurmountable barrier to col-laboration. Indeed, it can increase recognition and acceptance of the needfor partnership. For example, agencies in Cornwall are fully aware of theadditional costs associated with delivering services in rural areas. The prac-tical problem of dealing with dispersed demand and diseconomies of scalemakes it extremely desirable that different organizations work together tostreamline service delivery. There is also an increasing awareness of overlap-ping agendas, the need to strengthen and develop relationships and theimportance of being networked. This is felt to be particularly acute as thehealth service is further reorganized, Integrated Area Plans developed as aresult of Objective One status, and new area-based initiatives created.

Rurality therefore provides compelling reasons for different organizationsto work together. Nonetheless, the costs of building and sustaining networksin a dispersed rural county should not be overlooked. Indeed, there is astrong case for providing

additional

resources to areas where factors such asrurality, a lack of coterminosity or a lack of previous investment in commun-ity development present significant challenges to partnerships.

The political context

Within the short lifespan of health action zones, there has already beensignificant political turbulence. The initial emphasis on the need for HAZsto harness

local

energy, promote innovation and accept risk-taking has givenway to an emphasis on the need to achieve

national

priorities. The require-ment to show “early wins” has counterbalanced impetus to take risks. Fund-ing has been cut and the future role of HAZs beyond March

remainsunclear. The uncertainties created by national government, together with thetop-down, political imperative for partnership working can conflict with thebuilding up of (arguably more) sustainable relationships from the bottom up.However, the announcement of Local Strategic Partnerships also gave HAZsa meaningful role as a testing ground and springboard for developing newarrangements.

National HAZ policy is not the only area to experience political turbul-ence. Many of the key partner organizations have had to respond to changesin political steer. For example, the dissolution in April

of health author-ities, the bodies that established and housed HAZs, has created uncertainties



about future accountability arrangements as well as changes in personnelwho have played an important role in developing networks with and the trustof partner organizations.

Inputs to Partnership Working

If partnerships are to be successful, they need more than a vague assumptionthat partnership working is “a good thing”. One of the clearest findings ofthis research is that the development of meaningful partnerships rests onthe availability of key inputs. In the first instance, all HAZs carry addi-tional resources to support better inter-agency collaboration. This has beenfound to be a

necessary

input and one that immediately raises importantquestions about the resource implications of nationally mainstreaming thepartnership approach to public service planning and provision. Yet, theprovision of financial resources is an

insufficient

condition for partnershipworking. A number of less tangible factors also act as key inputs to theprocess.

Recognition of a need for partnership

Preliminary results from a partnership assessment exercise carried out inboth Plymouth and CIoS found that the recognition and acceptance of theneed for partnership was felt to be the key strength of the HAZ partnershipssurveyed to date (see also Hudson

et al

.

). However, motivation for col-laboration takes many different forms and all may have a bearing on thesubsequent strength and sustainability of partnerships (Bailey

; Hutch-inson

).The predominant motive here appears to be real need. The vast majority

of partners agreed that their organizations had now to work with others inorder to achieve some of their main goals and that other agencies similarlyhad to work in partnership with them in order to meet key targets. Stresswas thus placed on the increasing awareness of overlapping agendas, theneed to increase coordination and reduce duplication of effort and the needto strengthen and develop relationships. An allied motive was the importanceof being networked, both so that partners could receive relevant informationand so that they could keep others informed as to the work they were doing.Benefits thus focused on integrated services, information, communicationand raised awareness while costs were perceived in terms of time, travel andspeed of decision-making.

Sometimes agencies agree that there is a need to collaborate because thereis a political imperative to do so. The Nuffield Institute for Health, forexample, found that “it was common to find joint working flourishing whereit was funded by some distinct pot of money . . . [or where] central govern-ment [requires] documentary evidence of joint working, perhaps as a condi-tion of access to specific funds” (Wistow

et al

.

). The findings from thetwo health action zones similarly suggest that senior managers tend to bemore willing to commit to critical implementation issues (e.g. pooled budgetarrangements, new funding) when such developments are being taken

SPOL_285.fm 86 Friday, November 1, 2002 11:49 AM


forward nationally. This can then provide a catalyst for real commitment onthe ground.

Provision of resources

The development of partnerships requires support. In some cases this hascome from a strong history of collaboration whereby existing trust andunderstanding act as a resource. In other cases, the provision of tangiblesupport (e.g. staff dedicated to the process of partnership-building, formalcommittee structures, external facilitation) has provided an impetus to mov-ing partnership working forward.

Both HAZs have relatively limited financial resources compared to thecombined annual expenditure of the local statutory organizations for healthand social care. Both have thus focused on changing ways of working andstrengthening service infrastructures in order to maximize the capacity ofexisting budgets rather than focusing on service provision

per se

.In Plymouth, this has largely involved the use of “HAZ champions”,

often programme board leads, who take the message from the HAZ teaminto the different service sectors. In CIoS HAZ, programme-level cham-pions have played a pivotal role in developing a shared vision of a strategicagenda (e.g. around the modernization of services for older people). How-ever, this has also been strongly supported at the project level by theappointment of coordinators (often frontline staff ) who consult acrossagencies, professional and user groups in order to review, develop andpromote more integrated approaches to service delivery. With significantresources dedicated to evaluation, external evaluators have also provideda resource for facilitation, communication and trouble-shooting in Corn-wall. Knowledge, skills and contacts have been gained through thisapproach with project and programme leads becoming “resources” intheir own right.

Both HAZs have recognized that projects in very different programmeareas are likely to face very similar difficulties (e.g. sharing informationabout clients, establishing pooled budgets and integrating provisionbetween different statutory agencies) so strategic collaboration across the-matic strands also needs to be resourced. This has been one of the mostdifficult areas to address, reflecting the broader problem of how inter-agency initiatives relate to bureaucratic frameworks that remain largelystructured around individual agencies. The development of systems (e.g. acountywide Children and Young People’s Strategic Partnership in Corn-wall together with local Planning and Implementation Groups) illustratesthe positive efforts that are being made to provide joined-up strategic sup-port to partnership working at the local level. However, the power tochange existing bureaucratic arrangements does not always lie with themanagers of local organizations, however senior. It is often not until aninter-agency initiative is nationally mainstreamed, effectively giving per-mission for change, that local organizations have been found to be willingto let go of service arrangements for which they have traditionally held soleresponsibility. As discussed elsewhere (Maddock

), this suggests that a



key level of strategic support for local partnerships is the centre itself andits ability to legitimize.

Leadership and management

Evidence from both HAZs suggests that active leadership, as in many localpartnerships of this kind (Russell

; Evans and Killoran

), is a criticalinput in determining the extent and pace of partnership development at alllevels in the partnership. However, while evidence from both HAZs supportsother work (Crant and Bateman

) in finding that

personality

is an import-ant dimension of leadership, we also find that good leadership can have acollective rather than an individual source. Thus, it may stem from an effect-ive team with varied roles and responsibilities.

There is also evidence that key personalities can act as barriers to effectivepartnership working (Maddock and Morgan

). This is one of the moredifficult areas to evaluate objectively as one respondent’s perception of aninability to devolve responsibility, create space for partnerships, etc., can beattributed by a different respondent as a legitimate concern for issues suchas confidentiality and competency. It is important to explore conflicting per-ceptions of personality before attempting to identify the processes by whichsuch barriers can be circumvented.

Such issues remain important when we move beyond leaders per se toconsider the contribution of the wider participants to the partnership pro-cess. One key could be the relative effectiveness of partners based at differ-ent levels of the command structure, as hinted at by Callaghan et al. ().This seems to reflect the extent to which individuals have relative auton-omy within their organizations with respect to decision-making. Choice ofrepresentative can therefore be key to preventing delays and frustrationsconsequent on decisions that have constantly to be referred back for vali-dation. Alternatively, if less senior managers are successfully to lead theirorganizations into effective partnerships, it is critical that they are givenlegitimacy. However, even then, meaning is often attributed to the statusof the representative with, for instance, the attendance or non-attendanceof senior staff being taken as a visible signal of the strength or absence ofsupport.

Organizational ethos

The apparent dominance of the health authorities (which, until April ,ultimately held accountability for the HAZs) has been a source of frustrationfor partner organizations. However, both project teams have been pro-activein terms of establishing linkages with other organizations and securing anunderstanding of health-related issues in a wider arena. In Cornwall, forexample, inter-agency involvement was sought from the planning stages ofthe HAZ and strong efforts have been made to secure links with other localinitiatives such as Objective One and the Children’s Fund. There is now astrong sense that some of the partners most committed to the “HAZ way ofworking” come from outside the health sector. Similarly in Plymouth, HAZ



has been active in successful proposals outside what is strictly “health”, e.g.New Deal for Communities and Sure Start.

Processes of Partnership Working

Organizational cultures are often key to the ways in which the processes ofpartnership unfold. What is straightforward and apparently easy to achievein one organization can be difficult or impossible in the time-scale foranother. For example, it is often forgotten by those who do not work in thelocal authority that all major decisions have to be referred to elected mem-bers and are subject to committee cycles, making the progress of joint deci-sions very slow.

Conflict resolution and consensus-building

In the public context of meetings, very little conflict has been observed ineither CIoS or Plymouth HAZs. In part, this is a reflection of growingconsensus but there is also a feeling that partnership meetings may not bethe right fora to express strong differences of opinion. Strategic players havecertainly become very adept at using the rhetoric of partnership and dem-onstrating a willingness to align decisions. However, despite statements ofsupport, it can take them a considerable time to make decisions about thecritical issues (e.g. pooled budget arrangements or joint assessment protocols)that can move a project from a phase of service review and planning toactual implementation. That this is happening at all, however, should beviewed as an achievement.

Knowledge/information-sharing

Restrictions on formal data exchange are of central importance to the build-ing of effective partnerships as the development of holistic care plans andintegrated services demands systems in which client information can be rou-tinely accessed and updated by partner agencies. However, progress in bothHAZs has been slow. Concerns about ownership, confidentiality of informa-tion, limits of responsibility (especially where failure may lead to litigation)and the time costs of updating systems to facilitate sharing are some of thefactors that inhibit the utilization of shared information systems.

In addition to formal data exchange, there is a vast amount of morequalitative information about both policy-making and implementationissues which needs to flow vertically within and horizontally across organiza-tions. In both HAZs, provisions are in place to ensure that partners andother stakeholders receive written documentation and have opportunitiesfor consultation and dialogue. However, there is still a strong sense that themain mechanism for information exchange is through informal networkswith obvious ramifications for those who are outside such loops. Thereremain few opportunities for communication across different programmeareas. Yet projects attempting to streamline provision in very different areasof activity (e.g. specialized children’s services, adult mental health services



and rehabilitation services for the elderly) often experience similar organiza-tional barriers.

Both HAZs provide evidence of changes to vertical communication withinparticular programme areas including a number of positive attempts toconsult with user groups in service planning and review activities. In CIoSHAZ, for example, a parent advisory group is actively contributing to thedevelopment of joint-agency assessment and care planning protocols forchildren with complex needs. In Plymouth HAZ the representation of ser-vice users and carers on the Mental Health Programme Board is seen ashaving given this group a real chance to influence policy-making and ser-vice provision.

Networking

One of the aims of the health action zone initiative has been to “main-stream” or institutionalize networks so that relationships continue irrespect-ive of individuals and that the values and interests of different stakeholdersare represented in statutory decision-making processes. Again, there is evid-ence of the strengthening of networks between strategic actors andbetween frontline agencies and staff, but the forging of links between dif-ferent levels of the service hierarchy remains more problematic. There isalso a feeling that some powerful informal networks still function andbypass the safeguards that should ensure equity and accountability in part-nership relationships.

The reality for many inter-agency projects is that there is not equitybetween member organizations. This is particularly the case where thefuture of a project requires financial commitment beyond the lifetime ofthe HAZ and depends upon a single statutory agency taking a lead role.“Big” decisions such as the commitment of finance are unlikely to be madewithin formalized partnership meetings. Indeed, without informal network-ing (and bargaining) between the key strategic actors, such decisions mightnever be made at all. As the HAZs look to mainstreaming their originalwork programmes, the way in which such networks work requires increas-ing attention.

Accountability

It is generally accepted that agencies entrusted with the responsibility ofusing public resources and achieving public policy goals should be properlyaccountable for their decisions and actions. Within hierarchical public sectororganizations, these mechanisms tend to be upward. The emphasis on theneed for agencies such as the NHS to be “accountable to patients, open tothe public and shaped by their views” (NHS White Paper ) representsan acknowledgement of the role of other stakeholder groups. Despite thepolicy push behind the development of partnerships, however, little thoughthas been given to how to develop formal accountability relationships withother stakeholder groups such as partner agencies, professional groups andemployees.



The complexity of accountability in public administration has been docu-mented elsewhere (e.g. McGarvey ) and survey work in Cornwall andPlymouth HAZs reveals not only the considerable variation in both actualand perceived accountability arrangements but also the complexity of sucharrangements and the confusion that ensues. In both HAZs, considerablethought has been given to ensuring due process (e.g. openness, transparencyand impartiality in decision-making). Information-sharing has improved andservice access and quality standards are being established on a joint-agencybasis, along with quality assessment processes. However, ensuring financialprobity across organizational boundaries remains a sensitive area. Despitethe introduction of the Health Act, it continues to be difficult to estab-lish decision-making bodies that are prepared to accept responsibility and beaccountable for shared budgets.

Lines of managerial accountability have also been unclear. From the HAZperspective, this was in part a conscious decision to give individual projectsscope in determining their own ways of achieving their objectives. This hasbeen effective in encouraging outward lines of accountability with projectleads recognizing, via extensive consultation, the critical connections theyneed to make in order to progress their work. However, many projects strug-gled at the outset without a clear management structure and without theallied definitions of responsibility, reporting requirements or access to execu-tive decision-making powers. Evaluation suggests most would signal clarityin these areas from the outset as a key to effective project-planning.

Principles in HAZ Partnerships

Policy rhetoric promoting partnership working as the cornerstone of thehealth action zone policy suggests that a broad platform of interest grouprepresentation should evolve. In contrast, Hudson et al. (: ) arguethat good partnership depends on limiting the number of parties involved inthe collaborative endeavour as “members cannot be so great that the processof partnership becomes unmanageable”. This implies that the process ofpartnership should involve exclusion, which has important implications forprinciples of access, representation and power. On the face of it, it wouldappear that the principle of stakeholder inclusion or participation is in directconflict with the practical realities of effective decision-making and manage-ment. This dilemma can be partially resolved if the question is changed fromwhether to involve as many stakeholder groups as possible to how to involvethem most appropriately.

Interestingly, several “excluded” respondents in this research supportedthe idea of limiting inclusion as they felt disenfranchised by large decision-making structures which restricted their ability to contribute to and influencedevelopments. This may partly explain the continued domination of repres-entation at the strategic level by the key statutory agencies. The fact thatmany small organizations and representatives from the voluntary and com-munity sectors distance themselves from joint working at this level can, in apositive sense, reflect the priority given to focusing their energies on micro-level local partnerships. However, differences in access and perceptions of



power can also present obstacles to participation. Active representation iscostly in terms of both time and money and such costs tend to be feltdisproportionately by small organizations and disenfranchised sections of thecommunity (Unwin and Westland ).

In both HAZs, efforts have been made to support the participation ofthose who would not otherwise feel able to take part. In Cornwall, for exam-ple, youth forums have been used as a vehicle for bringing service providersand young people together in order to ensure that the latter have a voice inthe planning and delivery of youth services. In Plymouth, funding has beenset aside in local partnership meetings to cover such items as care for chil-dren or other dependants, or travel expenses for those who could not other-wise participate. Plymouth has also had a formal policy of community orvoluntary sector representation on all programme boards. User/carer repres-entation has been particularly active in the area of mental health.

Care needs to be taken, however, in assuming that such initiatives guaran-tee user representation. Service users require appropriate professional sup-port to operate at this level and there is also the potential for what has beendescribed as the hostage phenomenon (Damodaran ). Here users, throughthe very process of involvement, absorb new knowledge and take on differentvalues and perceptions from the group they initially represented. This is alsoa problem highlighted by some members of the voluntary and communitysectors who fear that, by formalizing partnerships, the radical voice willinevitably be lost or, at best, co-opted.

One group that has potential for more involvement at strategic level isfrontline staff and ways need to be found to encourage this. Again, CIoSHAZ has been innovative in its use of frontline staff as project coordinatorswho have consulted across multi-professional boundaries in order to build upconsensus about the development of integrated approaches to service deliv-ery. Progress made in the adoption and use of new protocols and systemsrelating to stroke care and falls prevention demonstrates the potential of thisapproach.

Outcomes

At this stage in the research only preliminary outcomes can be presented.However, it is clear that both HAZs have made considerable progress interms of partnership working. One key outcome has been the progress madein terms of shared principles, knowledge and understanding.

In CIoS, for example, the realization that partners need to work togetherin order to achieve some of their main goals has emerged as a cornerstone ofthe HAZ steering group. In the process, partners say they “have learnt moreabout the aims and philosophies of the other organizations” and come toappreciate that the “identification of the barriers to engagement, involve-ment and investment in other agencies [is] the first step towards a solution”and hence the first step towards other more tangible outcomes.

This has been particularly evident in the shift over time from a HAZwhich was perceived initially as an agent of the health authority to an initi-ative which now engages in an effective dialogue with partners around the



wider health agenda. CIoS HAZ is acknowledged to be a key partner forboth economic regeneration and emerging local strategic partnerships. Eval-uation has undoubtedly played a role in moving CIoS HAZ partners towardsthe range of outcomes outlined in figure , whether that be disseminatingknowledge and understanding, sharing information, agreeing goals, roles andresponsibility, or sharing accountability. This has been possible not onlybecause external evaluation has been iterative and partners have generallybeen concerned and responsive, but also because the HAZ has accepted theimportance of facilitation and individuals have become increasingly aware ofthe importance of establishing for themselves how their work is progressingand what is proving difficult. In the process they have become empoweredto take action on their own behalf to address the barriers and to furtherpartnership working and organizational development.

The Eldercare Programme currently being implemented across threeprimary care trusts (PCTs) in Cornwall is a case in point. This has acted asa springboard for and, in key respects, has evolved into the Local Implemen-tation Team for the national service framework (NSF) for older people. Thefact that CIoS is now “ahead of the game” with regard to the systems,processes, plans and services that it has put in place to support the NSFundoubtedly owes much to the HAZ way of working.

In Plymouth, the HAZ partnership has also showed signs of increasingmaturity and there is certainly a higher level of shared principles/values,knowledge and understanding among partners than there was at the outset.There is greater appreciation, for example, of the need to work in partner-ship strategically and operationally across the city to improve health andwell-being and to reduce health inequalities, while greater trust among part-ners is allowing more open discussion around both shared opportunities anddifficulties. There is also now a culture of inter-agency working that hasenabled integrated drugs services, mental health services, services for peoplewith learning disabilities and integrated planning of services for children andyoung people. This is not to say that all the problems have been solved butthat considerable progress in partnership working has been made.

Conclusion

As more and more staff are required to work in partnership, redefining thenature of their jobs and the boundaries of their parent organizations, infor-mation on the characteristics of effective partnerships becomes an increas-ingly salient resource. The evaluation of the HAZ programmes has focusednot just on assessing the value of service reconfiguration and delivery but,just as importantly, on assessing the allied changes to organizational andindividual work practice and ethos and ensuring that the learning from thischange is disseminated.

No framework for evaluation is intended to be a model of reality, rather atool that facilitates clear thinking. This paper has shown how such a tool canhelp dissect the complexity that is partnership working and provide assist-ance for strategic and operational staff alike in understanding the systems ofwhich they are a part and the factors which inhibit or facilitate change.



Acknowledgements

The authors would like to acknowledge Cornwall and Isles of Scilly andPlymouth Health Action Zones for their commitment to the evaluation pro-cess and would like to thank the many individuals involved for their coop-eration with this research.

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Partnership Working in Public Policy Provision: A Framework for Evaluation

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