The study, 'Conditions for Partnership' by Su Maddock and Glenn Morgan of Manchester Business School, was funded under the ESRC (Economic and Social Research Council) Management Innovation Programme. The researchers examined a number local authority and NHS agencies that encourage inter-agency partnerships and actively endorse staff working in inter-professional teams in order to improve and integrate care. Their findings show that such partnerships - although central to the government's modernisation agenda and to integrated responsible public services - are frequently undermined by institutional barriers and insensitive management.
Barriers encountered by those developing new ways of working within partnerships include inertia and the existence of 'blame' cultures, a lack of concern for staff, and policies which advocate sharing but management systems which reinforce only activities and efficiency. The report goes on to say that too often, innovative teams complain of
lack of support from senior management and are sceptical of management's change programmes when they are driven not by the need for service improvements, but savings.
Effective change strategies depend on clear values and an open, facilitative approach to staff, rather than on narrow, enforced targets. The autonomy of the professionals needs to be reinforced and extended to other staff groups so that they are more confident of risk-taking, personal judgement and collective work. The report says this requires a shift in attitude and senior management endorsement, and calls for an inclusive management framework that focuses on people not systems.
Maddock and Morgan conclude: 'Partnerships require a nurturing work environment which reinforces a synergy of interests between management and practitioners and therefore between 'quality' and financial objectives. Successful innovation occurs when partners operate with autonomy, but are cushioned by a protective work environment.'
An executive summary of the report follows:
CONDITIONS FOR PARTNERSHIP
Su Maddock and Glenn Morgan
Manchester Business School
Partnerships are central to the government's modernisation agenda and to integrated, responsive public services. However, sustained partnerships are difficult to achieve and depend on collaborative, emergent practice. Although there is extensive evidence of inter-agency and collaborative practice in local government and in the NHS, innovative relationships are frequently undermined by institutional and professional barriers or insensitive management. Manchester Business School was funded by the ESRC Management Innovation Programme to study those change programmes and management approaches which encouraged emergent relationships. The researchers tracked inter-professional and inter-agency collaboration where it was strong. Their findings indicate that that policy makers need to adopt a social development philosophy to partnership and an inclusive approach to staff and users in order to engender collaborative cultures. Partnerships require nurturing work environments as well as policy commitment, since it takes confidence and time to establish trusting relationships. Successful innovation occurs when partners operate with autonomy but are cushioned by a protective work environment.
Tracking Partnerships in Practice
The agencies involved in the study were those NHS and local authority agencies already encouraging partnerships and active in their endorsement of staff working in inter-professional teams in order to improve and integrate care. These included:
- Peterborough NHS Trust's transformation project
- The Mancunian Community Trust's jointly managed service for those with learning difficulties
- North Manchester District General's mental health services
- Salford and Traffords joint mental health strategy
- Lifespan Heathcare Community and Primary Care NHS Trust's integration of community services for the elderly
- Riverside Community NHS Trust's minor treatment clinics
APPROACHES TO CHANGE
All were concerned to find ways of involving staff in the transformation process and developed appropriate change strategies.
Within the public sector change strategies have been largely planned, top-down and mechanical in their delivery. Some agencies wait for a national lead, while others are ready to support local innovation. Internally most have adopted top-down directives either through specific scheme or corporate restructurings. Research shows that corporate processes such as Business Process Reengineering are often unsuccessful because they are systems driven and insensitive to staff and internal cultures.
Even within those agencies where emergent partnerships were endorsed by executives they remained marginal. The evidence of integrated practices was patchy even within the most cohesive and innovative organisations. However, collaborative relationships were evident in departments where staff were united in their desire for integrated care and were aware of business agendas. Emergent relationships and practice integration were evident in:
- new clinics
- pilot projects
- community based outreach work
- specific services
- joint initiatives (learning difficulties or mental health)
- crisis teams (A and E departments & minor treatment)
Top Down or Bottom Up?
Within each agency key stakeholders adopt very different approaches to change and leadership. For instance, politicians use policies, targets and economic levers and managers promote corporate change programmes, whereas practitioners are more likely to seek changes through professional development or teambuilding. Stakeholders often have very different motives for engaging in partnerships and their level of commitment fluctuates within volatile political environments. When commissioners or Trust boards dramatically change targets and timescales this leads to a collapse of staff confidence in new relationships and in risk-taking. Multi-professional teams were well established in all agencies. The problem was how to integrate these into the mainstream and to transform management practices such that they were sensitive to emergent practice and did not stifle it. Unfortunately, top-down initiatives were often not sensitive enough to the pace of staff learning needs. Practitioners were sceptical of management's change processes when they were not driven by the need for service improvements but savings. Practitioner-led initiatives also had their limitations. Professional teams often lack access to strategic decision making. They are also poor at communicating to those outside their own group and frequently insensitive to support staff and exclusionary when teambuilding. Where corporate change was clearly rooted in service integration and negotiated with staff groups resistance lessened and senior teams were able to dovetail management initiatives through a whole-system approach. Those steering corporate change need to hear what impact change programmes are having on users and on staff and to be capable of presenting these realities to boards and executives. Those agencies which allowed the pace of change to follow the rate of staff learning and negotiation were more likely to reinforce bottom-up emergent practice. Practitioners were concerned that executives tended to label change before it had occurred. and were antagonised by such terms as reengineering. Whereas top-down programmes tended to be labelled, emergent practices, especially initiatives on the margins, were less likely to be named and were therefore less visible. The conundrum for managers is how to devise corporate strategies which protect emergent practice within financial constraints. A 'whole-systems' or holistic approach to change is required where relationships are nurtured rather than decreed.
Where the senior team was united this resulted in greater confidence among staff, but if the executive body lacked cohesion this undermined collaborative and inter-agency partnership. The cohesion and confidence of the senior team was critical to staff confidence. Unfortunately too often innovative teams complained of the lack of support from executive bodies. Emergent practice was stifled in some places by executive directors (not leading the change programme) becoming impatient with the pace of change that teambuilding required. Some senior managers failed to observe how existing traditional management practices were thwarting emergent practices. Even managers committed to partnership frequently appeared unaware of the effect that their performance management systems had on staff. Poor management and communication is usually more by default than intent, yet the quality and integration of health and social care is dependent on staff relationships and staff learning.
Much management research is focused on the role of leaders, yet the local history and institutions thwart even the most innovative of executives. Several local authority chief officers and directors commented that the corporate level was poor at knowing how to intervene in large departments and their organizations continued to drift aimlessly. Consequently, strategic units and senior teams tinkered with one-off new initiatives and new projects on the margins leaving large departments, such as education and social services, unchanged.
Unfortunately persistent barriers are experienced by those working at new ways of working within partnerships. A major stumbling block is the incapacity of many organisations to mainstream those emergent and collaborative practices which are common in pilot projects. There are common and intransigent institutional barriers such as:
- inertia and blame cultures
- unstable finances
- a lack of concern for staff
- professional protectionism and gendered professions
- policies which advocate sharing but management systems which reinforce only activities and efficiency
- political environments which demand rapid results
- competitive cultures between agencies - where partnership is viewed as 'take-over', acquisition or merger
It is relatively easy to identify barriers to change such as short-termism, constant change, political clashes and an unwillingness to change. It is much harder to characterise the conditions and learning needs which can sustain partnership.
However, emergent networks, relationships and partnership appear more successful where all parties are motivated and engaged in change processes which are anchored in explicit and agreed service improvements. A nurturing environment is required which reinforces:
- a synergy of interests between management and practitioners and therefore between 'quality' and financial objectives
- an organisational system which encourages active communication with users and frontline staff
- cohesive senior management team
- the involvement of committed medical staff
- performance measurement systems sensitive to emergent practice and staff learning
Sharing Realities: Contexts for Learning
There is a wealth of collaborative working amongst public sector staff but it is patchy and easily undermined. Networks, partnerships and emergent practice depend on open communication between people who have previously avoided each other. Although the practitioner/manager divide appears to be reduced deep chasms remain between many agencies. Those agencies which valued staff 'learning' are more successful in their change management. Staff need time if they are to be confident in sharing perspectives and work-practices. One-off learning is rarely effective. Learning a not only a matter of knowledge transfer and yet there is a strong tendency among academics and doctors to believe in the technical-rational model which assumes that learning is a rational process rather than one underpined by powerful psychological dynamics.
Fifteen years of restructuring has left many suspicious of new initiatives. Even in innovative agencies the dominant culture continues to work against risk-taking. Unfortunately an autocratic management style persists in health and local government which does not aid learning and inhibits partnership development. Blame cultures are common even in innovative agencies and generate inertia rather than proactive relationships. When managers neglect internal cultures and staff perceptions and dictate change, their change strategies are unlikely to succeed precisely because they fail to reward innovative staff who are actively working at partnerships and emergent relationships. Too often unrealistic targets are demanded of managers who retreat under pressure behind managerial systems. Many report a mismatch between management systems and partnership objectives. In other words management practices are not 'fit for the purpose' of partnership.
Capturing Emergent Practice in Performance Management
Although inter-agency teams were well established within community-based services and collaborative relationships were strong these were often not measured by performance management. Inflexible performance measurement obscures emergent practice which often only thrives because of the commitment of particular individuals. A plethora of predetermined targets from the centre can act as a distraction from the more active work of building difficult new allegiances. Many practitioners in community services reported that collaborative practices existed on the margins but had been unnoticed by management. Consequently they remained unrecorded. The visibility of emergent practice appears to be strongly connected to the innovator's profession, location and gender, and of their positioning within the agency. Those furthest from head offices were the least visible but also the most likely to be engaged in inter-agency relationships. These innovators often lacked credibility because they were marginal to the mainstream and therefore their work and new relationships were less valued within business planning and corporate thinking.The question is how to formulate tools for assessing and valuing emergent practices when they are hardly visible, yet changing and developing.
The most dominant obstacle to partnerships and new practices is not active resistance but fear and a lack of staff confidence in change. Demoralized and overworked staff are less likely to bring positive energy to new relationships. Too often those staff required to be responsive within the current 'modernising' agenda are the most fearful, the most controlled and the most lacking autonomy. Users are not concerned whether staff are fulfilling protocols or not, but whether they are responding to them. Intrusive management and monitoring can undermine employees' confidence to break from old practices into new relationships and responsiveness. The impact of staff morale and relationships on performance is discussed informally but rarely in the boardroom. And yet there appears to be an inverse relationships between managerial control and staff responsiveness.
Towards Inclusive Management
Policy makers and managers need to ask whether existing performance management systems are rewarding or inhibiting emergent relationships. Too often, it appeared that even those executives committed to partnerships and learning principles did not query whether their organizations had a consistent approach to staff or whether existing management measures valued the shared relationships they sought to achieve. Because emergent practice is by its nature ad hoc, this presents a problem for managers. Do they encourage or control it? Developing local accountability is not only dependent on public consultations but also on internal staff relations and internal democracy. Public sector management frameworks need to be inclusive of staff as well as of users. Management is not merely a technical matter. Effective change strategies depend on clear values and an open, facilitative approach to staff rather than on narrow, enforced targets. These will only be successful when managers and politicians move towards more democratic forms of management, set clear agendas and develop incentives which value responsive behaviour and collaboration. The autonomy of the professionals needs to be reinforced and extended to other staff groups, such that they are more confident of risk-taking, personal judgement and collective work. This requires a shift in attitude and senior manager endorsement, but more importantly, an inclusive management framework which:
- focuses on people not systems
- values sustained social relationships within performance management
- values staff
- encourages a sharing perspective across agencies and across professions
- encourages professionals to step out of their professional training
- respects voluntary agencies and junior staff
- integrates central government departments as well as local services
Research funded under the ESRC MANAGEMENT INNOVATION PROGRAMME [L.125251049]
- NORTH WEST CHANGE CENTRE
- MANCHESTER BUSINESS SCHOOL
- AND THE AGENCIES BELOW
Salford & Trafford Health Authority
Riverside Community Health Care NHS Trust
Peterborough Hospitals NHS Trust
Mental Health Services of Salford
Manchester Healthy City
North Manchester Hospitals & Community Service