PARTNERSHIPS BETWEEN HEALTH, LOCAL
AUTHORITIES AND THE VOLUNTARY SECTOR
136. Partnerships are a key feature of the Government's
modernisation programme for public services including the NHS
and local government.
They are seen to be essential to overcome fragmentation between
services and to avoid duplication and an inefficient use of resources.
A 'whole systems' approach to providing services is consistent
with the policy of 'joined-up' government and the support for
integrated care involving primary and secondary prevention as
well as treatment. All of these have in common a commitment to
partnership working. Indeed, in the absence of partnerships they
would be unlikely to succeed. The long-term nature of community
regeneration and health improvement means that sustainable, long-term
funding and robust partnerships are vital.
137. This recognition of the need for partnership-working
is to be welcomed. However it can also lead to problems. Valerie
Little gave us an example:
"We have what we refer to locally as a plethora
of partnerships, because it is quite a Government flavour at the
moment. So everything is done in partnership and if you are not
careful you can end up with an awful lot of partnerships ... The
recent DETR guidance on local strategic partnerships and a desire
to rationalise this a little bit was very welcome. Then I had
the direction from the Department of Health to set up a Modernisation
Board in every health authority, which was like a partnership
but not quite the same and did not match the local strategic partnerships.
We are now trying to make all that fit together."
138. Although the evidence suggests that partnership
working is improving, in general progress remains patchy and uneven.
This is despite partnerships having been a priority in one guise
or another for over a quarter of a century; joint planning was
one of the key themes of the NHS reorganisation in 1974.
139. Partnerships carry with them high transaction
costs. There is a dilemma, therefore, in making an optimal trade-off
between the costs incurred in partnerships and the benefits to
which they give rise. Often the outcomes may be intangible or
not immediately evident or cannot be traced back to the partnership
directly. We accept there is obvious "collaborative advantage"
when something is achieved that could not otherwise have been
achieved. But we also believe there is the potential for "collaborative
inertia" where the rate of output is slow and where even
successful outcomes involve a great deal of energy and hard work.
The short history of Health Action Zones is testimony to the salience
of these issues. Collaborative advantage has been the hallmark
of some HAZs, often those which already had a history of effective
joint working like Sandwell, but collaborative inertia is evident
in many others for a variety of reasons.
140. A difficulty with current partnership arrangements,
as we have already noted, is the number of different initiatives.
Making the Links describes the numerous regeneration community
and area-based initiatives, which involve different boundaries
and separate partnerships.
The problems of co-ordinating local initiatives were outlined
in Reaching Out, a report by the Cabinet Office's Performance
and Innovation Unit.
This looked at how central government initiatives could achieve
better integration at regional and local level. It found that
such initiatives are often run separately and not linked together.
This reduces their effectiveness and imposes unnecessary management
burdens on local organisations. Reaching Out recommended
a greater focus on strategic outcomes of central government initiatives
affecting local areas, with success judged against these. The
Social Exclusion Unit has also suggested a number of ways to improve
co-ordination in its national strategy for neighbourhood renewal.
In its evidence to us, the HDA argued that:
"The inter-relationship of several major
strands of government policy needs to be made much clearer. For
example, there are the neighbourhood renewal strategy, Sure Start,
the various zone-based initiatives, as well as planning mechanisms
such as HImPs, community plans and regional development strategies.
Each has its own goals and targets and measures of success. People
need to be able to understand the relationships among them (and
the links between goals to do with economic success, social regeneration,
eliminating child poverty, sustainable development, quality of
life, well-being and health)."
We endorse this view and recommend that the Government
clarifies how the various strands of policy are connected to provide
a more coherent policy framework. Otherwise there is the risk
of serious failure in partnership working. Paradoxically, the
danger of so many partnerships in existence is that a new order
of fragmentation will occur.
141. A similar problem is evident in the plethora
of overlapping local plans and strategies in existence. Tony Elson
"At the moment we are bedevilled by far too
many planning processes. ... we have more than 40 statutory plans
which local authorities have to produce and they are all driven
by separate sets of guidance and separate government departments
requiring separate presentational styles."
142. Increasingly, the separate status of HImPs and
Community Plans is unhelpful and potentially dysfunctional as
well as increasing the workload on already overstretched agencies.
Some witnesses expressed concerns about HImPs. Central Southampton
Primary Care Group termed them "disease dominated" and
tending to marginalise the "wider agenda". They also
commented on the weak links between HImPs and other regeneration
The Local Government Information Unit's Democratic Health Network
described HImPs as being "skewed more and more towards the
health service interests and treatment services" arguing
the HImP has become less of a "partnership and more of a
health service document".
The LGA commented that HImPs are sometimes developed "in
The HDA noted that early HImPs have not defined targets and also
suggested that "public involvement in HImPs, particularly
that of minority ethnic groups, has been hard to achieve".
143. We heard how, in many areas, health and local
authorities were developing joint community strategies and HImPs,
or were incorporating the HImP into the wider community strategy.
We commend this joint-working and consider it a key way of making
health a core objective for local government. In their evidence
to us the King's Fund commented it was "disappointing"
that the NHS Plan did not look at the integration of Community
Plans and HImPs.
We agree. The evidence from Manchester Health Authority is persuasive
on this point:
"It may be more effective for all agencies to
focus on one (local authority led?) plan. This would serve to
free up time and resources to implement rather than to write plans."
144. We were persuaded by the evidence from Sandwell
and Hillingdon Health Authorities where progress had been made
in integrating the HImP and Community Plan. We recommend that
other localities should follow suit and that the Government issues
guidance accordingly. Such guidelines will require collaboration
between all the Government departments involved.
145. The LGA expressed its concern that partnerships
which have been established between local and health authorities
will be compromised by the arrival of PCTs, especially because
of the focus of PCT boards on social services, rather than local
government as a whole, and the risk of duplication of effort.
We have discussed the role of primary care in public health above.
146. There is a distinction to be made between partnerships
and integration. The Government appears to have moved from a position
of favouring a system of incentives in the form of pooled budgets,
lead commissioning for selected services, and integrated provision
to promote partnerships to one of integrated structures in the
shape of care trusts. The evidence from Northern Ireland, where
there is a system of integrated health and social services boards,
is that structural integration is in itself no guarantee of partnership
working, which leads us to conclude that the issues have more
to do with culture and values than with structures alone.
147. A further obstacle encountered by attempts to
secure effective partnerships is the complex bidding processes
which exist. We discuss the bidding process below at paragraph