As integrated care systems develop, NHS, local authority and voluntary sector organisations working in health and care in England are coming together and working in partnership to improve the health and wellbeing of local populations. Partnering can be tricky, but the rewards, for both participants and communities, are potentially great. What does it take to ensure these new partnerships succeed? And how can those involved learn from the evidence and experience of others to inform the early months of their work and their development over time? Drawing on a rapid review of published evidence, and on learning from six partnerships that are part of the Healthy Communities Together programme, we offer a framework for reflective learning that partners can use together.
The Healthy communities together (HCT) programme was developed by The King’s Fund and The National Lottery Community Fund (TNLCF), to enable and learn from new local partnerships between voluntary, community and social enterprise sector (VCSE) organisations, to improve health and wellbeing and reduce health inequalities in their communities. It particularly seeks to understand how the disadvantages and power imbalances experienced by VCSE organisations working with the NHS and local authorities might be reduced.
The value of partnering
Partnership working between NHS, local authority and voluntary, community and social enterprise (VCSE) organisations is integral to how leaders are being asked to work to reduce inequalities and improve health and wellbeing for communities, both at a strategic, system level and locally in ‘places’. At a system level, integrated care systems (ICSs) are developing formal agreements for engaging and embedding the VCSE sector in governance and decision-making arrangements. In addition, organisations collaborating over smaller geographies within ICSs – often referred to as ‘places’ – and teams delivering services on even smaller footprints – often referred to as ‘neighbourhoods’ – will drive much of the activity to integrate care and improve population health.
For leaders of NHS and local authority organisations, partnering with VCSE organisations – especially grass-roots organisations – can be transformative. It offers the potential to include communities’ voices, experiences and resources at the core of work to improve health and wellbeing. For VCSE organisations, these partnerships offer the opportunity to become more formally embedded in local decision-making, rather than having to lobby for a seat at the table on an issue-by-issue basis. To reach a partnership’s full potential, ‘partnering’ (see definitions below) also asks all leaders to work in new, more collaborative and equitable ways, which move beyond ‘commissioning’ or ad hoc ‘consultation’ relationships.
Defining ‘partnership’ and ‘partnering’
The terms ‘partnership’ and ‘partnering’ are used in different ways and can have broad definitions. The definitions we have chosen to use in this framework are outlined here.
A partnership is a group of people who come together to achieve something they can only do together. This sets partnerships apart from other kinds of groups who may meet regularly but aren’t formally interdependent to progress their work. Similar to other groups however, partnerships each have unique contexts, histories and reasons for existing, and these can change over time.
Partnering refers to the work that partnerships engage in to achieve their aims, which might relate to relationship-building, logistics of project delivery, the practicalities of convening, how the partnership learns or anything else partnerships do together.
In practice, forming partnerships between different NHS and local authority organisations and between these and VCSE organisations can be difficult, with NHS and local authority partners being insufficiently able to capitalise on the strengths and capabilities of the VCSE sector in decision-making processes, and VCSE organisations feeling marginalised and excluded. There have been a number of attempts to understand the barriers to partnering between the VCSE and the NHS and local authorities (see for example Bell and Allwood 2019; Baird et al 2018; Department of Health et al 2016), which have informed our thinking in creating this framework.
A framework for reflective learning in partnerships
This framework outlines some of the core issues in establishing and progressing partnerships, that we have identified through our HCT programme. The programme work included a rapid evidence review, observations of partnership meetings, development workshops and reviewing documents associated with the partnerships’ work in the first nine months of the HCT programme. We will develop the framework further as we learn with the partnerships over the next three years.
Every partnership is unique, but this might not be clear until people and teams start to work together. So, rather than prescribing a series of ‘must dos’, we have developed questions that partnerships could use as a preparatory and reflective tool in their work. New partnerships can use the questions to explicitly consider and be better prepared for some of the challenges and opportunities they may encounter in the early stages of partnering. More established partnerships, can use the questions on an ongoing and iterative basis, as a reflective learning framework to support their partnership’s development. They could also use their experiences to iterate and develop the framework itself.
The framework comprises five questions
What is the purpose of the partnership’s work?
What is the distinctive role of this partnership?
Who are the partnership’s members and stakeholders?
How is work being shared and recognised within the partnership?
How is the partnership learning and adapting?
Each question is followed by explanations and examples from the experiences of the HCT partnerships, and a set of ‘points to consider’, which partnerships could use as prompts for their thinking and discussion. While HCT partnerships are located at the level of ‘place’, in practice members also operate across system and neighbourhood levels, and so these examples are relevant to partnering at any level. Similarly, while the HCT programme involves partnerships in a relationship with external funders, many of the examples are relevant to more general partnership development. We have also included some resources that partnerships might find helpful to their development.
What is the purpose of the partnership's work?
Partnerships are a way of people coming together to achieve something they can’t do alone, so understanding and articulating what the partnership is trying to achieve is pivotal to success. Purpose provides motivation and energy for the partnership, and a means to guide and organise its work.
'Purpose provides motivation and energy for the partnership, and a means to guide and organise its work.'
That purpose or goals might come from a range of factors. In the Healthy Communities Together programme, the partnerships initially established their stated goals when applying for funding and support as part of their application to the programme. In other settings, partnerships may form in response to policy or governance requirements, which may come with pre-agreed goals.
In their early months, Healthy Communities Together partnerships frequently revisited their stated goals, with members of the partnership trying to, individually and collectively, make sense of, (re)construct and articulate the partnership’s purpose and what it was trying to achieve. While the funders from the outset took a flexible approach to recognise the complex environments in which partnerships were forming, not least due to the impact of the COVID-19 pandemic, members still had to balance the funders’ requirements with the emerging interests and motivations of the partnership, stakeholders and the organisations and communities they represented.
Partners asked themselves who would benefit from their work, what impact they wanted to have and who they were trying to influence. Some partnerships discovered that members held a number of different but compatible aims, which were focused on different timescales and/or ways of delivering change, and decided they could work with those differences in emphasis once they had surfaced. For example, in one partnership, some members placed greater emphasis on delivery of a particular service to a community, while others were most animated by the partnership’s overarching aim to shift ways of relating and leading within the wider health and care system. In another partnership, a member proposed that ‘improved partnership working’ should be an intended outcome alongside the vision of improved wellbeing in their communities, to enable the partnership to justify investing in relationships and ways of working.
Presenting the partnership’s work to stakeholders and to the funder became important moments when partnerships needed to pull together and articulate their current aims. In some cases, partnerships undertook the preparatory thinking for this work collaboratively in partnership meetings. In other cases, the partnership lead undertook the work outside discussions, which in practice translated into just one or two partners unilaterally developing the partnership’s vision. This latter approach meant fewer opportunities for collaboration, and risked unbalancing the workload between partnership members (see question 4).
Main points to consider when clarifying purpose
Who are the intended beneficiaries of your work together?
What impact does your partnership want to have?
Who are you trying to influence?
How are you collaborating to develop your partnership's purpose?
When will you need to articulate the partnership's vision to local organisations and communities and who needs to be involved in this?
An activity to help members of a group uncover the purpose of their work.
What is the distinctive role of this partnership?
Partnerships rarely work in isolation from other local projects. Healthy Communities Together partnerships found it was important to define their purpose in the wider system and community to differentiate their work from other similar work in the local area. Doing this gave partnerships meaning, and members a sense of commitment and belonging. It also enabled them to provide a compelling narrative to stakeholders from whom they were seeking support. As one member put it, ‘Every individual and every organisation is part of so many projects, programmes and priorities that HCT needs to be valuable and impactful enough to sustain engagement.’
'Doing this gave partnerships meaning, and members a sense of commitment and belonging. It also enabled them to provide a compelling narrative to stakeholders from whom they were seeking support.'
Different partnerships took different approaches to doing this. Some mapped out how the partnership had evolved from and related to other programmes and groups. Some refined and developed the descriptions of their partnership and project in terms that defined its distinctiveness from other local work, while others were more comfortable with the ambiguity of overlaps, appreciating the flexibility it provided for maximising resources and transferring learning between groups and projects.
As part of describing their purpose and its distinctiveness, the partnerships also worked to articulate how their activities could contribute to particular outcomes. But many partnerships were undertaking complex with no obvious ways of knowing what the outcomes would be; this didn’t lend itself to coming up with simple theories of change.
Some partnerships felt pulled by external requirements – for example, the relationship with funders – to provide a more linear account of how their projects would lead to particular outcomes, demonstrating value for investment. These partnerships tried to balance ‘telling a story’ about how their work could deliver change, with being honest about the extent to which they had control or predictable influence within their systems.
Main points to consider when clarifying role
How do you see your work leading to the change you want?
What other work is going on in your area/system on this topic?
How is your work distinct from and related to that work, and what does it contribute?
Myron Rogers, a leading thinker and practitioner in organisation development, has developed five maxims for work to effect systems change.
Who are the partnership's members and stakeholders?
Taking time for members to get to know one another as people – not just roles – helps partnerships make progress over their early months, but also requires an understanding of how different people relate to the partnership, as core members, or broader stakeholders.
Getting to know one another
Each member of the partnerships (and their stakeholders) brought with them a set of assets, motivations and constraints. These were influenced by multiple factors – them as an individual; their role in their home organisation or community; and the resources, limits and interests of their home organisation. Individuals brought skills, knowledge, connections and interests, some of which were related to their roles, and some of which were not.
The partnerships also involved members with different relationships to their home organisations and different authorisations to act. For example, the chief executive of a small VCSE organisation may be fully authorised to take any decision that affects their organisation; while a director in an NHS trust, by contrast, may need to work through the trust’s relevant governance channels.
'Across all the partnerships, members valued getting to know one another as people, rather than as representatives of organisations or sectors.'
Across all the partnerships, members valued getting to know one another as people, rather than as representatives of organisations or sectors. As members put it, ‘[I try to] keep true to the original aims and be here not as my NHS trust but as part of the partnership’ and ‘This conversation_,_ it’s not [VCSE organisation, local authority and NHS] it’s [Tracey, Luke and Radha]’.
Developing these relationships also revealed new resources the partnership could draw on. For example, one partnership learnt of a member’s artistic interests and talents and started to explore how they could support creative-thinking sessions within the partnership, and communicating the partnership’s work to external stakeholders.
We saw how taking time to discuss ‘non-core’ work matters could feel difficult for people who are time poor and have multiple competing and urgent priorities. This was amplified by virtual meetings, where it is difficult to have informal smaller-group or bilateral conversations around the edges of larger meetings. As one member reflected: ‘Normally in a two-hour meeting you would have a coffee break and talk about which biscuits you like.’
Consciously making space to build these connections seemed to better prepare partnerships to take on challenges that arose during partnering. In one partnership, a member reflected that the trust members had built up by getting to know one another in the early stages made it possible for them to have ‘dirty-washing conversations’ in which they shared sensitive information and challenges about their professional and personal contexts.
Partnerships tried different ways of building these connections.
Some did frequent relational check-ins to understand the context each member was working from and why membership was important to them. This seemed to make it easier for members to be compassionate towards one another and to have harder conversations when they were needed.
In one partnership, a VCSE partner and a statutory partner experimented with updating the group on behalf of one another as a way of learning and demonstrating their understandings of each other’s perspectives and positions.
Some partnerships did progress without spending time getting to know one another or building these connections. As one member described, some months into partnering, ‘It seems weird to me that we’ve been able to achieve as much as we have without any personal connection whatsoever, other than a little bit of chat.’ However, by not attending to these informal, human connections, there was a risk that when challenges arose, members would struggle to have the depth of relationships necessary to address them.
Working with fluid membership and engagement
The shifting membership of partnerships made getting to know each other and building relationships more complicated. All the partnerships experienced fluidity and change in the engagement of members and stakeholders and so understanding and managing this seemed to become a key activity. This included dealing with losing and gaining particular skills, knowledge, perspectives and connections to organisations as members came and went.
'All the partnerships experienced fluidity and change in the engagement of members and stakeholders and so understanding and managing this seemed to become a key activity.'
There was also no clear or consistent distinction or boundary across the sites between partnership ‘members’ and wider ‘stakeholders’. For example, one partnership involved a pair working to build a network or movement for change among a wider range of potential partners and stakeholders. In other partnerships, there were ‘concentric circles ‘of involvement in the Healthy Communities Together project, with individuals, roles and organisations shifting in their positions over time. Some partnerships were more well-defined groups with a relatively stable membership, though even in these cases, membership around the edges of the group shifted in the early months.
Members were routinely mapping and meeting with relevant stakeholders – both those working in the system and local communities and members of the public – to promote the partnerships' work and to understand how it related to those various stakeholders' knowledge and interests. We also observed members having to translate and negotiate between the partnerships' work and the norms of home organisations and communities. For example, one grass-roots community organisation help important accountabilities to and relationships with particular local communities, which could be jeopardised if the organisation was seen to be ‘too closely affiliated to the statutory sector’. A statutory sector organisation lead found themselves underconfident in talking to colleagues about the emergent and relational work of their partnership, because it was at odds with the language of project plan, ‘products’ and ‘deliverables’ which were the dominant ways of understanding and organising work in their home organisation.
Main points to consider when building relationships
How are you learning about the knowledge, skills, perspectives, interests, connections and wider resources that your members bring?
Who are your stakeholders, and how are you engaging with them in your work? What are your accountabilities and how might that impact on decisions?
What do changes in your membership mean for the range of skills, knowledge, perspectives and organisational affiliations you have, and your capacity to work towards your purpose?
How can you create regular spaces in which informal and personal connections can develop among members?
Stakeholder analysis (Peter Block)
A framework, created by Peter Block, for mapping stakeholders according to the extent of their agreement with a proposed change, and their trust in an organisation’s capacity to make change happen.
The human-centred design toolkit
Understanding how to engage those you are seeking to support in devising your purpose and approach.
How is the workload being shared and recognised within the partnership?
Partnerships need to pay attention to sharing the workload equitably and recognising different contributions, not doing so risks an unbalanced workload or reinforcing unequal power dynamics between members from different organisations. In the Healthy Communities Together partnerships, members participated in different ways and to different extents in the work. These differences reflected the individual, role and institutional differences described above and the power relationships between individuals and organisations within and outside the partnership, and were shaped by roles and power relationships that emerged early during partnering.
'Partnerships need to pay attention to sharing the workload equitably and recognising different contributions, not doing so risks an unbalanced workload or reinforcing unequal power dynamics between members from different organisations.'
The ‘lead partner’ role, required by the Healthy Communities Together programme, was particularly influential in how several of the partnerships partnered. The lead partner organisation received the initial round of funding, and in some cases the organisations used the funding to appoint a member of staff to the partnership, who was often line managed by the lead partner. Within the partnerships, this created a tendency to default to the lead partner which meant they often had a more dominant role in hosting meetings, making strategic decisions and carrying out (or overseeing) a much larger proportion of the partnerships’ work than other members. For example, decisions about when and how meetings happened, what they focused on, how they were chaired and even the tone and language used were often implicitly decided by the lead partner, who was also more likely to speak more frequently and to speak first.
We saw examples of this when both statutory partners and VCSE organisations were leading. As one VCSE member reflected to the statutory partner lead:
Because of the [system’s] structures, you guys assumed a lead provider role [for this partnership], and that’s to be understood. Because of the way the bid was put together, you guys did all the heavy lifting, and we didn’t do it in a truly collaborative way… we need to have a conversation about this. We are stuck in a very hierarchical system.__
Another site reflected:
[There has been] too much delegation to [the VCSE lead] as the funded partner. [There is a] risk that it feels like their work when it is the partnership’s work.
In terms of interactions in meetings, in one partnership a VSCE partner gave feedback after several months that partnership meetings could feel inaccessible to members from small VCSE organisations because they were dominated by the language of one professional discipline.
Naming and recognising these dynamics early on seemed important to prevent them becoming embedded and leading some members to feel disenfranchised or disconnected. We observed members doing this and seeing it as an area for development, and some were already taking proactive steps towards a more equal and collaborative approach to working together. There was no one way to do this, but we observed some examples:
reopening discussion in the partnership about when and how members should convene and communicate, and experimenting with different mediums and technologies to allow members to contribute to the work in ways that fit with their needs and constraints
learning about the opportunity cost of meeting participation for grass-roots VCSE leads and their communities, and making arrangements to encourage their attendance, such as and looking into back-filling their time, and exploring non-financial forms of reciprocity arrangements, such as a time-bank model
explaining the meaning of technical or profession-specific language being used to support better shared understanding
changing the person in the lead role to support colleagues’ changing capacity or to disrupt established power dynamics
making sure all voices are heard, for example, though meeting facilitation and supporting those with less powerful voices as they begin to speak up more.
Main points to consider when thinking about workload
How will you come together as a partnership in ways that take account of everyone’s capacities and preferences?
Do you have a lead, and what is their role? Has this been agreed collectively? And is it congruent with your values as a partnership?
How will you communicate between meetings? Which other modes could be useful?
How will you ensure that power differentials between members are recognised and all voices are equally heard in conversations?
Do smaller VCSE organisations need to be reimbursed for their time? What are the different forms this could take?
How will you hold yourselves to account for whether you are working in the ways you have agreed?
Kantor's 4-player model
A simple structure that you can use to observe how you are communicating with each other, and to identify how you can develop your approach to have more effective and inclusive conversations.
Understanding group dynamics and team functions
Unspoken and sometimes unconscious dynamics in groups have a significant impact on what the group can achieve together. Becoming aware of and talking about these dynamics, and reclarifying how work is shared out across team functions can help to partnerships to work together towards their purpose.
How is the partnership learning and adapting?
The complexity of partnering means that paying attention to purpose, role, membership and ways of working is an ongoing task. Partnerships have to navigate multiple changing dynamics – both internally, such as membership changes, and externally, in the shifting landscape of services, providers, community assets and needs.
However, in practice we saw that it was easy to be preoccupied with delivery-focused conversations, rather than attending to how the partnerships were partnering and what they were learning in relation to their overall purpose. For example, in one partnership, even meetings that had been set up specifically to ‘surface things in the room that aren’t spoken about [and] understand each other’s pressures’, were frequently repurposed to focus on pressing operational questions.
'Where partnerships made time for more reflective conversations, they did seem to help to uncover insights that sometimes reframed how partnerships saw and approached their main delivery task.'
Where partnerships made time for more reflective conversations, they did seem to help to uncover insights that sometimes reframed how partnerships saw and approached their main delivery task. In one partnership, which had prioritised relational work over task delivery, a statutory partner described how, for them personally, engaging in that work over a number of months had led to a ‘fundamental change in mindset’. In other examples, revisiting purpose in relation to recent experiences of delivery prompted members to re-envisage what their programmes should focus on ‘in the next phase’ of the work.
Some members also actively shared learning from parallel and related projects and partnerships, for example, ideas for how to fairly reciprocate community members, how to host meetings that are open and encourage relationship development. ‘Learning’ was sometimes combined with an interest in ‘evaluation’ and seen as something separate to the main work of the partnership that needed to have its own strategy, framework and resourcing. Embedded this learning in the partnerships’ ongoing work also brought benefits.
Further, some partnerships identified how their own learning to work differently across sector boundaries within their HCT partnership could have a second important purpose: to use this experience to generate insights and models for the types of changes they were seeking to achieve in wider health and care system.
Main points to consider around learning and adapting
How are you balancing your attention between task delivery, how you are working together and what you are learning?
What spaces and times do you have to reflect on your membership, purpose and ways of working?
How are you holding yourselves to account for acting on what you are learning?
How are you sharing learning in your wider networks?
This framework complements existing evidence, guidance and support available to health and care organisations and VCSE organisations setting out to build or develop effective cross-sector partnering.
There is good evidence for a consistent set of factors that are characteristic of effective partnership working (see box below), but there is less evidence on how these are achieved.
NHS England has produced a checklist that the NHS and local authority organisations can use to help to embed VSCE sector organisations and alliances in ICSs, and a ‘maturity index’ that describes the key features of systems at different stages of their integration maturity. ICSs in particular also have access to support for developing multi-sector partnerships.
Kaleidoscope Health and Care, a UK consultancy firm, has produced a guide to collaborating, describing what successful collaboration looks like, including links to international and cross-sectoral case studies.
The Institute for Voluntary Action Research produces practical resources on partnership working involving the VCSE sector. In addition to generic resources, there is a programme specifically on Connecting health communities.
Public Health England has produced guidance based on its work evaluating whole-system approaches to community-centred public health. It includes insights on ways of working and behaviours that are supportive of co-ordinated and collaborative approaches to working together and with communities.
Summary of characteristics of effective partnerships from the research literature*
Genuine agreement on need for partnership
Purpose and aims are clear, shared and realistic
Relationships characterised by trust, respect & reciprocity
Partners openly discuss and attend to the balance of power
Partners are committed to working collaboratively and get development support to do so
Roles and responsibilities are clear, and may be flexible
Communication is open, honest, frequent
Information is shared
Decision-making practices are clear and transparent, and involve operational staff
Communities and wider stakeholders are involved in the partnership’s work
Leadership convenes convenes facilitates; encourages understanding and learning; and provides hope and energy
The partnership assesses and learns from its activities