Partnering for change: six key insights for cross-sector partnerships

Introduction

Any kind of change programme… requires a huge amount of tenacity, a heavy dose of optimism and, to a certain extent, some blind faith. It requires us all to make a bit of a leap, really, in terms of what we want to achieve. And I think that’s what we’ve been really successful in doing as partners in the Healthy Communities Together programme.
- One Croydon Alliance

Collaboration across health and care services is increasingly vital. Growing numbers of people are living with multiple conditions, and there is an urgent need to make the best use of collective resources. 

To address these challenges and improve the wellbeing of local populations, people have been working together across organisational and sector boundaries for some time. There are examples of good practice, yet partnerships face consistent barriers to achieving meaningful change at scale. 

Through the Healthy Communities Together (HCT) programme, The King’s Fund and The National Lottery Community Fund have been supporting five partnerships of local authority, NHS and voluntary sector organisations. Over a three-year programme, we’ve worked with, and learnt from, these partnerships to understand what it takes to work towards real change within the health and care system and in people’s lives.  

At its heart, partnering is about relationships and bringing emotional competence to work. But these partnerships don’t function in a vacuum – they are inseparably part of the wider health and care systems in which they operate.  

In the first year of HCT, we developed a learning framework that partnerships can use to navigate those relationships and learn together to work in new ways. In this long read, written as our role with these partnerships comes to an end, we share insights from the HCT programme about how working as a partnership can support system change. We also look at the factors within the wider health and care context that can support partnerships to make change happen – using the themes of our learning framework to explore them. We offer reflective questions for those involved in this type of work to consider in their own practice, whether as partnership members or wider system leaders. 

This long read is aimed at people directly involved in partnering or those who support and facilitate partnership working. This includes system leaders, commissioners, leaders of large organisations and other stakeholders in the health and care system who might work alongside or within these partnerships. It’s important that partnership working is understood and supported by all of these stakeholders.  

Reassessing and clarifying the partnership’s purpose to engage with the system 

A clear purpose can support a partnership in working towards its aims. Revisiting, reshaping and reaffirming that purpose is also pivotal to how partnerships develop and continue to work. During the HCT programme, members found themselves combining clarity and pragmatism about purpose with structure and playfulness in how they worked together.  

Partners need to be pragmatic about the purpose of their partnership and how it engages with the wider system  

Working with large groups of different partners or stakeholders is complex, and it’s important to recognise what is realistic and achievable with the time and resources available. One HCT site spent the first 10 months working out where to focus but then dropped some aspects to make the work manageable. Another partnership focused on what their work could achieve for their communities and who they needed to share with and influence. For example, they supported existing services to develop new communication tools to improve their offer, rather than trying to create a different service or change funding routes.  

Playfulness, and flexibility to let things emerge without prejudging outcomes, can also be a useful tool for adapting to change  

Members in one site told us about the value of playfulness – of spending time together without a specific work agenda or outcome – as an intentional practice. This can be hard to justify in pressured working contexts but can lead to positive outcomes. They described how making contacts and connections and building relationships with each other opened up new awareness and relevant links, as well as common language. This flexibility and space have been vital in enabling the partnership to adapt to the changing circumstances within their wider system, and to continue to engage with and influence wider stakeholders. 

Distinguishing the partnership’s role from other work in the system 

By establishing a distinct role, partnerships can engage more effectively by clearly articulating how they contribute to wider system working. During the HCT programme, partners took different approaches to establishing their partnership’s distinctive role, appreciating that whichever boundaries they defined would impact upon this engagement. Some assumed that what differentiated the partnership from other similar work would emerge through doing the work; others used models and theories as an anchor. Regardless, they needed creativity and adaptability to ensure that the partnership’s boundaries remained enabling, and relevant to wider stakeholders.  

Defining a distinct role is a process of exploration, testing and learning  

HCT partnerships beginning without a firm sense of their distinctive role tried out different ways to establish their contribution within the wider system. For example, one partnership struggled to define operational boundaries or easily articulate its deliverables. This changed when they decided to focus their efforts on specific topic areas that defined the partnership’s remit and made members’ contributions clearer to themselves and to the system.  

In one site where members didn’t go through this process of exploration, partnership members consistently brought their own organisations, priorities and stresses into the HCT space. This hindered the work they could do as a group, because the distinctiveness of the partnership – as opposed to the different organisations it represented – was blurred. 

Theories and frameworks can be helpful tools to define the boundaries of a partnership’s work 

One site drew from human learning systems approaches for the language to describe their work, their distinctive role and their contribution to wider areas of improving health locally. Human learning systems are about partners recognising the complexity of the environment within which they’re working, creating spaces for building relationships, learning and innovation. Their role is to model these new ways of working to influence wider stakeholders. Here, according to members, ‘relationships are the work’ and create the mechanisms for change. 

Creativity and adaptability are key aspects in redefining how to use a partnership’s role effectively 

Throughout the programme, the challenges involved in influencing the wider system meant that some partnerships had to be creative, redefining how they use their role in making change. For example, one partnership has shifted their focus from direct system influence to making change in their local communities through working with existing voluntary and community networks.  

Having a distinct role can also facilitate openness to collaborate and build on what is already in the wider system. One site member described how they ‘are beginning to build effective partnerships by pooling resources’ – for example, linking up existing and new commissioned services with those from the programme to enhance and embed their model.  

Building relationships within the partnership and with wider stakeholders  

How members manage their own relationships with each other forms a feedback loop to their management of relationships with wider stakeholders. The centrality of these interpersonal relationships was emphasised consistently throughout the HCT programme. Partnerships’ members and stakeholders inevitably changed, and this emphasised the need for regular attention to relationship building. 

Open-mindedness about what people can contribute 

People have expectations of each other; getting to know each other sometimes challenges these assumptions, so partnerships have to work out different ways to get things done.  

It’s important to develop a good understanding of each other’s ability to influence other parts of the system 

Understanding these abilities and how to use them to further the partnership’s aims – for example, understanding the roles and capabilities of individual partnership members – is important. In one site, a member described how she made use of her positional power as a health professional to influence those outside the partnership to involve the community more. In another, members found that senior leaders were well positioned to link up with other senior leaders supportive of their way of working to connect their own staff with the partnership and its learning. Another partnership found that building networks across statutory and VCSE organisations has provided legitimacy for their work and enabled them to bring together marginalised communities with very senior health and care stakeholders. Members learnt that in their area the work is bottom-up, but to influence wider change, they need top-down support from executives and boards.  

It’s also important to realise the limits of other members’ power and how decisions are made  

One VCSE leader described how initially they were sceptical about how inclusive the partnership would be of their sector as opposed to statutory leaders. They found, through taking part, that ‘there was no hidden cabal’, which over time helped them feel more comfortable and united as they worked together to serve their local community. A better understanding of each other’s limits was also helpful for identifying who is best placed to influence which decisions. Some sites reflected how more seniority does not always mean more ability to influence change, and sometimes people in more operational roles might be better placed to act. As one partnership member noted:  

Key to this aspect of the work is… recognising that the higher up you go does not always directly relate to the more power to influence change.

Deepening relationships 

If you really want to support systems change, you’ll need to invest in relational work 

Several partnerships developed regular informal meetings to create psychological safety for colleagues to share and develop and, through their experiences in the group, begin to influence outwards. For example, one site described how members bring issues they have been encountering from their work within the local system to explore with their partnership. The high level of support and challenge within the group enables them to get more comfortable with discomfort, and in turn notice this in their day-to-day work. This means that outside of the group, they can model different ways of working, such as challenging and reframing issues to support more collaborative, less hierarchical ways of working.  

Deepening relationships within the partnership also supports members’ creativity and ability to appropriately challenge the wider system  

One partnership member reflected: 

Maybe the answer lies – at least in part – in how people are enrolled and supported/encouraged to go on ‘their own’ journey of relationship-building, developing psychological safety and learning to sit with uncertainty… [The partnership] is about creating a different quality of solution by ‘slowing down to speed up’. It’s about allowing creativity and innovation to emerge from relationships between people, organisations, cultures and perspectives. It’s about challenging business-as-usual perspectives and processes in service of seeing if something qualitatively ‘better’ can emerge in a safe-to-fail way that everyone can learn from.

In contrast, another site reflected how they’d done a lot of relational work at the start but hadn’t checked back in often enough. This had caused tensions between statutory and voluntary leaders in their partnership.  

Managing fluid membership 

People involved in partnerships inevitably come and go, and the five partnerships found ways to smooth these transitions. This included a theme that came up throughout the programme about the balance between focusing on relationships or processes. One partnership found that governance, contracts, memoranda of understanding (MOUs), etc were important for ensuring that work continued even when key individuals moved on. Making sure that partnership working is ‘baked in’ to processes avoids the risk of losing all contact/influence with an organisation when one person leaves. Yet as members in another site noted, it isn’t always possible to fully understand an individual’s influence until they leave. 

Thoughtful handovers can help smooth transitions  

Handovers may also indicate the level of investment from an individual or the organisation being represented. Where we saw ‘warm’ handovers (such as the person leaving personally introducing their replacement at a partnership meeting), this supported continuity. But this wasn’t always possible, particularly in the context of rapid statutory sector reorganisations. 

Working with wider stakeholders  

Finding a strategic and adaptable approach to building wider stakeholder relationships is helpful for making change 

There can be an assumption that the varied influence of different stakeholders can make navigating the system easier. For instance, VCSE members were assumed to facilitate effective connections between community and statutory leaders within the wider health and care system. However, building trust with communities and developing relationships that facilitated meaningful work took time. At a system level, the task of navigating and aligning a new piece of work within the context of all the different activity in the system proved challenging. One partnership’s response was to turn to a ‘human first’ approach, starting with what mattered to the communities they served, and using this to inform which stakeholders to engage with. Similarly, another partnership tried to build wider, looser connections to enable their work and ‘go where the energy is’, recognising that you can’t change something that isn’t ready to change. 

Addressing unequal power dynamics within the partnership 

Power dynamics are a good example of how relationships within the partnership can influence its external work. Continuing to notice and name unequal dynamics, avoiding replicating external power imbalances, recognising contributions and addressing inequitable processes are all necessary within partnerships as well as in relationships with wider stakeholders.  

Being explicit about local power dynamics, and taking active steps to address inequalities, is a key part of working differently 

But power, and its nuances, can be hard to talk about. Often it’s avoided, which can risk damaging relationships. This is also not a one-time thing. It’s important to continue to notice and name unequal power differentials – and who is able to highlight these. We observed members with perceived lower status being more likely to notice unequal power dynamics, but these had to be recognised by those with perceived higher status to enable change. We also heard about needing to look out for unfair expectations sometimes made of community members who live, work and make decisions in their locality. There is a risk that much is expected but not enough support is given. 

Partnerships need to be careful to avoid perpetuating power imbalances felt from their own funding relationships 

Funding relationships and the tools for managing funding, including grant applications and theories of change, can be used to define relationships between the funder and funded. However, they can’t replace the benefits of taking time for people to meet, find connection and collaborate. The HCT partnerships have experimented with changing this dynamic and developing more equal structures for collaboration. One is using different tools, such as polarity mapping, finding that this could lead to a deeper understanding between funded/funder. Funders also need to actively avoid perpetuating imbalances. Despite thinking we were already doing so, The King’s Fund and The National Lottery Community Fund realised that we needed to have more open conversations about power with the sites and open up discussion about how we were learning to manage this issue too.

Rebalancing power dynamics also involves recognising others’ contributions and supporting capacity building where needed 

Some partnerships have sought to address the balance of power to influence change. One supported a group of young people to feel confident going into meetings with senior stakeholders in the wider system. Members prepared them for conversations and made sure that different questions and ways of starting conversations were used in the meetings. They felt this led to better conversations about what could be improved, and ‘opened doors’ at the local council. Another partnership reflected on how the allocation of a large sum of money by a neighbouring programme to a local community group led to decisions being dominated by professionals in the group because of their experience in managing larger sums. They noted that an alternative approach could have been to upskill members who were less familiar with these larger budgets.  

Process elements are important to address power imbalances 

How you do things plays a key role in how people experience power. Communities that have been involved with programmes and have had poor experiences may mistrust new initiatives. One partnership responded to this. They sought to disrupt existing poor patterns of engagement that residents were used to by involving residents in planning groups for the activities and exploring options for the sustainability of their project.  

In another site, the partnership brought together members of marginalised communities with senior health and care system and voluntary sector stakeholders. In doing so, they disrupted some key power dynamics – who speaks and who gets heard – in different ways. For example, they gave each member of the group three opportunities to contribute using a small ‘talking stick’, plus limiting contributions to two minutes or holding the space if a person didn’t use their two minutes. Although some of the system participants found this awkward initially, they settled into the rhythm and community participants were able to share their perspectives and be meaningfully heard. As one community member who had attended multiple sessions reflected, feeling able to advocate for her community in these spaces kept her coming back.  

Demonstrating impact and achievements to the wider system 

Demonstrating impact – to wider system stakeholders such as commissioners, and to The King’s Fund and The National Lottery Community Fund as funders of the programme – became increasingly important as the programme developed. The HCT partnerships wrestled with this challenge. Often, examples of impact reflected what was valued and the habitual ways of working in their context. But partnerships can challenge traditional assumptions about what’s important and reimagine what impact looks like. 

Relational work is extremely hard to measure in the short term 

Longer timeframes that enable the development of deeper relationships, such as the work of the HCT programme, frequently sit at odds with the statutory sector’s shorter-term planning cycles. Partnerships grappled with external pressures from statutory organisations – or felt pressures from partnership members from these organisations – as well as a concern to demonstrate progress to funders. As one member explained: 

That is probably part of the system we need to change – our need to be seen as successful, rather than part of something genuinely different within our system that needs to go on well past the end of the programme.

One partnership found that it took three years to build up the levels of trust needed with extremely marginalised communities to start doing meaningful work. They described their impact as about catalysing something with stakeholders that will continue to develop after the HCT programme, rather than delivering it within the timeframe of the programme itself.  

Partnerships can demonstrate the value of relational working by modelling it 

Working out how to demonstrate the value and contribution of these approaches is vital. One member shared that ‘the relational stuff might be harder because it’s more or less intangible and finding a place to focus on is really tricky because it’s about the interactions’. In some sites, members modelled these relational approaches in their own organisations and in meetings with external partners.  

It may also be necessary to challenge the usefulness of traditional methods for measuring impact 

It can be difficult to capture and monitor system change, especially if there is a ‘ripple effect’ that can’t easily be seen or captured. A further issue is the limitations of data. As one member described, ‘The system is driven by data… [but that] is really hard because [our target communities] purposely work to stay out of that data’. But challenging traditional methods doesn’t mean throwing out accountability; there is still need for good governance. Our partnerships acknowledged this and were attempting to create alternative processes for governance, including using different tools to monitor progress. 

Reimagining what impact – and outcomes – might look like is also vital 

Learning to work differently within their partnership helped members to generate insights about the types of changes they wanted to achieve in their wider health and care system. This was very important for sites that were more uncertain about their purpose and how they would achieve their goals. One statutory partner shared that the shift of focus from data and outcomes to being comfortable with not knowing what outcomes would look like was difficult for them, but they benefited from the reflective conversations and learning from other sites.  

Closing thoughts 

The six insights identified here reveal just some of the complexities of partnering for change, and the diversity of approaches the HCT partnerships used to grapple with these. Although partnership working is increasingly seen as the solution to integrating care and supporting local communities, it’s the relational work at the heart of this that is often overlooked – and can be the hardest to measure. The experience of HCT has shown how valuing, developing and maintaining local relationships, and using these as the foundation for making change in local contexts, is crucial for anyone wanting to improve the health and wellbeing of people in their area.