Power is inherent to all forms of organising, and so we expected to find it as a theme in the work of the Healthy Communities Together (HCT) partnerships. But power can be hard to address directly, because it means confronting assumptions about what – and who – matters. It means examining the sources of pre-judgements and thinking creatively about how to disrupt what may be longstanding ways of working. The HCT partnerships came together with the explicit aim of trying to find out how building more effective and equal partnerships can contribute to improving outcomes for people and communities. This work is complex. This long read is organised around four themes that emerged from observing and reflecting on the work of these five partnerships as they learn about what transforming power in relationships means. These themes are:
- partners’ expectations of each other’s roles
- funding and commissioning
- working with communities
For each theme, we describe how we’ve seen power play out in the partnerships’ work. We offer ‘work-in-progress’ examples of how partnerships are trying to transform relationships and a flavour of the complexity they are working with. This complexity means that actions have consequences – sometimes helpful, sometimes less helpful – that can’t be known in advance. There are no easy routes through the messiness of partnering, so it’s important to reflect on what’s changing in relation to intentions, how power is experienced, and to challenge our own views and assumptions.
There are many ways of conceptualising power. Here, we talk about power as a property of relationships that arises because what we need from each other is not equally balanced. We use this framing to draw attention to how relationships must change for power dynamics to change. We explain more in the box below.
What we mean by ‘power’
There are many different theories about power. Here, we use a framing drawn from the work of many thinkers, including Hannah Arendt and Mary Parker Follett. They understood power as a dynamic property of all relationships – a balance of who needs what from whom – as opposed to a tangible asset that can be divided up or passed from one person to another. As one of the partnerships’ leads put it, ‘power is not cake’; it is not a simple case of sharing a slice with someone else.
Power dynamics are often reflected in organisational norms and rituals – for example, professional hierarchies, financial arrangements and language. Power is also embedded in wider social structures, and is arguably at the heart of inequalities including racism, sexism and colonialism. So, one way of thinking about what people mean when they say people ‘have’ or ‘don’t have’ power (that goes beyond using ‘power’ as a proxy for ‘resources’) is in relation to these structures; when people say they want power to be ‘given’ or ‘taken’, they are asking for a change in the balance of needs in relationships.
This understanding of power can offer a different set of opportunities to identify how imbalances arise, how they might be addressed, and how each person involved can influence how ‘power’ plays out. Table 1, drawn from the work of Pansardi and Bindi (2021), outlines some key distinctions between different ways of thinking about power as relational – from ‘power over’ to ‘power with’ and ‘power to’.
|Power over||Power with||Power to|
Power is seen as finite and zero-sum – you either have it or you don’t.
Use of authority to coerce, control and repress others seeking to claim power.
Power is negative and repressive and perpetuates inequity.
Power with others through collective action and coalition.
Mutual support, solidarity and collaboration.
The power of humans to be agents of change and to exercise their agency.
Partners’ expectations of each other’s roles
Partners’ expectations about their roles and how they take them up can reflect power imbalances. These expectations might relate to seniority, length of experience, newness to the group, and to sector expectations (for example, linked to funding). They may also relate to more societal patterns (such as gender and race).
Who needs to ‘give up’ what?
In the first year of the HCT programme, we observed partnerships grappling with initial assumptions about the skills and priorities of members from different organisations involved in the partnership. We often saw staff from larger VCSE or statutory organisations dominating conversations and decisions at the expense of those in smaller VCSE organisations. Newer members also felt they had less voice than more established members. Noticing the impact of this, one member reflected:
I think we should have been having more conversations about those of us who are more powerful in this space, what are we going to give up in order for others, who are less powerful in this space, to take up this space to make it happen.
This statement might be read as a ‘zero-sum’ understanding of power, and we tended to see this perspective among partners who only considered how formal structures created hierarchical power dynamics. It may be that what needs to be given up is the comfort of feeling ‘in control’ as others begin to have a stronger voice.
Making the most of each other’s status
While recognising power imbalances can be helpful for addressing them, seeing power as a property of relationships that changes with new understandings of who needs what from whom (rather than something to ‘give up’) can offer more ways to approach imbalances.
For example, over time, partners have increasingly recognised the benefits of statutory positional power and organisational status in raising the profile of their local HCT programme in service of the partnership’s desired aims. Some partners encouraged people in senior roles outside the partnership to use their authority and influence to encourage other senior stakeholders to engage with their local HCT programme’s aims and approach. Similarly, one partner noticed the value of understanding another organisation’s ways of working as a way to develop influence:
Of course, no one is fully free to do what they like. Action involves risk. For example, one partnership of relatively senior system leaders discussed their concern about speaking truth to power externally, expressing that they, too, felt relatively powerless in terms of their ability to influence external stakeholders to establish a generative sense of ‘power with’. This highlights another aspect of addressing power imbalances – which is, that if people do not understand the constraints that one member operates under, then the asks of that member may not be realistic. In this case, for example, while the leaders within the partnership were powerful in relation to many other staff in their own organisations, they were also caught in a power imbalance with the wider system, which constrained their actions.
What are partnerships doing to address these power imbalances?
Individuals within partner organisations hold multiple roles at the same time – for example, within the partnership, in their ‘day job’, and in their personal lives – which means that the associated power dynamics are complex. Reflecting on this complexity became very important to the HCT partnerships – to identify these different positionalities and how they might have to be recognised or addressed in different contexts, as well as reflections on the wider work and learning from it. There were mixed views across partnerships on the value of spending time together reflecting on their work to identify patterns that may help or hinder the group in achieving their ambitions. Some were naturally drawn to reflection, whereas others found it harder. People experimented with different approaches – for example, using Google Docs journals, group reflection sessions, or filling in reflection templates at set times.
Getting to know each other beyond roles emerged as another important part of transforming power dynamics related to role expectations, as knowing more about each other makes it harder to default to simple assumptions about people’s interests and abilities. Acknowledging each other as fellow humans, with similar everyday concerns, can start to challenge hierarchies and create a more inclusive basis for relating. We’ve seen this play out in lots of ways over the past two years and one very practical example stands out. One partnership had instigated and continues to use a weekly online meeting, including an informal ‘check-in’. This has taken different forms – for example, using a simple question prompt (such as ‘What’s your ideal mode of travel?’) with people responding in turn, sparking conversation as well as offering a small insight into people’s lives beyond the meeting. Committing to these check-ins as a core part of the work – even when the check-ins felt difficult or time pressured – is just one way in which members have developed strong working relationships and can safely have more honest, challenging conversations.
Questions to consider
- What are you expecting of each other in terms of authority to act, and ability to access resources and influence others? How realistic are these expectations?
- What rituals are you creating to help build a sense of community and trust, which help you to have more difficult conversations when you need to?
- What more could you learn about each other, foregrounding inclusivity in the approaches you take?
Funding and commissioning
Money is a common proxy for power, and relationships that are conditional on money often reflect power imbalances. Funders are dependent on the organisations they commission to provide services and expertise, but they tend to be regarded as being at an advantage over those who need the funds. In the health and care sector, this often looks like VCSE organisations and community groups depending on statutory organisations.
The HCT programme requires partners to work differently, attempting to overturn existing and historical power imbalances in local contexts. Partners are being asked to move away from traditional ‘commissioner/commissioned’ funding arrangements towards a more collaborative approach, exercising their joint agency and ‘power to’ influence change through new ways to establish 'power with'. This can look like identifying a common purpose to work towards, rather than relying on more transactional lobbying or commissioning approaches. Members from different partnerships have reflected that working in this new way has changed how partners behave and has felt more collaborative. There are challenges though, and the examples below illustrate some of the complexities involved.
Who holds the funding
Early on, we observed that because HCT funding is held by a ‘lead partner’ (chosen by each partnership), partners often defaulted to that fundholder – whether a statutory or VCSE organisation – as meeting host, strategic decision-maker and overseer of the work. Members from different partnerships described being ‘stuck in a very hierarchical system’ or ‘a risk that it feels like [the VCSE lead]’s work when it is the partnership’s work’. We also saw examples of partners distancing themselves from responsibility – for instance, implying that parts of the work were out of their hands because they didn’t hold the budget. This shows how some of the power dynamics and tensions that partnerships were trying to change were inadvertently reinforced. Whatever the intentions of the partnerships themselves, the wider circumstances of where money sits in a system, as a marker of power imbalances, remain in play.
For example, members talked about how new arrangements could reinforce competition between VCSE organisations due to unequal distribution of funding locally outside the HCT programme, as well as historical power imbalances linked to commissioning and funding. The time-limited nature of the HCT programme added to this: while statutory partners continue to exist outside and beyond the HCT programme funding, members from some VCSE organisations described how their organisation’s survival was at risk after the programme ends. This introduced a potential ‘power over’ dynamic as those VCSE organisations worried about how relationships in the context of HCT would impact on future potential for funding – for example, if partners had difficult relationships as part of HCT, they might not get funding in the future.
The complexities of evidencing the impact of a programme or project in relation to commissioning and funding of VCSE organisations are well documented. HCT partnerships experienced this as tensions about how to evaluate progress. Some partners raised this in relation to data collection and sharing:
Partners are exploring which types of data and evidence are acceptable to different organisations involved. Reflecting wider social patterns, those with most to lose by not conforming to group norms often have the least say in deciding what counts. But not engaging with the assumptions that sit behind these decisions, or not considering whether organisations (particularly in the VCSE sector) have the capacity to generate the kinds of data statutory partners are used to working with, risks reinforcing the very patterns that partnerships want to change.
Some partners were starting to consider the changes in expectations that may be required to address these historical imbalances.
What are partnerships doing to address these power imbalances?
Shifting financial resources and activities
One of the HCT partnerships is working to move funding and commissioning to the VCSE sector through a ‘locality commissioning model’. The partnership sees this as a way to increase the power of VCSE organisations and local people to meet community needs through having more say in how funding is directed. Although, in principle, this offers an opportunity to alter the balance of power, some VCSE organisations have not felt confident to take up the responsibility and accountability involved in commissioning. Also, if their focus is only on finances, there is a risk that VCSE organisations could replicate power imbalances between themselves and the other VCSE organisations they commission, rather than addressing the processes and structures that contribute to the status quo.
The partnership has been working to create single decision-making bodies that include different VCSE organisations, aiming to reduce competition among organisations and develop a more equal partnership – for example, by having a leadership board that brings together different VCSE organisations to fulfil a common purpose and to promote mutual trust and confidence. Partnerships may also need to look for under-explored possibilities within their current arrangements to increase their power to act.
Ensuring that partners are financially resourced to take part in programme activities
Some of the HCT partnerships were grappling with how funding affected different partners’ ability to influence local HCT programmes. Although VCSE and statutory partners were invited to the same meetings, those from statutory organisations could attend as part of their job, while those from some voluntary organisations could only attend outside their normal working time as there was no one else to do their work. This resulted in these VCSE partners limiting the number of meetings they could attend – so their voices were missing from some conversations.
One site enabled VCSE partners to participate by sharing resources and paying for them to attend meetings. However, this resulted in some unintended consequences, with some partners feeling that their attendance was under scrutiny. Another partnership had tried simply sharing money without conditions rather than for specific things (for example, attending meetings), but this was not straightforward where the HCT funds were held by a statutory rather than VCSE organisation because of their different institutional governance arrangements.
Questions to consider
- How do your funding/commissioning practices reflect a ‘power over’ rather than ‘power with’ attitude? Whose needs are and are not prioritised, and in what ways?
- What are partners' non-negotiable constraints? How can these be acknowledged?
- What flexibilities are there within these constraints, especially in the move to more collaboration, to acknowledge interdependence and satisfy more of everyone’s needs?
- What can you learn from your partnership that could be applied to local commissioning processes more widely?
Power imbalances between system professionals and local communities
The power dynamics between statutory and VCSE organisations within partnerships can be mirrored between partnerships and their local communities. Assumptions about knowledge, different ways of communicating and organising, as well as more entrenched societal issues relating to colonialism, gender and class relations are at play. Co-designing with communities is an established way to address these power imbalances, but this can be difficult to do in practice.
Who decides the partnership’s vision and aims?
As we observed in our Reflective learning framework, those involved in devising, articulating and evolving the vision and aims of work often decide, without conscious intention, what will be valued in that work. One member reflected on how decisions were made by statutory and VCSE partners using data and reports available to them, alongside organisational priorities, but without community involvement. Another reflected on what they had learnt about the impact of this lack of involvement from conversations and engagement with community members and staff:
VCSE partners often highlighted the lack of community voices in statutory organisations’ decision-making and work, and used their resources and influence to challenge statutory services to create opportunities for community involvement. These VCSE organisations viewed their embeddedness within communities – ‘power with’ based on a common ambition – and their ability to adapt to community needs and demands as advantages in creating equal partnerships. This contrasted with perceptions of statutory organisations having ‘power over’ communities, and ultimately excluding them. And it’s important to note that there are also power dynamics to consider in VCSE organisations’ relationships with their communities. This ‘politics of representation’ that tries to achieve deep engagement and avoid tokenism has no ‘one-size-fits-all’ solution.
Impacts of wider social structures
One partner commented on ‘colonial ways of working’ across their local system that were reflected in relationships between statutory and VCSE sectors, and between the VCSE sector and local communities. Relationships were often framed as a ‘power over’ dynamic, where one group or individuals sought to direct the other.
This might manifest as paternalism, where organisations viewed community members as weaker or less able or in need of intervention or support, or by ‘anointing’ representatives to act within existing governance arrangements, rather than working to understand how a particular community might choose to represent themselves and which engagement approaches would be most useful. For example, in one site, partners described an established VCSE umbrella body as not engaging meaningfully with particular marginalised communities and therefore being unable to properly represent their needs. Elsewhere, partners talked about how their groups and networks reflected (or often failed to reflect) the diversity of their communities. As with the wider lack of community involvement, the lack of diversity in partnerships could also limit their power to act, risking lost opportunities for supporting communities.
What are partnerships doing to address these power imbalances?
Attending to each other’s needs
Some partnerships are supporting community members to work with system professionals on a more equal footing – by providing community members with information about meetings they might attend, what is required from them and any training that might be helpful.
One partnership was bringing together system professionals and community members at workshops to try to disrupt traditional power dynamics. They considered who felt more comfortable (usually those in stronger positions) and less comfortable, and tried several approaches to making this relationship more equal. These included using accessible language, explicitly not sharing information in advance (as system professionals were more likely to have the time to prepare), and not asking people to introduce themselves by role. They wanted statutory partners to attend the events with a sense of ‘openness and curiosity, to come into the room… without the security of your lanyard or title or prep, but you’re here because you’re valued’.
Their experiments had mixed results. Although people didn’t share their roles, these were often still apparent by lanyards, accents or use of jargon. Not sharing information in advance meant that statutory colleagues struggled to connect to the topic being discussed, and the accessible language used sometimes meant that conversations stayed more generalised and did not get deeper into the specific issues. However, community participants reported a positive experience of the workshops, with one saying: ‘That’s how it should be done.’ Reflecting on the workshops afterwards, the partnership explored the complexities of prioritising the comfort of the community participants, and used this to develop its approach further.
Sharing lived experience
Another approach to rebalancing relationships was using people’s lived experience of services as a tool for influencing change. One site collected stories via community researchers to try to get closer to the issues that people were facing in their lives and shared these with wider system leaders. However, while acknowledging the importance of lived experience, local statutory organisations also had to rely on summary data to understand local needs in general, and aligning these two sources of data proved challenging. The partnership’s members are working out how best to use these stories, and to support those who shared them to not get ‘consumed’ or drained by the work with system professionals.
Another partnership discussed how sometimes people who shared an aspect of their lived experience became identified with only that part of their experience. They also described how sharing conversations with system professionals was difficult because they ‘don’t want to hear’ about things they can’t influence. This again reveals the complexity of power dynamics. While it might be assumed that sharing stories can influence system professionals to make changes, those system professionals may feel powerless to do so in the context of their roles.
Taking account of wider social structures
The wider societal issues identified cannot be addressed in partnerships alone, and indeed, all the HCT partnerships (and The King’s Fund itself) struggle with realising ambitions around social justice. What partnerships can do, however, is acknowledge these imbalances and try to mitigate their impacts.
For example, one partner noted that while there was a lot of work happening to reduce health inequalities for people from minority ethnic backgrounds, there appeared to be little change at a leadership level in terms of who is making decisions about these groups. The partner decided to open a conversation about anti-racist practice after being part of a non-diverse participant group at a large programme event. This conversation enabled those taking part to reflect on how power imbalances exist at different levels of the system, and to be more aware of how leaders could inadvertently use their positions and power to exclude seldom-heard groups.
Questions to consider
- How does your partnership habitually prioritise some people’s needs over others and how are you understanding the impact this has?
- What could addressing power imbalances look like and what might be the consequences – intended and unintended – of doing so? How could you engage with local communities to find out?
- How willing are you to do the uncomfortable work of challenging your biases and assumptions about each other in service of increasing your collective ‘power to’?
The role of language in creating and maintaining power
Some HCT partnerships noticed the importance of language in transforming power in relationships.
Established groups often use shorthand when communicating. This may take the form of jargon, acronyms or assumptions about words or phrases whose meanings are not always obvious to others. Language can implicitly convey a power relationship. For example, members from VCSE organisations sometimes used the term ‘the system’ – which they perceive as rigid and imposing – to differentiate health and care and local authority organisations from the VCSE. Some partners felt that the implied oppositional ‘them and us’ limited the scope for working together. For example, one VCSE leader told their partnership that they need to move on from old ways of working, by overcoming the historical perception of ‘them and us’. This meant that all members of the partnership needed to shift their perceptions.
Power imbalances may be reinforced by people with greater influence in how language is used – through what is said, and who is allowed to say it. This can show up in how statutory and VCSE organisations use language to define communities. For example, when those in stronger positions talk about ‘the disadvantaged’, ‘empowering poor people’, or ‘giving them a voice’, it is difficult to imagine a person who would match or identify with that description. This language might imply that the speaker has ‘power over’ the person or group they are speaking about.
Those in historically stronger positions can also set the tone for what is valued in a system. For example, a partner pointed out that transactional (relying on rewards or sanctions to motivate performance, for example) as opposed to relational (relying on trust and purpose) working styles were valued by the ‘people in power’ locally; this meant that people might pay more attention to talking about tasks and clear objectives, rather than someone’s reflections. Opening up these assumptions for reflection can help to reveal some of the implicit power dynamics, and increase partners’ individual and collective power to act.
What are partners doing to address these power imbalances?
As partners are learning more about their local health and care system, they are also learning about how their experience and ideas about ‘the system’ may not align with the reality that organisations in ‘the system’ are experiencing. In some cases, this is helping to deepen relationships – changing the power dynamics within the partnerships and with communities.
Creating a new shared language
We observed one partnership trying to identify how the language they use was reinforcing power imbalances between the different organisations, and limiting what individuals could do within the partnership. Members have started to create a shared language that can be understood and is more inclusive of the people in the partnership and beyond.
Another partnership decided to change the way it used language to address an implied power imbalance. This partnership had planned a workshop for system professionals and local under-represented groups to talk about the ‘misuse’ of urgent care services. However, during planning, they realised that the language of ‘misuse’ could be offensive and stigmatising to the groups they were looking to engage with. The partnership changed the title to ‘getting the best out of’ urgent care to remove the negative connotations of the word ‘misuse’.
The facilitators also wanted service providers to attend the workshop with a sense of openness and curiosity rather than preconceived ideas about the communities represented at the event. Although the discussion went well, the facilitators noted the unintended consequence of not using language familiar to professionals, and not providing more of a context for the discussions; the conversation was quite generalised and did not get into addressing the specific issues they wanted to focus on. This highlights how addressing power imbalances can involve a change in everyone’s expectations about how things should be done, and spoken about.
Questions to consider
- Whose experience is centred in the language you are using, and who might be included and excluded as a result?
- How are you identifying and assessing the assumptions about value and ability that are implied by how you categorise groups or ways of working?
- How can you pay more active attention to the impact of the words you choose?
The HCT programme has an explicit aim to find out whether building more equal partnerships between the statutory and VCSE sectors can contribute to improving outcomes for people and communities. In this long read, we have tried to reflect some of the ways in which the HCT partnerships are trying to transform power dynamics in their relationships. We have also highlighted some of the complexities of navigating power dynamics as histories, expectations, values and assumptions bump up against each other. Of course, partnerships are not working in isolation from society, and so wider social patterns also play out in these relationships.
Working to create more equal relationships means being able to recognise, call out and take action to address the inequities of the status quo, if partnerships want to do so. This is not straightforward; actions to rebalance power can feel disruptive and unhelpful as well as generative and helpful. There are no simple answers, but we hope the questions we have posed can help any partnership to reflect on the dynamics they are working with, and act with a greater understanding of what is at stake.
About this long read
This long read is based on an ongoing programme of work with the HCT sites, including observation, written reflection and joint reflection sessions. A group of learning leads from each site meet regularly to discuss the work with us and they help to identify key themes, such as power imbalances.