Policy and practice in health and social care is full of references to the need for agencies to ‘work together’ and ‘collaborate’ and for multidisciplinary working to blur professional boundaries. The term ‘partnership’ has become a catch-all phrase for a range of different concepts in relation to joint working. The Department of Health initially used the term ‘healthy alliance’ to define the way agencies can work together to promote health, emphasizing cooperation and partnership: ‘A healthy alliance is in effect a partnership of individuals and organizations formed to enable people to increase their influence over the factors that affect their health and well-being’ (DH 1993, p. 22). WHO used the term ‘Intersectoral Collaboration’ to emphasize that collaboration should take place across public sectors and involve a wide range of agencies. The Alma Ata declaration (WHO 1978) stated that health could only be attained by action in spheres additional to the health sector, in particular: agriculture, animal husbandry, food industry, education, housing, public works and communications. Accepting the impact on people’s health of a variety of policies and programmes outside the health service sector requires the development of mechanisms so that policy makers are aware of the consequences of their actions on health. The WHO Health for All strategy stressed the need for intersectoral collaboration for just this reason (WHO 1985). The revisited Health for All strategy, ‘Health 21, p. 21 targets for the 21st century’, contains a specific target (number 20) on mobilizing partners for health: ‘By the year 2005, implementation of policies for health for all should engage individuals, groups and organizations throughout the public and private sectors and civil society, in alliances and partnerships for health’ (WHO 1998, p. 200).

By the late 1990s, a new partnership culture had emerged and partnerships were defined by WHO as ‘a recognized relationship between part or parts of different sectors of society which has been formed to take action on an issue to achieve health outcomes or intermediate health outcomes in a way which is more effective, efficient or sustainable than might be achieved by the health sector acting alone’ (WHO 1998, p. 14–15). The Jakarta Declaration (1997) and Bangkok Charter for Health Promotion (2005) both emphasize the importance of partnerships to development. National strategies also place partnership working as the cornerstone of health improvement strategy, for example the White Papers Working Together for a Healthier Scotland (Scottish Office 1998) and Well Being in Wales (Welsh Assembly 2002).

Partnership working has come to represent a new means of governance – it has been at the heart of public service reform in England since the 1990s and the demand for health and social care to work together and for service providers to work with service users (see Chapter 8). The last decade has seen Local Strategic Partnerships (LSPs) between primary care and local authorities, Children’s Trusts, Sure Start, and education, employment, health action and regeneration zones. Boydell and Rugkasa (2007) highlight concerns over whether the growing commitment to public governance through partnership adds value and suggest that there is little evidence that collaboration has improved health status, quoting Davies (2002, p. 175), who comments that ‘it is easy to assume partnerships generate added value in a politico-ideological culture that assumes they will’. Partnership working is not necessarily straightforward and this chapter discusses some of its challenges. It requires different organizational structures, budgetary control and working practices. Instead of hierarchies or competition, the dominant mode of organization is networks. Networks are based on trust. Yet to expect this to happen automatically is unrealistic. Indeed, many practitioners’ experience of collaborative working is of intense competition and rivalry and a reluctance to share information or ‘give up’ areas of work. Many professional training and education programmes stress the unique perspective and skills of the profession, which may lead to ‘protectionism’ when professionals feel threatened by rapid organizational change. In such uncertain situations, instead of recognizing the potential for partnership working, professionals may retreat within their own professional role and identity.

There are also the differing perspectives that organizations have on what exactly constitutes promoting health. There is little identifiable theory of collaboration which can help to illuminate this. There are a few empirical studies in the UK of intersectoral collaboration in the health promotion field which attempt to develop a theory of collaboration (Davies et al., 1993, Delaney, 1994a and Springett, 1995). There are only a small number of studies which focus on collaborative activity for public health. Barnes and others (2005) conducted an evaluation of Health Action Zones (HAZ). These established partnership structures, albeit dominated by NHS Primary Care Trusts (PCTs), failed to move into the mainstream of working across sectors or change to pooled budgets, joint posts, joint performance management or planning. Similar challenges in working across boundaries and aligning planning were highlighted by Hamer and Smithies (2002) in their review of community strategies and health improvement. Other conclusions about the features of successful collaboration draw mainly on the experience of practitioners (see, e.g. Balloch and Taylor 2001). These accounts tend to be enthusiastic about the prospects but pessimistic about the actual outcomes of partnerships.

Working in partnership is a core competence for public health practice. The knowledge required to do so is identified as (www.skillsforhealth.org.uk):

As discussed in the introduction, there is uncertainty and overlap in the definitions of concepts such as partnership, collaboration, alliance, network and coalition. Table 7.1 shows the distinctions made by Leathard (1994) between:

The underlying assumption of partnerships is that agencies work together. In Table 7.1, there are many process-based terms to describe working together, most of which involve sharing, trust, and a willingness to work towards a common purpose.

Plampling et al (2000) make a distinction between coordinating partnerships, where the partners agree about the nature of the problem and its solution, and corporate partnerships, in which partners pursue their own goals most effectively by working with others. In a coordinating partnership the underlying assumption is that all the partners agree about the nature of a problem, the nature of its solution, and how it is to be achieved. Every organization has to do its own part of the work in a manner that allows the whole project to be completed. This usually means appointing someone to manage the joint work, chase everyone up, and hold everyone to account. Cooperative partnerships enable partners to pursue their own goals most effectively by cooperating with others using enlightened self-interest. ‘Cooperative’ partnerships use mechanisms that facilitate the completion of individual goals and targets: ‘you scratch my back and I’ll scratch yours’.

Concept-based terms include those most commonly used in the health sector: ‘interdisciplinary’ or ‘multidisciplinary’ working. Both these terms refer to a team of individuals from different professional backgrounds (e.g. nursing, education, social work) who contribute a distinctive perspective and skills to the team. Interdisciplinary working usually means within the same professional group, for example community nurses and acute sector nurses, whereas the term multidisciplinary is normally taken to refer to a wider group which includes members from different professions. Multidisciplinary public health is a term used to describe the many different practitioner groups and associated bodies of knowledge that are involved in promoting public health.

Much of the literature on partnership working in health and social care is concerned with analyses of practice – what partnerships do and how they can be more effective (e.g. Audit Commission, 1998 and Hardy et al., 2000; HDA 2003). Recent policy reforms have encouraged different professional groups to break down barriers and work together, and there has been some analysis of how the governance of welfare has driven this (Balloch and Taylor 2001; Glendinning et al 2002). Increasingly, there have been attempts to theorize partnerships and the literature discussing definitions and concepts is plentiful (Carnwell and Carson, 2005, Peckham, 2003, Plampling and Pratt, 1999, Plampling et al., 2000, Pratt et al., 1998a and Pratt et al., 1998b). However, understanding how to facilitate partnership working remains limited (Whitelaw and Wimbush 1998) even where services have been brought together into single organizations as in, for example, PCTs. Partnerships appear to be a rational response to service delivery and professional working. They expand the budget available to tackle an issue, they may help to achieve better coordination and through the pooling of ideas and resources may achieve ‘added value’.

Partnerships are seen as important tools for improving public health because:

Yet there is an increasing acceptance that partnership working is neither easy nor a panacea for tackling big issues. That organizations will find issues of commonality is unrealistic given that they all recognize that they each have a legitimate ‘core business’ – what Braito et al (1972) have described as ‘domain consensus’. The legitimacy of their ‘core business’ rests partly on perceived expertise, on funding streams, on governance arrangements and partly on statutory responsibilities. As a Health Education Board for Scotland report comments (HEBS 2000, p. 7), ‘many writers stress the inevitability of conflict and the need to accept it and work with it’ and the need to identify the collaborative advantage (Huxham, 2003 and Huxham and Vangen, 2005).

Much of the guidance about partnership working is about improving process; building a shared vision and trust; brokering power, information and resources; and monitoring progress (Audit Commission 1998; HDA 2003). The public health competences for practitioners and specialists (www.skillsforhealth.org.uk) reflect this in their focus on the development of negotiation, influencing and interpersonal skills. An awareness of how different organizational cultures can influence outcomes of collaborative work and of the roles different organizations, agencies, individuals and professionals play is also key to partnership working.