Barriers to Partnership Working

Chapter 4:
Barriers to Partnership Working
HEALTH, SOCIAL CARE AND HOUSING
PARTNERSHIP WORKING
BRIEFING NOTES FOR PRACTITIONERS AND
MANAGERS
August 2009
Chapter 4 – Barriers to Partnership Working
Contents
INTRODUCTION………………………………………………………………………………………….. 3
THE CAUSES AND EFFECTS OF PARTNERSHIP BARRIERS………………………… 3
PEOPLE……………………………………………………………………………………………………… 5
Roles (including power)…………………………………………………………………………………… 5
Behaviour…………………………………………………………………………………………………….. 5
Skills and Knowledge ……………………………………………………………………………………… 6
STRUCTURES…………………………………………………………………………………………….. 7
PROCESSES………………………………………………………………………………………………. 8
Lack of Agreed Outcomes………………………………………………………………………………… 8
Decision-Making Mechanisms……………………………………………………………………………. 8
Poor Communication………………………………………………………………………………………. 9
RESOURCES ……………………………………………………………………………………………… 9
Money…………………………………………………………………………………………………………. 9
Information ………………………………………………………………………………………………….. 9
Time …………………………………………………………………………………………………………. 10
EXTERNAL AND CULTURAL INFLUENCES………………………………………………… 10
UNINTENDED CONSEQUENCES ……………………………………………………………….. 11
CONCLUSION …………………………………………………………………………………………… 12
REVIEW QUESTIONS………………………………………………………………………………… 12
This series of brief guidance notes is aimed at helping managers and
practitioners understand and apply the evidence of best practice in partnership to
their own practice. Based on extensive review of the literature, it provides short
and practical guides, with review questions, on
:
1. Why work in Partnership?
2. What is Partnership?
3. The Scottish Policy Context for Partnership
4. Barriers to Partnership
5. The Characteristics of Successful Partnerships
6. Partnership Assessment and Development Toolkits
7. Bibliography
.
Full references to works cited are given at Chapter 7
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Chapter 4 – Barriers to Partnership Working
3
INTRODUCTION
A third of public bodies experience problems in partnerships (Strachan, 2005) and
some very high profile partnerships have failed in a messy and public way
(Thistlethwaite 2006). Others have found the experience of partnership very painful,
progress very slow and occasionally unproductive (Huxham and Vangen, 2004).
Huxham and Vangen ask if achievement of
collaborative advantage is the goal for
those who initiate collaborative arrangements, why is
collaborative inertia so often
the outcome?
This chapter reviews the relevant literature and presents the
barriers to public sector
partnership and the potential
unintended consequences of even successful
partnerships.
Writers reflect that not acknowledging barriers to partnership is, in itself, a cause of
failure (Rummery and Glendinning, 2000; Lymbery, 2006) and that it is important to
recognise the hurdles in advance.
“It is important to recognise that the very
term “partnership” might increasingly be
perceived pejoratively, synonymous with
lengthy, fruitless meetings, forced upon
unwilling organisations by….government
policy”
(Armistead and Pettigrew, 2004)
THE CAUSES AND EFFECTS OF PARTNERSHIP BARRIERS
In analysing the barriers to, and problems with partnership working, many different
authors (Keele and Strathclyde, 2006; Wistow and Hardy, 1991; Lloyd and Wait,
2006; Glasby and Lester, 2004) have offered different categories, levels and other
means of presenting the issues for partnerships.
This chapter organises the literature review output using a Cause and Effect diagram
(see page 4). Also called Ishikawa, fishbone or characteristic diagrams, these
represent all the factors that contribute to or affect a given situation. The fishbone
diagram seeks to identify root causes, rather than symptoms, and examines the
whole system within which the problem arises, allowing remedial action to be
focussed on the relevant area of the system. It is an industrial (six sigma) tool which
also works well, with some development of the categories, for service sector problem
analysis.

Chapter 4 – Barriers to Partnership Working
Cause and Effect Diagram of Common Barriers to Partnership
Partnership doesn’t work
Resources
People
Structures
Processes
Environment Culture
Different Boundaries
Constant
change
Partnership
Fatigue
Roles
Skills
Different employment
conditions
Behaviour
Power and
Hierarchy
Loss of
autonomy
Lack of knowledge
of other professions
No training
in partnership skills
Poor morale
from past failures
Revert to type
Professional identity and
interprofessional mistrust
Unclear roles
Threatened
Poor engagement of local people
and service users
Wrong Partners
Blurred
Accountabilities
Different
Funding Cycles
Flawed decision-making
mechanisms
Poor communication
Not planning for
when things go wrong
No integration of partnership
and partner agencies’ activities
Lack of focus
on action
Lack of
common goal
Cost shunting
Lack of integration
of information
Reluctance to share data
No Time
Balance between operational
and change management
Poor alignment of national targets
and standards between different sectors
Short term political
timescales and funding
Power
differences
Competing policy agendas
and maze of initiatives
History of unproductive partnership
‘good news’ imperatives
Different ways
of working Allegiance to uni-professional
Government departments cultures
remain entirely separate
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Chapter 4 – Barriers to Partnership Working
PEOPLE
Roles (including power)
Authors found a range of differences around values and roles which served to place
barriers in the way of increased integration at team level.
Key themes were:
Power and hierarchy in professional and managerial relationships can
stultify effective partnerships. Joint working is difficult where there are perceived
status differences between individual participants or occupational groups. Some
practitioners perceive threats to their professional status, autonomy and control
when asked to participate in more democratic decision making. Dominant, high
status professions (often reported as medics) or higher graded officers are
perceived to silence others’ contributions and risk skewing the outcome of
integrative efforts.
(Glendinning, 2003; Freeman and Peck, 2006; Hudson,
2005; Improvement Network; Lloyd and Wait, 2006; Wistow
and Hardy, 1991)
Differences in employment conditions between different organisations can be
a barrier to integration, particularly where new patterns of working are being
requested at the same time – e.g. 24-hour cover. GPs’ independent practitioner
status was seen as a barrier by many, which allowed GPs to elect whether or not
to join attempts at collaboration.
(Freeman and Peck, 2006; Leutz, 2005; Rummery and
Coleman, 2003)
The role of the voluntary and community sector and of service users and
carers
is often unclear in partnerships and integrated teams. There is rarely
clarity about whether this is expected to be an advocacy, operational,
representative or strategic role.
(Marks, 2007)
Behaviour
Closely related to issues of power and status in professions covered above, are
behavioural barriers to engendering trusting relationships. These include:
The professional identity, autonomy and inter-professional mistrust of any
one profession in relation to others limits understanding of other professions.
Individual practitioners’ lack of knowledge of other professions leads to a
tendency to stereotype other workers. Efforts to exchange information about
respective roles, if badly handled, can simply reinforce prejudice rather than
enlighten multidisciplinary teams.
(Banks, 2002; Fabbricotti, 2007; Glasby and Lester, 2004; Lymbery,
2006; Rummery and Glendinning, 2000)
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Chapter 4 – Barriers to Partnership Working
When threatened by organisation change, authors found that people revert to
NHS, local authority or professional type
and that each profession will want
the other to change its organisational culture. A variety of behaviours were
displayed such as the
“job’s worth” syndrome, “power plays”, and other
manifestations of
“skilled incompetence”. In some cases, practitioners
deliberately withheld referrals on to other services which could have benefitted
the service user/patient.
(Armistead & Pettigrew, 2004; Edwards, 2007; Kharicha et al, 2005;
Thistlethwaite, 2006)
Managers and practitioners will reflect in their behaviour what they feel to be
a lack of back-up from above
– a lack of commitment from senior managers;
non-executive board members or local authority councillors with a poor grasp of
the subject area, but who are nevertheless expected to lead change.
(Glasby and Lester, 2004; Rummery and Glendinning, 2000)
Poor staff morale and poor morale from other partners – particularly service
user and community representatives who are unpaid and poorly recognised – will
impact on the ability of partnerships to be established and to continue.
(Armistead & Pettigrew, 2004; Glasby and Lester, 2004; Glasby and
Peck, 2005; Maguire and Truscott, 2006
A lack of alignment of clinical, financial and managerial perspectives of the
partnership causes barriers in making progress
(Woodward et al, 2007)
Skills and Knowledge
Most writers reviewed recorded a poor understanding of the aims of partnership
and a lack of attention given to the development of skills of all individuals
involved in partnership
– practitioners; managers; elected and non-executive
members; representatives of people who use services; voluntary and community
organisations.
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Chapter 4 – Barriers to Partnership Working
STRUCTURES
‘Endless business meetings that no-one wants to attend will result in –
guess what? – no-one attending

The Improvement Network, Top 10 partnership killers
The design of partnership structure can militate against achievement of the aims
of the partnership:
‘Partnership Fatigue’ occurs when agencies are involved in large numbers
of partnerships whose purposes are unclear. They will be unable to list
partnerships comprehensively or name their fellow collaborators without
referring to papers from meetings. New work is frequently grafted onto old
partnership structures without reviewing their composition.
The wrong (or insufficient) partners are involved – not looking beyond
health and social care, especially to
housing and voluntary agencies, but
also crucially to
users of services and local communities.
Different geographical boundaries (lack of co-terminosity) will hamper
accountability, decision making and budgeting.
If no link is made between the work of the partnership and of its member
organisations
, it loses ownership and momentum. Partners will set up
parallel mechanisms, rather than adapting those that already exist, increasing
bureaucracy.
A lack of formal structure, accountability and clear roles and not having a
formal partnership agreement will make failure twice as likely.
Many partnerships are based on distant and formulaic consultation rather
than active engagement.
Continual shifting of organisational structures disrupts relationships within
and across partnerships. Structural change can be an unhelpful distraction,
stultifying progress for up to 2 years.
(Audit Commission, 1998; Audit Commission, 2005; Cook et al,
2007; Glasby and Lester, 2004; Glasby and Peck, 2005; Hudson,
2005; Hudson et al
., 1998; Huxham & Vangen, 2004; Improvement
Network; Lloyd and Wait, 2006; Local Government Information Unit,
2004; SSI/Audit Commission, 2004; Wistow and Waddington, 2006)
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Chapter 4 – Barriers to Partnership Working
PROCESSES
The way in which partnerships approach the mechanisms of working together can
obstruct good partnership.
Lack of Agreed Outcomes
A general desire to work together is not enough. Absence of agreed outcomes is a
common cause of partnership failure and can include the following symptoms:
Goals are dominated by service perspectives, rather than based on outcomes
desired by citizens, service users and patients.
An agreed partnership vision may be at odds and not integrated with
visions of the member organisations
. Partnership activity will be seen as a
distraction and possibly threatening to the stability of host organisations
There can be outright conflict or disagreement about the purpose of the
partnership;
Even if common agreed outcomes can be lost sight of in restructuring,
bureaucracy and well-intentioned, but off-beam, new activity
(mission creep)
or in ‘collusion’ – being preoccupied with maintaining good relationships and
losing sight of outcomes for local people;
Where there is no clear goal or end point or agreement about when it has been
reached, partnerships can outlive their useful purpose
(Audit Commission, 1998; EIU, 2004; Glasby and Lester, 2004;
Glendinning, 2003; Huxham & Vangen, 2004; Improvement Network;
Local Government Information Unit, 2004)
Decision-Making Mechanisms
Actions will be blocked when members lack delegated authority and have to
refer to their parent organisations for decisions;
Different decision-making processes in host organisations make getting
agreement a cumbersome process;
Decision-making structures dictated by dominant partners and not geared to the
needs of all partners, particularly the voluntary and community sectors, will create
mistrust and bad decisions.
Failure to acknowledge the complexity of achieving change through public
sector partnership (or, conversely, over-complicating analysis of situations) –
become an excuse for lack of action.
A lack of focussed action can kill partnership – making it into a talking shop
with slow and complex decision-making structures, lengthy, fruitless meetings
Not planning in advance for when things go wrong will leave partnerships illprepared to deal with conflict and lead to loss of trust and momentum.
(Armistead & Pettigrew, 2004; Audit Commission, 1998;
Improvement Network; Maguire and Truscott, 2006; Marks, 2007;
Smith, 1995)
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Chapter 4 – Barriers to Partnership Working
Poor Communication
the use of specialist language excludes some partners;
Not supporting members in their communication within communities will result in
conflicting messages;
communicating selectively to a few members fuels suspicion and personal
agendas.
(Cameron and Macdonald; Improvement Network; Maguire and Truscott, 2006)
RESOURCES
Resource Barriers can be divided into three areas:
Money
Inappropriate (short term) funding cycles, separate budgets and financial
pressures
are some of the most commonly cited barriers to effective partnership
working.
Partners with scarce resources are reluctant to fund partnership objectives,
which may not be their direct responsibility
.
Tensions around cost-shifting or ‘cost shunting’ from one agency to
another
are contributed to by concerns over the stability of partners’ budgets and
the risks of being drawn into financial crises.
There are significant costs to partnership working and, aside from the
arguments about who will provide the resources needed to implement decisions,
there are also obstacles to overcome in trying to identify
whether the outcomes
justify the costs.
(Audit Commission, 1998; Banks, 2002; Frye and Webb, 2002;
Glasby and Lester, 2004; Lloyd and Wait, 2006; Roy and Watts,
2001; Walshe et al, 2007)
Information
The degree of integration of information will pose constraints with:
Separate and incompatible IT systems with no links to communicate across
organisations, even where staff are co-located;
Reluctance to share data or develop confidentiality and access protocols;
Perceived or actual problems with data accuracy, robustness and timeliness.
Problems of aggregating different versions of the same data
(Audit Commission, 1998; Effective Interventions Unit, 2003;
Improvement Network; Integrated Care Network, 2004; Woodward et
al, 2007)
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Chapter 4 – Barriers to Partnership Working
Time
Time is the currency which practitioners and managers spend most preciously
and is most scarce.
A proliferation of partnerships can make even the most
necessary and successful partnerships achieve less than they otherwise could as a
result of the critical people on the ground being spread too thinly. There are difficult
choices about how to allocate time where it makes most impact:
Practitioners are torn between face to face contact and time invested in
developing links and connections
, which can be as valuable as the face to
face time, but undervalued by many information and performance systems.
Middle managers have to fulfil operational roles at the same time as leading
change
and developing partnership working.
(Banks, 2002; Frye and Webb, 2002; Kharicha et al, 2004)
EXTERNAL AND CULTURAL INFLUENCES
Barriers to effective partnership are sometimes caused by external, cultural and
political influences:
Time sequences for effective partnership may be longer than political
expediency allows.
Short term, ad hoc funding and non recurrent grants are
counter-productive to tackling the sort of
complex and long term problems that
partnerships are required to deal with.
‘Good news’ imperatives disengage key stakeholders and stifles openness in
resolving difficult issues
The raft of policies and maze of initiatives can be difficult – and contradictory –
to negotiate.
Partnership are often expected to join up services and systems which remain
entirely separate at central government level
Poor alignment of targets, performance measures and standards for health
and social services
together with separate central performance monitoring and
regulation is disintegrative and causes duplication of effort
NHS performance management is found to be still very acute hospital
focussed
; mismatching priorities between health and social care
Competing policy agendas, in particular those forces of competition and choice
versus collaboration and integration are confusing and counter-productive. This is
illustrated in the table below:

Competition and Choice Collaboration and Integration
Short timescale Longer timescales
Mutual benefit Trust
Good news/careful with
performance information
Getting to the bottom of a
problem/open with performance
information
Market driven Values/belief driven

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Chapter 4 – Barriers to Partnership Working
A failed partnership can leave a long-term legacy of mistrust or conflict
between different organisations. It can also leave individuals damaged and
compromised in their communities
Partners come to the table with a history of pre-existing relationships
including, possibly, misconceptions, suspicion and a lack of trust. Even in
previously successful partnerships, the ‘but we’ve always done it this way’
syndrome may impede new approaches.
Different types of organisation have ways of working which are often difficult
to combine
. They come to the table with their own set of attitudes,
experiences, beliefs and values
– the organisation culture. In public, private,
voluntary and community sector health and social care partnerships, culture
comes not only from constituent organisations but also from the different
professional groups.
(Armistead & Pettigrew, 2004; Audit Commission, 1998; Banks,
2002; Caines, 1999; Coe, 2002; Cook et al, 2007; Edwards and
Miller, 2003; Effective Interventions Unit, 2003; Glasby and Lester,
2004; Glendinning, 2003; Holtom, 2001; Home Office, 2007; Hudson,
2005; Hultberg et al, 2005; Kharicha et al, 2005; Local Government
Information Unit, 2004; Marks, 2007; NAO, 2001)
UNINTENDED CONSEQUENCES
Finally, a few words about the implications for other parts of the system of even the
most successful partnership.
It is not possible to make a change in one place
without impacting elsewhere in such a complex system
. Partnerships need to
understand and manage the consequences of improved integration and service
outcomes in one part of a system upon others.
Integrated services must have boundaries at some point and some of the
common problems of partnership relate to the risk of
creating tensions at the new
interfaces
in the following areas:
Relationships with specialist services;
Linkage to generic community or locality based strategies by care programmespecific partnerships
Fragmentation of mono-professional networks
‘Your integration is my fragmentation’ (Leutz, 2005). Generalists (particularly
GPs) get pulled in different directions by integration of different care programmes
and can experience it as fragmentation of their jobs.
(Edwards and Miller, 2003; Fabbricotti, 2007; Glasby and
Lester, 2004; Kharicha et al, 2004)
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Chapter 4 – Barriers to Partnership Working
12
CONCLUSION
The factors outlined above will occur in more or less degrees in many types and
levels of partnership. The first defence against them is knowledge – and open
acknowledgment within the partnership – of their existence. Thereafter, partnerships
will need to identify those factors which they can and cannot control and take action
on aspects within their power.
Armistead and Pettigrew (2004) described “partnership viruses”, which may be
caught from founding members who unwittingly carry poor practice and poor skills
into partnership, or from new members or via environmental influences external to
the partnership. Those working in partnerships should be on the look out for viruses
and vigilant in maintaining a “healthy life style” to minimise the chances of
contracting the virus.
The strong advice from most writers is unless there is no other way of tackling a
problem or achieving your goals than through multiple agencies; don’t. It is time
consuming, difficult and expensive. Reduce the number of partnerships you are
involved in and apply the best principles of openness, clarity of purpose, active
organisation development and adequate resourcing to the few very important
partnerships without which you can achieve nothing alone.
REVIEW QUESTIONS
Think of the partnership in which you are involved or trying to establish.
Does the goal you are trying to pursue really require a partnership approach? If
not, do it another, easier way
Circle the specific problems (small black text) you are encountering in the
fishbone diagram
Look to see where the majority of your problems seem to lie – culture, people,
process, structure, resources or environment?
Tackle the most pressing areas first. Use Chapter 5 of these Briefing Notes –
Characteristics of Successful Partnerships – to tackle barriers
Don’t try to tackle things over which you have no control, but acknowledge and
live with them – just identifying and talking openly about them within your
partnership will help