The importance of being efficacious: English health and social care partnerships and service user outcomes

The need for health and social care agencies and their professionals to work in partnership is a central component of contemporary English health and social care policy. Partnership is predicated on the notion that this way of working improves services and outcomes for service users. However, as there is little evidence that partnerships improve service user outcomes, some commentators suggest that this indicates either a failure of the policy or a deficit in terms of implementation. This thesis investigates the link between health and social care partnerships and service user outcomes. Rather than adopting the types of rationalist and instrumental approach which the majority of studies in this field have done, the thesis develops a new conceptual framework for partnership which is interpretive and performative. This framework is developed and tested in four exploratory case study sites and concludes that partnership is not necessarily simply an instrument of improvement in a traditional sense. The power of partnership lies in its cultural and symbolic value. This takes partnership beyond traditional discussions of partnership and governance; rather than representing a particular mode of governance, instead arguing that partnership is an active tool of governance.


Introduction
Partnerships take a number of different forms and do not constitute a particular model of care. Some of the more theoretical discussions around partnership involve debate over whether partnerships are synonymous with a particular mode of governance (i.e., network, hierarchy or market). However, in practice partnership has been implemented as all of these different modes and through a range of different means. The one commonality is that health and social care partnership are conceptualised as instrumental tools of improvement, introduced in order to bring about positive changes to service user outcomes. Yet, an analysis of the policy context indicates that there are a range of reasons that partnerships might be introduced, beyond simply being a means to bring about better service user outcomes. The thesis identifies four dominant 'frames' that seek to explain why it is that health and social care partnerships exist and what it is that they should achieve (see Table 1). Although central government has predominantly cited improved service user outcomes as the motivation of these frames, this does not appear to be a central driver

Thesis summary
The importance of being efficacious: English health and social care partnerships and service user outcomes Table 1. Four frames of health and social care partnerships

Frame
Why are health and social care partnerships necessary?

Structural
Legacy of Beveridge. Due to the way the welfare state was established, according to notions of big hierarchical government therefore health and social care organisations exist as silos. Partnerships must exist to overcome these structural barriers.

Social Challenges
The issues facing public services are primarily 'wicked' ones, which no one organisation could possibly deal with on their own. Partnership coalitions are necessary in order to combat these issues and must be led by the public sector because of the values which these moral institutions enshrine.

High Performance
Public sector organisations must become more 'business-like' if they are to be more efficient and better able to respond to public demands. This has led to the disaggregation of larger public sector organisations to the local level.
Partnerships are necessary to oversee the strategic direction of local areas and to performance manage service delivery organisations within the local area.

Third Way
Partnership is a central tool of the third way political ideology and is necessary in overcoming the limitations of 'big government' on the one hand and the free market on the other. of any of these frames suggesting that service user outcomes are therefore not the sole driver of partnerships. This may also go some way to explaining why there is a lack of empirical evidence linking partnerships and service user outcomes.
This thesis argues that the power of partnership is not as an instrumental mode of improvement, but instead in terms of its symbolic and cultural power. A new conceptual framework of partnership was constructed that is interpretive and performative in nature. This framework is developed and tested with four exploratory care study sites in the thesis. Data was collected using the Partnership Outcomes Evaluation Toolkit (POET), an evaluation framework that was designed specifically for this thesis [1].

Results/findings
The findings of this study conclude that partnership is not necessarily simply an instrument of improvement in a traditional sense. Although all of the partnerships involved in the research claimed to be driven by the aim of improving service user outcomes, the observations made in the thesis suggest that their local enactment was rather different. It appeared that there were other factors driving local changes that were not being explicitly articulated. Partnership was being used as a means of framing a series of changes and engaging a variety of stakeholders towards some specific local changes, and actions that might otherwise have been resisted. The power of partnership therefore lies in its cultural and symbolic value. This takes partnership beyond traditional discussions of partnership and governance; rather than representing a particular mode of governance, instead arguing that partnership is an active tool of governance.

Implications for integrated care
For the readers of the IJIC it is of special interest to learn that the impacts of integrated care are more extensive than simply in terms of efficiency or organisational effectiveness. In England, notions of partnership and its implications extend beyond service improvement processes to include notions of politics and power in the reform of health care. It may be of interest to compare these findings across other countries and other service areas.
The results presented in this review are based on the author's thesis presented at the University of Birmingham in December 2010.