- Partnership
A group of two or more organisations working collaboratively to pursue and achieve common goals and objectives
- Stakeholder
‘Anybody who can affect or is affected by an organisation, strategy or project’ (Morphy, n.d., para. 2)
- Alchemical effect
‘Participants seek to achieve more than the sum of their individual parts by creating leverage and synergy based on and between key components of the partnership’ (Nelson & Zadek, 2000, p. 15)
Importance of stakeholder partnerships
Health service demand is rising because of factors such as ageing populations, rising levels of chronic and non-communicable disease, environmental health concerns and public expectations of longer and healthier lives. Human and financial resources are limited. Collaboration, in the form of collaborative partnerships, is recognised as an effective means of addressing complex healthcare problems and issues of service coordination and healthcare demand (Beatty, Harris & Barnes, 2010; Brownie, Thomas, McAllister & Groves, 2014; Conway et al., 2006; Daley, 2009).
- Collaboration
‘A process through which parties who see different aspects of a problem can constructively explore their differences and search for solutions that go beyond their own limited vision [and/or resources] of what is possible’ (Gray, 1989, p. 5)
The need for improved coordination of services is a central theme driving current health service reform (National Health and Hospitals Reform Commission, 2009; Brownie et al., 2014). The term wicked problems is used to describe difficult health and social problems that are hard to define, unstable, without a clear solution, and socially and politically complex. In order to be resolved, they require significant changes in individual and population behaviours (Australian Public Service Commission, 2007; Head & Alford, 2013; Termeer, Dewulf, Breeman & Stiller, 2013).
- Wicked problems
Difficulties that ‘have many interdependencies and are often multi-causal’ and cause issues as they are ‘highly resistant to resolution’ (Australian Public Service Commission, 2007, pp. iii, 3)
It is widely accepted that improvement in these issues requires the cooperation and input of multiple parties. This means that delivery of improved healthcare depends on the capacity and willingness of different partners to work together (National Health and Hospitals Reform Commission, 2009; McMurray, 2006). Partnering with stakeholders has a number of benefits, including increased and streamlined access to services, cost efficiencies and avoidance of duplication. By working together, partners can also develop creative solutions to difficult barriers or obstacles. Partnerships are means by which policies and programs can be more flexible and health services more responsive to community and health service user needs (Laffin & Liddle, 2006; Taylor & Thompson, 2011).
Providing consistent access to high-quality, timely and affordable care is particularly challenging in rural communities. Innovative collaborative partnerships can overcome demographic and geographic barriers to provide health and social services.
A general practitioner in a remote New Zealand community was nationally recognised for his leadership, vision and advocacy in healthcare, including his work in developing a low-cost health clinic to make basic healthcare accessible in an area where access was difficult, working in partnership with schools and other stakeholders to establish a full-time school-based health clinic and establishing a ‘well home’ initiative in which run-down homes were repaired on the basis that wellness begins in warm, safe homes. Even though these initiatives were a result of individual passion, vision and drive, they depended on the development of interagency and cross-sector relationships and partnerships for implementation and ongoing success.
Similarly, in Western Australia, the WA Cystic Fibrosis Model of Care was developed to deliver services across the continuum of care to people with cystic fibrosis nearer to their homes. It incorporated a number of service components, including co-care, self-management, transition from paediatric to adult services, and outreach. These factors depended on well-developed partnerships between public, private and non-government organisation services to provide care and support to people with cystic fibrosis and their families across urban and rural areas. Central to this partnership were consumers and their families, with continuous liaison ensuring that care was delivered to the right people at the right time and in the right place.
Stakeholder groups in healthcare
Consumers
A key stakeholder partnership in any health system is between healthcare professionals, or service providers, and the people who use health services. The terminology describing users of health services varies and includes patients, clients, service users and consumers. For the purpose of this chapter we refer to health service users as consumers.
Meaningful partnerships with consumers within a model of patient-centred care are now an expected aspect of quality health services (NHS Choices, 2012). An effective partnership allows the consumer to become active in their own care and participate in decision-making processes. However, for these partnerships to be truly collaborative, consumers may need to be educated and supported into a more active role (Doss, DePascal & Hadley, 2011).
Establishing and maintaining a partnership between health professionals and consumers takes time and effort on both sides (Doss et al., 2011). Effective and appropriate communication is essential. Like any partnership, collaboration must be based on shared understanding, trust and respect. Considerations include incorporating consumer perspectives, knowledge and values into planning and delivering care; sharing information openly and in a way that encourages participation; and supporting consumers and their families or caregivers to participate as much or as little as they wish (Conway et al., 2006). Meaningful partnerships also involve inviting consumer collaboration on the development and implementation of health policy and programs, as well as service design and delivery. This can encourage quality improvement and can be effective at local, national and global levels (Crawford et al., 2002; Kotter, Schaefer, Scherer & Blozik, 2013). Committed providers develop ways for consumers and families to be involved at different levels and offer relevant training and support for individual consumers (Conway et al., 2006).
Families and caregivers
The health status of many consumers is often maintained through extensive support from family members and other caregivers (Barrow & Harrison, 2005). Partnering with consumers requires partnership with families and other caregivers (Crawford et al., 2002), and such collaborative partnerships can be particularly important for vulnerable and dependent consumers, such as children or the elderly, and those with chronic or other health problems that require high use of health services. Family and caregiver involvement is also important for consumers from vulnerable populations, such as those living with mental illness or intellectual disability (Wallcraft et al., 2011). These partnerships can be complex, due to challenges such as when both the consumer and the care-giver age; often, there is no alternative family member able to provide care as the carer becomes increasingly in need of supporting health services (Walker & Ward, 2013; Yorke, 2013). Key components of successful partnerships with families and caregivers include mutual respect and consideration, good communication, sharing information and joint decision-making.
Well-developed partnerships between healthcare professionals and families and caregivers result in significant improvements in health outcomes and events. For example, a systematic review by Kuhlthau et al. (2011) found that partnerships between health professionals and the families of children with special needs are associated with improved health outcomes, including better access, communication and efficiency. Partnering with family and caregivers can increase understanding of the individual consumer’s needs, develop knowledge of their specific health concerns and provide a basis for shared participation in care and decision-making. In addition, families have unique knowledge about the consumer; they understand the consumer’s personal and social context and how their health concerns impact their daily life. They can assist the consumer in communicating with health professionals and assist the health professional in communicating with the consumer. This means the consumer is better supported throughout their healthcare experience.
Research collaborators
Compared with medical research, health services research is a relatively new science. Traditionally, research in hospitals was the domain of academic clinicians, and research tended to have a clinical focus. Increasingly, the focus has shifted to health service and health outcomes research (Dimick & Greenberg, 2014). The phrase ‘better research – better healthcare’ is now well known (Evans, Thornton, Chalmers & Glasziou, 2011), and commitment to patient wellbeing and safety has become paramount (Kronick, 2014). Against this backdrop, partnerships among academic researchers, health service providers and policy-makers are increasingly active.
Commonly identified areas for health service research include prevention of hospital-acquired infections, reduction of medication error rates, strategies for reducing harm in labour and delivery, prevention of falls and improving safety in nursing homes, and other areas of patient dissatisfaction or hospital error. This is driven by ‘a requirement for a strong clinical evidence base to ensure patient safety and effective practice across biomedical, complementary and integrative health care settings’ (Adams, Sommers & Robinson, 2013, p. 1).
Whole-of-government collaborators
Collaborative interagency partnerships are increasingly important in addressing healthcare complexity and entwined health and social issues (Head & Alford, 2013). Slogans such as ‘Mental Health Is Everybody’s Business’ highlight the need for collaboration and service coordination across all government departments, including health, housing, police, social welfare and more. Recent Australian health reforms are based on the understanding that well-coordinated, integrated continuity of care is central to effective health systems, especially for those serving consumers with multiple, ongoing and complex conditions (National Health and Hospitals Reform Commission, 2009; National Health Workforce Taskforce, 2010).
While the mandate for whole-of-government partnerships and collaboration is clear, implementing such partnerships is complex and challenging (Australian Public Service Commission, 2007; Brownie et al., 2014). Structural reform can provide part of the solution, but success also depends on fundamental changes in the way in which health professionals form working partnerships to deliver services.
Success factors in stakeholder partnerships
The success of a partnership depends on several factors: strong leadership, a clearly defined purpose with realistic goals and objectives, and a high level of participation and input from all partners are central to success.
Good, timely communication is particularly important for the success of a partnership. Channels or mechanisms for communication need to reflect the different internal structures and information needs of each partner. To reach all partners, communication may therefore need to be in multiple forms or styles. A strategically focused communication plan is an essential tool, as it ensures that information flows within and between partnering organisations as well as to and from stakeholders outside the partnership.
Trust and respect are also important factors for successful partnerships (Daley, 2009). Within a partnership they allow partners to work alongside one another towards common goals, encourage input and participation, and facilitate sharing of resources and responsibilities. A genuine partnership is based on an understanding that each partner has something to contribute and implies that the risks and benefits are shared. Trust and respect between partners allow partnering organisations to gain from the partnership without compromising partnership goals. To achieve this, all partners must be committed to reciprocity, equity and recognition of the independence of partner organisations (Zafar-Ullah, Newell, Ahmed, Hyder & Islam, 2006).
A partnership structure must be robust and have the flexibility to adapt to meet changing needs as the partnership progresses. The frequency of interactions between partners and clear definition of roles and expectations, both internal and external, are central to a partnership’s success (Beatty et al., 2010). All partners must work to establish a shared understanding of the underlying purpose of the partnership, and all parties must be committed to the partnership. Partnership structures need to be transparent and to allow shared planning, implementation and evaluation; the partnership also needs sufficient human and financial resources (Taylor & Thompson, 2011). Partners must understand how to jointly make decisions within the partnership structure (Grudinschi et al., 2013).
Management and stakeholder partnerships
The concept of stakeholder partnerships is easy to talk about but difficult to put into action; ‘partnerships are sometimes compared to a “black box”: inputs and outputs are visible, but the mechanisms enabling the transformation from input to output are not’ (Organisation for Economic Co-operation and Development, 2001, p. 18). On their own, traditional management competencies are not sufficient to respond to increased interagency collaboration and partnership with stakeholders.
In his book Getting agencies to work together: The practice and theory of managerial craftsmanship, Eugene Bardach (1998) outlines how managers need to develop individual and organisational interagency collaborative capacity, described as ‘managerial craftsmanship’. This concept has been expanded by other writers, with Friend (2006, p. 270) describing how managers need to engage in ‘responsible scheming’ – for example, mapping changing structures and relationship patterns among stakeholders and partnering agencies. Getting things done when you are not in charge and being able to influence when you do not have authority are additional competencies necessary for effective stakeholder engagement. This is because power held through a role in one organisation may not be relevant in a partnership context (Bellman, 2001; Cohen & Bradford, 2005; Middleton, 2007).
The range of skills needed by health service managers is outlined by Termeer et al. (2013), who identify four characteristics managers need to address complex or wicked problems specifically:
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