barriers and facilitators to partnership working between early intervention services and the...

Health and Social Care in the Community (2008)

16

(5), 493–500 doi: 10.1111/j.1365-2524.2008.00760.x

© 2008 The Authors, Journal compilation © 2008 Blackwell Publishing Ltd

493

Abstract

Partnership working between health and the voluntary and community sector has become an increasing political priority. This paper describes and explores the extent and patterns of partnership working between health and the voluntary and community sector in the context of Early Intervention Services for young people with a first episode of psychosis. Data were collected from 12 Early Intervention Services and through semistructured interviews with 47 voluntary and community sector leads and 42 commissioners across the West Midlands of England. Most partnerships were described as ad hoc and informal in nature although four formal partnerships between Early Intervention Services and voluntary and community sector organizations had been established. Shared agendas, the ability to refer clients onto an organization that could provide a service they could not and shared training facilitated partnership working in this context. Barriers to closer working included differences in culture such as managing risk, the time required to make and maintain relationships and recognition of the advantages of remaining a small and autonomous organization. The four more formal partnerships were also built on the organizations’ experience of working together informally, in one case through a specific pilot project. The voluntary and community organizations involved were also branches of larger national organizations for whom finding sustainable funding was less of an issue. In theoretical terms, eight Early Intervention Service: voluntary and community sector partnerships were at a stage of ‘pre-partnership collaboration’, three at ‘partnership creation and consolidation’ and one at ‘partnership programme delivery’. The empirical data viewed through the lens of the partnership life-cycle model could help early intervention services, and voluntary and community sector professionals better understand where they are, why they are there and the conditions needed to realise the full potential of partnership working.

Keywords:

community settings, mental health services, psychosis

Accepted for publication

7 December 2007

Blackwell Publishing Ltd

Barriers and facilitators to partnership working between Early Intervention

Services and the voluntary and community sector

Helen Lester

MD

1

, Max Birchwood

DSc

2

, Lynda Tait

PhD

2

, Sonal Shah

MSc

2

, Elizabeth England

MBBS

2

and Jo Smith

PhD

3

1

National Primary Care Research and Development Centre, The University of Manchester, Manchester, UK;

2

University of Birmingham, Birmingham, UK and

3

NIMHE/Rethink Joint National Early Intervention Programme Lead, c/o Worcestershire

Mental Health partnership NHS Trust, Psychology Department, Wulstan Unit, Newtown Hospital, Worcester, UK

Correspondence

Professor Helen LesterNational Primary Care Research and Development CentreThe University of ManchesterOxford RoadManchester, M13 9 PL, UKE-mail: [email protected]

Introduction

Partnership working between health and the voluntaryand community sector is a high priority for the govern-ment with a stated aim of making the ‘voluntary and

community sector part of mainstream service provisionwhile respecting and promoting the independence ofthe organisations’ (Department of Health 2004, p. 7). It isseen as a mechanism for integration within an increas-ingly fragmented landscape and as a way of tackling

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complex ‘wicked issues’ (Stewart 1996). Most previouswork in this area has, however, focused on barriers andfacilitators to partnership working between health andsocial care (Peck

et al

. 2002, Freeman 2006) or betweenlocal government and voluntary and community sectororganizations rather than between health and thevoluntary and community sector.

Early Intervention Services provide specialisedfocused treatment for up to 3 years for young peopleaged between 14 and 35 with a first episode of psychosis.

The National Plan for the NHS

(Department of Health2000) stated that 50 Early Intervention Services foryoung people with psychosis would be establishedacross England by 2004, a situation that has now beenlargely achieved. As a statutory mental health service,they are being strongly encouraged to develop part-nerships with the voluntary and community sector(Department of Health 2000). Indeed, a recent UnitedKingdom government report proposed that promotingpathways to social inclusion should be a core role forthe National Health Service, but that mental heathservices cannot do this alone (ODPM 2004) and need todevelop strategic partnerships with the social care andthe voluntary and community sector. Such partnershipworking could be particularly important for the youngpopulation referred to Early Intervention Services, forwhom the stigma and social exclusion attached to‘sticky’ mental health labels can be particularly difficult.Eighty per cent of first episodes of psychosis also occurbetween the ages of 16 years and 30 years at a time ofmaximal life changes, and educational and vocationalopportunities that cannot always be addressed purelyby the health sector. However, there is little empiricalevidence to guide how an increase in partnershipworking might be implemented in practice.

The aim of this study was therefore to describe andexplore the extent and patterns of partnership workingbetween health and the voluntary and community sectorin the context of Early Intervention Services. This paperpresents the empirical findings and frames them con-ceptually within (Lowndes & Skelcher 1998) a four-stagepartnership life-cycle model. We also identify a series oftheoretical and practical tensions relevant to improvingpartnership working between Early Intervention Servicesand the voluntary and community sector, and keyingredients in creating successful partnerships.

Methods

The EDEN PLUS study, funded by the National Institutefor Health Research Service Delivery & OrganisationProgramme in 2004, was carried out in the West Midlandsregion of England (population 5.3 million) between2004 and 2006. In order to understand the complexities

of partnership working, the study team collected datafrom three key groups: voluntary and community sectorgroup leads, Early Intervention Service team membersand senior management staff in mental health providerand commissioning (funding) bodies across the region.

Managers of the 12 active Early Intervention Servicesin the West Midlands region were asked to provideinformation about the type of partnership arrange-ments they were involved with, and nominate voluntaryand community sector organizations they had workedin partnership with during the previous 12 months. Forthe purposes of the study, we defined

partnership

as anysituation in which people worked across organizationalboundaries towards some positive end (Huxham &Vangen 2005). Each of these voluntary and communitysector organizations was then contacted by letter to askif the lead would be prepared to be interviewed. Theletter also included a brief description of the study andKendall & Knapp’s (1997) definition of a voluntary andcommunity sector service: independence from thegovernment, an element of voluntarism and all profitsploughed back into the organization.

Focus groups were conducted with Early Interven-tion Service team members to explore their perspectivesof partnership working with the voluntary sector. Focusgroups were used rather than semistructured interviewsto maximise any dynamic interactions within themultiprofessional teams that might provide insightsinto attitudes, perceptions and opinions, and tap intounderlying assumptions (Kitzinger 1994).

Invitations to participate in a semistructuredinterview were also sent to senior managers in each ofthe four Strategic Health Authorities, the 30 PrimaryCare Trust mental health commissioners and 12 MentalHealth Trust and Social Care Trust Chief Executives inthe region at the time of the study.

An interview topic guide with a series of predeter-mined open questions was developed for each of thethree sets of interviewees (voluntary and communitysector leads, Early Intervention Service teams andservice funders). The content arose from a priori issues,a literature review by the study team and ideas thatemerged as the study progressed. Each topic guideincluded common questions around barriers and faci-litators to partnership working, funding mechanismsand examples of good practice. At the end of each of theinterviews and focus groups, participants were givenan opportunity to add any further comments they feltwere important.

Data were collected during a 12-month periodbetween May 2005 and April 2006. Data collection andanalysis were concurrent. Each interview or focus grouplasted between 60 minutes and 90 minutes, wasaudiotaped and fully transcribed.

Partnerships between health and voluntary sectors


495

Data analysis

All transcripts were read by two of the research teamindependently, and a preliminary coding frame wasconstructed. A constant comparison method was usedto interpret the data (Glaser 1978). Key concepts andcategories were identified using an open-coding methodfrom deconstructing each interview sentence by sentence.Key categories were then compared across interviewsand reintegrated into common themes. Disagreementsduring this process were discussed until a consensuswas achieved. ‘Sensitive moments’ within focus groupinteractions that indicated difficult but important issueswere sought (Barbour & Kitzinger 1999). Deviant caseswere actively sought throughout the analysis, andemerging ideas and themes were modified in response(Silverman 1997). Analysis also took into account thedifferent professional backgrounds of the participantswhere this was possible and appropriate (Barbour 2001).

In view of the volume of data, NVivo (QRS release2.0) computer software was used to help manage thedata. This relational database enabled both individualstatements to be analysed according to the initialidentified themes, and the overall set of themes to becollated and grouped into related issues from across theentire set of transcripts. All topic guides, transcribeddata and thematic indices are available, on request,from the correspondence.

Results

The 12 Early Intervention Service managers nominated68 voluntary and community sector organizations thatthey worked with. Four organizations replied that theywere statutory in nature, one no longer existed, 10 didnot respond and six did not wish to participate. Forty-seven of the 53 eligible voluntary and community sectorprofessionals who responded (89%) agreed to beinterviewed. Thirty-nine of the interviewees were theorganization’s manager or chief executive. Fifteen of theorganizations focused on housing provision, 15 onyouth services, 12 on mental health issues and five werecategorised as ‘other’ (including counselling and drugtreatment services). The number of full-time paid staffranged from 0.75 to 368 (median = 15), and the numberof referrals in 1 year ranged from five to 70 000 (median= 475).

Forty-two of the 62 (68%) Strategic Health AuthorityMental Health Leads, Primary Care Trust mental healthcommissioners and Mental Health Trust and SocialCare Trust Chief Executives agreed to be interviewed.

Focus groups were held with 10 of the 12 EarlyIntervention Services (83%), and included 60 teammembers from a range of professional backgrounds

(see Table 1). Two Early Intervention Service teams didnot participate in a focus group, citing time and workloadpressures.

We report the extent and type of partnership working,and the facilitators and barriers associated with part-nership working from the perspective of funders, EarlyIntervention Services and the voluntary and communitysector. Quotes have been chosen on grounds of repre-sentativeness with the Early Intervention Servicemember’s role and number, and voluntary and communitysector organization’s focus and number shown in brackets.

Extent and type of partnership working

Only four of the 12 Early Intervention Services had anyform of formal partnership with a voluntary andcommunity sector organization. One of these moreestablished Early Intervention Services described aformal partnership with a voluntary and communitysector organization where a legal agreement had beenentered into, on both strategic and operational levels,documenting the type of partnership and how it wouldbe managed to achieve its aims. Three Early Interven-tion Services described partnerships where voluntaryand community sector staff were integrated into EarlyIntervention Service teams with geographical co-locationin one case. The Early Intervention Service in this casebenefited from respite units provided by the voluntaryand community sector, and funded by the PrimaryCare Trust. Each of these four more formal partnershipswas built on the organizations’ experience of workingtogether informally, in one case through a specific pilotproject. The voluntary and community organizationsinvolved were also branches of larger national organiza-tions for whom finding sustainable funding was lessproblematic than for some of the smaller organizations.Each of the remaining eight Early Intervention Servicesdescribed a range of more informal partnerships withthe voluntary and community sector.

Table 1 Characteristics of focus group participants

Professional background Total staff interviewed n

Community psychiatric nurse 34Community support worker 1Occupational therapists 3Psychologists 12Social workers 2Support, time and recovery workers 4Youth workers 2Personal adviser 1Team secretary 1Total 60

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Facilitators to developing partnership working

There were three issues that both voluntary andcommunity sector and Early Intervention Service staffhighlighted as important in fostering good formal andinformal partnership working.

Coincidence of agenda

Shared priorities and principles appeared to underpinthe development of both formal and informal part-nerships. These included an emphasis on a social modelof care and on prioritizing a return to independent living.

One of our strengths is working with organisations that aresocially orientated because that’s what we’re about. (CPN, 14)

The aims and objectives are the same as in it’s the well-beingof the young person that counts and that’s the secret andessence of it all and then we have targets as a sideline.(Youth, 24)

Partnership working was also more likely to occurwhere the arrangement led to some form of mutualbenefit and where there was a coincidence of agenda.

If I can help them hit their target and they can help me hitmine, then we can all work together. The Chief Executiveof our Primary Care Trust calls it a coincidence of agenda.(Youth, 45)

Complementary skills

Almost all voluntary and community sector leads wereenthusiastic about developing some form of partner-ship working with Early Intervention Services becausethey felt they were able to provide holistic serviceswhich added value for the client.

I think there’s a good fit with what we do and what they doparticularly in a family context because of the issues and alsothe stigma attached. If we’ve got that partnership then I thinkwe are working a lot more safely and if we are working withthem then I think the outcomes, perhaps, have a better chanceof being positive. (Other, 38)

Early Intervention Service team members echoed thevoluntary and community sector view of the value ofworking in partnership in terms of providing clientswith skills outside their own remit. The services mostcommonly sought included substance misuse, bereave-ment counselling, housing advice and access to localcommunity facilities that could provide opportunitiesfor clients to engage in sports, arts and leisure activities.They also recognised that the voluntary and communitysector provided a lower stigma setting, which might bemore conducive to service engagement.

I think coming from a non-medical background has a massiveimpact on individuals and them wanting to use services. So Ithink yes, I think just that kind of being involved in ordinary

services, rather than strictly mental health services, is valuablereally. Most of our clients who don’t particularly want to be seenin mental health services in the first place need to be groundedback into the community in voluntary services. (CPN, 20)

A further advantage of working in partnership withthe voluntary and community sector from the per-spective of most Early Intervention Services was the abilityto access vocational and educational resources. Manyoffered clients opportunities to become involved involunteering within the organization, facilitating socialinclusion and increased self-esteem and self-worth.Some of the voluntary and community sector organiza-tions employed vocational workers who were able tohelp access work placements for clients, helping toaddress ongoing pervasive issues of social exclusionthrough increasing opportunities for employment.

... We’ve got access to a whole range of opportunities forservice users and one of them would be to be involved in ourorganization which is like service users become membersof a project management team, can become members of theorganization, can become part of our regional structure.(Mental health, 36)

Joint training initiatives

Joint training initiatives underpinned many of theexamples of good practice in formal and informalpartnership arrangements. These enabled separate organ-izations to forge relationships and understand differentorganizational perspectives.

We have done some training with the ... team and they alsoprovide training. We run a core training programme which isa 12-week programme for all new staff and volunteers andthey deliver at one session about general mental healthawareness and in addition to that they run some slightly morein depth mental health training that has been hugely beneficial.Then they come to our training on drugs. (Youth, 45)

Barriers to partnership working

There were five major barriers to partnership workingdescribed by Early Intervention Services and the vol-untary and community sector organizations. Many ofthe barriers reflected the cultural differences betweenstatutory and non-statutory services.

Cultural differences

A frequently noted barrier to forming more formalpartnerships concerned communication about levels ofrisk and the need for a risk assessment prior to referral.Many Early Intervention Service team members objectedto a minority of voluntary and community sectorprofessionals asking for risk assessments, and felt therequests reflected a misunderstanding about associationsbetween psychosis and violence.



497

Everybody wants a risk assessment if they go [to a voluntaryorganization] ... we have to send a risk assessment. (CPN, 30)

Information-sharing protocols, which enabled infor-mation about risk to be passed between organizations,appeared to facilitate better partnership working in thisrespect, especially from the perspective of the voluntaryand community sector, many of whom also wanted thisto be accompanied by a rigorous confidentiality policyto protect clients.

In our neck of the woods, there’s a new information-sharingprotocol set up between the local voluntary and statutorysector and I think everybody, not just the Early InterventionService. All the services now are much more willing to sharecare plans and risk assessments which, just a few years ago wewouldn’t have had access to.

Interviewer: How was it before that?

Absolutely awful and that has made one heck of a difference.(Other, 12)

A minority of Early Intervention Service memberscommented on the difficulties of working with indi-viduals who used potentially stigmatizing languageand sending clients to organizations where notions ofrecovery from mental illness were not widely accepted.This was not, however, an issue highlighted by any ofthe voluntary and community sector.

One of the issues that we had is around the language themesof mental health. The sort of facilities I suppose within thesmall rural areas have stigmatised mental health to someextent ... so for our clients, we’ve had to really think aboutwhether we want those links. They’ve got these posters on thewalls that say ‘severe mental illness’ ... (CPN, 12)

Investing in the partnership

Barriers were described from both perspectives in termsof the time and resources required to make any formof partnership working a reality. Early InterventionService team members reported that organizationswere identified by a mixture of serendipity and focusedsearching for local organizations that could provide aspecific service. However, it was difficult to find thestaff time to take on and, as importantly, maintain suchdevelopmental work.

Part of the induction process for a new case manager is thatthey put themselves about a bit. They get to know all the localresources. In doing that, they create links. (CPN, 1)

I think it’s very clear that they’ve got to be sustained andyou’ve got to put a lot of work into partnerships to keep themgoing, and I think that’s what happened with [nameremoved], we’ve got good links with [name removed]. We gota presentation and then because we didn’t have a lot of contactwith them it sort of seemed to drift away a bit. You know, it’ssomething that you’ve got to constantly feed. (Clinicalpsychologist, 40)

Two of the better-funded and more establishedEarly Intervention Services included a communitydevelopment officer post which allowed them the timeto find local voluntary and community sector organiza-tions, and then to develop and maintain good workingrelationships with them.

If community development had not been part of my jobdescription, I guess I would have felt that I had less of a rightto do development work. As it is, I can, and I think the wholeteam has benefited because they are able to tap into a range ofgroups and agencies that we probably would not even knowabout. It’s been great to have it as part of my role. (Communitysupport worker, 18)

Many voluntary and community sector leads alsocommented on time pressures in the context of thenumber of meetings that occurred in 1 week and theneed, particularly within smaller organizations, to makeevery second count. Most felt that the time andresources required to both develop and maintain formalpartnership working outweigh potential benefits.

Amateur status

A number of the voluntary and community sector leadshighlighted the advantages of their autonomy andindependence from the statutory sector. They felt thatyoung people might trust them more than the statutorysector, and therefore, be more likely to access their services.

We are an organization that stands alone. It’s a charitableorganization so it’s not perceived to be part of The System.(Youth, 18)

Indeed, some voluntary and community sector pro-fessionals expressed a reluctance to engage in moreformal partnership working with an Early InterventionService, feeling their independence could be com-promised both in terms of choosing which referralsto accept and a potential over reliance on one source ofstatutory sector funding.

However, one of the consequences of independencefrom the statutory sector was a perception of a majorityof voluntary and community sector professionals thatstatutory service staff viewed them as ‘amateurs’, at leastuntil they had worked with them informally for sometime. This ‘second-class citizenship’ within a hierarchyof organizations was at the same time recognised asincongruous, because most were also highly valued bythe statutory sector precisely because of their particularexpertise.

There’s a kind of mindset that because you are voluntary,you’re amateurish, so you’ve got to get over that before peoplecan take us seriously. (Mental health, 3)

Very often, we’ve acknowledged that we haven’t got the skillsor we haven’t got the resources or, for example, you know it’s

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a specialist area, it’s a bereavement counselling, for example,and we’re not frightened to actually use those agencies, thevery skilled workers within those agencies. (Early interventionsupport time and recovery worker, 9)

Economies of scale

The majority of voluntary and community sector organ-izations in this study were small (median 15 staff), flexibleand easy for clients to access. Most voluntary and com-munity sector leads said they felt this gave them a distinctadvantage over the statutory sector in being able torespond to clients’ needs flexibly and innovatively.

Somebody once described it to me, if you want to make achange and do something in a different way it’s like turningaround a juggernaut, whereas for us it’s like turning a mini.So, we can do things differently on Monday morning if wewant to, because that’s easy to change.... (Youth, 45)

Interestingly, I worked with the voluntary sector for 3 yearsbefore I came to this post. I worked with the NHS prior to that,so I can acknowledge both sides. It’s been interesting reallybecause I’ve seen practice on both sides and I’ve seen thevoluntary sector. I mean they’ve got a lot to offer. I think thevoluntary sector acted more responsive to me. It moved a lotquicker than the big machine of the NHS. (CPN, 13)

However, the corollary of being small and flexiblewas a lack of capacity at times to respond to issuesbeyond the immediate client work.

Funding issues

Barriers were also created by Primary Care Trustcommissioners’ apparent lack of understanding ofpartnership working issues, strategically or locally. Onlyfive of the 42 commissioners who made decisions aboutfunding services could describe meaningful examplesof partnership working within their locality.

Someone delegates tasks to me and developing EI is one. ButI haven’t really got a handle on what is going on within thePCT let alone trying to get other groups on board. [Jointcommissioner for mental health (PCT), 6]

Indeed, two commissioners felt that their efforts toengage the voluntary and community sector werelargely ‘tokenistic’.

We set out to get broad representation from all of the stake-holders: so service users, carers, psychologists, psychiatrists,social workers, the voluntary sector – about 20 people in total.My view is that it was unmanageable and we were doing‘what we were required to do’ rather than engaging whole-heartedly in the process. [Director of service development(MHT), 15]

Many of the commissioners at Primary Care Trustlevel expressed views that responsibility for mentalhealth services was often seen as a difficult brief withintheir organization, and that arguing for money to fund

services was not easy in competition with other generalmedical services. Some felt this could be an expressionof the stigma of mental illness.

I think what I’ve found within NHS organizations is that it(mental health commissioning) doesn’t seem to be everybody’sbusiness and you have to work really hard to get it profiledonto other people’s agendas. I have come across NHS managersthat still don’t want to have to attend to, or prefer not to beinvolved with mental health. They just don’t want to know.[Commissioner for mental health (PCT), 3]

Worries over funding, in particular of achievingcaseload targets to be eligible for a future funding, werealso a problem within most Early Intervention Services.This reduced their ability to undertake the developmentwork that was critical to creating future partnerships withthe voluntary and community sector.

I think one of the issues with us is to find the time to supportthose relationships and those partnerships. I do worry abouthaving time to feed them because there’s pressure on us totake the 1–15 ratio of clients. (Clinical psychologist, 40)

In turn, voluntary and community sector leadsdescribed the problems that uncertain funding createdin terms of the administrative burden of constantlyhaving to bid for further funding. These time commit-ments and uncertainties meant that many voluntary andcommunity sector organizations had limited capacity tocreate formal partnerships with Early InterventionServices and to make or commit to longer term plans.

... It takes time to write bids and then if you don’t get them,then you have wasted 1 or 2 weeks of your time and it mightbe that it is only a £5000 or £10 000 bid which is quite disheart-ening. (Youth, 2)

Discussion

This is the first study to examine partnership workingbetween Early Intervention Services and the voluntaryand community sector. While most previous work hasdescribed forms of partnership working and focused onmanagerial perspectives (Glasby & Peck 2006), thisstudy has highlighted the type, extent and practicalrequirements necessary for implementing partnershipworking from multiple perspectives. It adds to ourknowledge of the complexities of the issues, and high-lights practical solutions such as joint training, the valueof community development posts and information-sharing protocols that could be adopted to encouragepartnership working.

Limitations

This study has a number of limitations. Only one personwithin each voluntary and community sector was



499

interviewed (almost always the organization lead), andit is possible that other team members might have haddifferent views. The study design also meant we focusedmainly on describing processes rather than on possiblerelationships between partnership working and serviceuser outcomes.

Relevance to previous work

These findings support previous work on partnershipworking between health and social care. Glendinning(2002), for example, found that shared priorities andprinciples were important in developing strong part-nership links. Harris

et al

. (2004) highlighted a lack oftime and resources as a critical barrier to developingpartnerships. Coid

et al

. (2003) and Alcock

et al

. (2004)both identified short-term non-sustainable funding as akey hindrance to partnership working. Perhaps of mostinterest, however, are the resonances between our dataand Lowndes & Skelcher’s (1998) conceptual work onthe partnership working life-cycle (see Box 1) whichmay increase the generalizability of these findings tosettings and patient groups beyond Early InterventionServices (Green 1999). In particular, an appreciation ofthe life-cycle model could help Early InterventionServices and voluntary and community sector pro-fessionals understand where they are, why they arethere and the conditions that need to be created andthen maintained to realise the full potential of futurepartnership working.

The life-cycle of partnership working

In their four-stage partnership life-cycle model, Lowndesand Skelcher describe the first stage as ‘pre-partnershipcollaboration’. This is characterised by an ‘ideal type’network relationship based on informality, trust and asense of common purpose, including deriving mutualbenefit from the partnership. Most of the relationshipsdescribed by Early Intervention Services and voluntaryand community sector fell into this category, underliningthe importance of coincidence of agenda and of informalpersonal relationships. These informal partnershipsare theoretically and were, in practice, vulnerable to

short-term funding and staff turnover, and took timeto build and maintain.

The second stage of the life-cycle, ‘partnership crea-tion and consolidation’, is characterised by increasinglyfocused activity including the development of morehierarchical relationships and the formalization ofprocedures. Three Early Intervention Services describedthis type of partnership with the voluntary and com-munity sector. This relationship was perceived as lessvulnerable to staff turnover and could be (and indeedwas) strengthened by joint training. It was seen as avital part of the partnership’s life-cycle as it moved fromexchanging ideas and information towards a focus on aspecific project. However, our data also suggest thatgreater formality can also limit flexibility and innova-tion, which was particularly prised by the voluntaryand community sector. The perception of amateurismnoted and disliked by many voluntary and communitysector leads and differences in approach to risk and useof language voiced by some Early Intervention Servicesreflect cultural differences and the potential for mis-understandings between sectors. They also highlight theneed to negotiate the rules of partnership working andspend time learning about each other’s worlds if moreEarly Intervention Services and voluntary and communitysector want to move towards this second stage of thelife-cycle. It is noteworthy that one of the partnershipsat this stage of the life-cycle had initially engaged in aformal pilot project. This was described as helpful inestablishing which policies and procedures would beused, and in highlighting potential difficulties in workingtogether formally.

The third stage, ‘partnership programme delivery’,is characterised by formal contracts which theoreticallyintroduce competition for funding, lower levels ofcooperation and the associated need to demonstrateadded value. Only one of the more established EarlyIntervention Services had recently entered into such aformal legally binding partnership with a voluntaryand community sector organization, and such tensionswere not yet in evidence.

The final fourth stage of the life-cycle, ‘partnershiptermination or succession’, is where the partnershipcomes to an end with an exit or succession strategy. NoEarly Intervention Service in this study had reached thisstage of the life-cycle, perhaps because of the relativeyouth of most of the services. However, the theoreticalmodel suggests a number of caveats as Early Interven-tion Services in particular become more widespreadand established. Increased competition between differentpartnerships can lead to the fragmentation of resourcesand duplication of effort as neighbouring localities bidagainst each other. This has costs for broader inter-agencyrelationships and time costs for the ‘losers’. Relationships

Box 1 Lowndes & Skelcher’s (1998) model of the partnership working life-cycle reflecting the status of partnership working from the Early Intervention Service perspective in the West Midlands

• Pre-partnership collaboration 8• Partnership creation and consolidation 3• Partnership programme 1• Partnership termination and succession 0

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built initially on mutual trust can become underminedby the imperative to compete. Secure funding, currentlyseen as a panacea by many services, may not necessarilycement partnerships but could potentially damageemerging relationships built on trust.

Conclusion

This study suggests that although informal collabora-tion is widespread, there is, despite strong policyencouragement, relatively little evidence of more formalpartnership working between the Early InterventionService and the voluntary and community sector. Fourof the Early Intervention Services had developed formalpartnership links with larger national voluntary organ-izations for whom funding was less of an issue. Theselinks were strongest where the Early InterventionService had been established for some time and teamshad a history of successful working together thatinspired mutual trust and confidence. For these organ-izations, the policy framework has provided support forthe creation of vibrant partnerships built on a bedrockof good local relationships. However, most partnershipsbetween the voluntary and community sector and EarlyIntervention Services were ad hoc and informal innature, constrained by issues of time and insufficientworkforce capacity to enable more formal links to bedeveloped and insecure funding, particularly for thevoluntary and community sector.

Key ingredients in creating successful partnershipsbetween Early Intervention Services and the voluntaryand community sector appear to be initial capacity toseek out relevant potential partner organizationswho share coincidences of agenda. These can be fortifiedthrough joint training, sharing information about clientswhere appropriate and pilot runs of more formal arrange-ments to highlight and address cultural differences.

Our findings also suggest that a better understand-ing of the complexity of the issues at a commissionerlevel and sustainable funding for Early InterventionServices and voluntary and community sector organiza-tions may also better enable partnership working toflourish.

Acknowledgements

Funding was provided by the National Institute ofHealth Service Delivery and Organisation Programme.We would like to thank all of the interviewees who gaveus their time and thoughts, and Siobhan Conroy fororganizing many of the administrative aspects of theEDEN Plus study. Ethical approval was granted by theSouth-west Multi Centre Research Ethics Committee(03/6/54).

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