Partnerships in primary care in Australia: Network structure, dynamics and sustainability

https://doi.org/10.1016/j.socscimed.2008.03.046Get rights and content

Abstract

Partnerships represent a prescriptive form of network governance, based on the idea of cooperation. This article has four aims. The first is to describe why network governance and partnerships are important now, and what one particular example – Primary Care Partnerships – is addressing. The second is to analyse the network structure of two of these partnerships, and the third is to examine network dynamics. The fourth aim is to explore relationships and sustainability over the longer term. Two government-funded and steered partnerships, which were established to increase coordination between primary care services in Victoria, Australia, were examined. Annual interviews at three points in time between 2002 and 2005 were used to explore relationships between organizations within these two partnerships. The structure of two different communication networks, based on contacts for work and contacts for strategic information, were examined using social network analysis. Tracing network structures over time highlighted partnership dynamics. The network structures changed over the three years of the study, but an important constant was the continuing centrality of the independent staff employed to manage the partnerships. Over the longer term, it seems to be more important to fund independent partnership staff, rather than people who connect partnerships to the funding agency. If partnerships are seen as valuable in improving service coordination and health outcomes, then long term rather than just start-up funding support is required.

Introduction

Partnerships have become a common manifestation of network governance ideals. Network governance refers to a mode of governing that uses cooperation as its central coordinating mechanism. It is often used in a descriptive fashion, to understand the highly fragmented world of policy and administration that spans different levels of government, and crosses sectoral boundaries. This world, which reflects the growing complexity of society as well as changes in the ability of governments to govern, needs solutions that join-up the disconnected components of systems. So, network governance is also used in a prescriptive fashion, to describe deliberate attempts at joining up. The last decade has witnessed the proliferation of network forms of governing around the world, and one of the most common of these is the array of arrangements termed ‘partnerships’.

Partnerships cover a multitude of coordination mechanisms, from public–private partnerships which can in effect be straightforward contracts, through to voluntary alliances between agencies where no funding is involved. The form of partnerships of interest here are those that represent a local and practical manifestation of the macro level principles of prescriptive network governance: They have been funded and are steered by governments and others, with the explicit purpose of increasing cooperation in order to reach desired ends.

This paper has four aims. The first is to describe why network governance and partnerships have become important now, and what this particular example of partnerships – Primary Care Partnerships – is addressing. The second is to analyse the network structure of two of these partnerships. Who communicates with whom? How important are the different partners? The third is to examine network dynamics. Do particular organizations become more or less important over time? What happens when key actors leave the partnership? The fourth is to explore relationships and sustainability over the longer term. Should government see them as something that can be kick started with policy support and new funding, then left to their own devices? Are such partnerships sustainable without ongoing support?

Section snippets

Network governance and partnerships

Over the last three decades, governing trends in the public sector have changed considerably. As attention shifted to cutting costs and maximising outputs, laws and rules were de-emphasised while plans and targets became more important. Corporate management was a major strand of the new approach. Public organizations were to be seen as corporations, run along private sector lines by business managers. Plans and targets were emphasised, in line with a private sector approach rather than a

Primary care partnerships in Victoria

In Australia, the states and territories retain the major responsibility for health service provision, with the Commonwealth responsible for providing substantial additional funding for hospitals, medical services and pharmaceuticals. The states and territories deliver services through community health services, hospitals, and other agencies, with local governments also providing a range of services. The presence of multiple actors operating at different levels (national, state, and local), in

Methods

Two PCPs were involved in this study, chosen on the advice of DHS that these were likely to be successful on the basis of their initial community health plans. These two should be at the leading edge of changes in PCPs, based on the DHS evaluation that their plans were good and they were likely to move ahead quickly. Hence, they are somewhat atypical and not necessarily reflective of the experience of all PCPs.

One of the PCPs is located in Melbourne and the other is in a rural area about 200 km

Network structures

The first part of the analysis compares the strategic information networks of both partnerships in their first year, shown in Fig. 1, Fig. 2. The squares (PCP staff) and circles (all others) represent the individuals interviewed, and the lines between them and the direction of the arrowheads indicate who goes to whom for strategic information. They are labelled with both their organization and their individual number for ease of tracking over the three years. So, Fig. 1 shows that 13 actors

Network dynamics

As Table 2 indicates, the pattern for the second year of results is generally quite similar to the first. PCP representatives are again the most centrally placed in both networks for both partnerships, with DHS also well represented in the top five. This is despite the departure of two key actors – the Campaspe PCP Manager, and the original Chair of Westbay. A third departure that made a lesser impact was the replacement of the original DHS person on the steering committee. Notably, the new

Partnership relationships and sustainability

A range of factors underpinning these structural attributes and network dynamism were canvassed with network members in relation to the control and management of the partnerships. The two most important themes identified from the interviews were partnership management and local versus central control. The theme of partnership management covers building relationships, engaging individual partner agencies, and managing the collaborative process. This theme was important throughout the three

Discussion and conclusions

This paper had four aims. The first was to describe government-funded and steered partnerships, demonstrating that they can be usefully conceived of as a prescriptive form of network governance, and to describe what PCPs were designed to address the coordination dilemmas faced by a fragmented system of primary health care. This paper does not examine whether local coordination was improved, which has been reported elsewhere (Lewis, 2005a).

The second aim was to analyse the network structure of

Acknowledgements

This research was supported in part by a senior research fellowship from the Victorian Health Promotion Foundation and the Department of Human Services. We acknowledge the contribution of steering committee members from Campaspe and Westbay, for agreeing to be interviewed over three years, and the useful comments from the journal's reviewers.

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