Much discussion of policy making and governing at the beginning of the 21st
Century, indicates a significant shift in the model of governance across many sectors, away from an emphasis on competition between agencies (markets), to a model of inter-agency coordination and collaboration (networks). In Australia, this general trend is spelt out in the recent 'Connecting Government' paper [1
]. This reflects the increasingly complicated arrangements for organizing and delivering services, which cross horizontal (levels of government) and vertical (government, private and third sector agencies) boundaries, and are in part a legacy of the earlier managerial and market based modes of governing [2
]. It is helpful to conceive of many organizational contexts as network-like in order to understand them, without claiming that they are necessarily "good".
Partly driven by this shift, but also indicating a desire to find better approaches, there has been an astonishing growth in public policies which embrace the concepts of partnerships, alliances, collaborations and networks. Health policy has been a part of this broader trend, and there is no shortage of discussions of a range of collaborative forms of governing. In particular, partnerships of many varieties have become a key means for governing a range of policy initiatives at the local level [3
This paper does not intend to make a full explication of what the characteristics of these partnerships are, or how they are being used. Neither does it address the question of whether there is in fact a clear commitment to them as a new form of governance, or whether they are better than previous approaches. Instead it explores new theories and methods for examining partnerships in health. As the current emphasis on partnerships shows no signs of abating, health policy research is in need of new concepts, methodologies and techniques for establishing their positive and negative effects.
While partnerships range from the bottom-up, locally self generated and voluntary, to the top-down, centrally steered and government mandated arrangements, those of central interest here are the latter, and are considered to be 'managed networks' [4
]. Partnerships in the public sector often reflect efforts to institutionalise the positive effects of networking (such as increasing diversity by involving a greater range of actors) by requiring organisations and programs to have more formal connections to each other [5
]. Those in focus here are created by government and are centrally steered with specific deliverables and targets defined by the centre rather than the individual partnerships. They cover defined geographical areas and have dedicated network coordinators. Leadership is undertaken by formal agencies rather than by mobilised communities. They have some ability to shape their own local priorities, but within limits set by a central authority [4
Evaluations of a number of these types of partnerships in the UK have demonstrated that there are benefits, but that partnerships also face substantial difficulties. It is a slow process which clashes with the demands of government for results in the short term, and the need for local partnerships to reflect national priorities [4
]. The most ambitious of these was Health Action Zones, and a recent evaluation of this program proclaimed the need for a new body of theory about what these kinds of programs can reasonably be expected to deliver in the face of bewildering complexities [6
]. This paper argues that it is not only theory that is needed but also more appropriate methods for exploring their pluses and minuses.
A number of partnership tools have been created. One of the most relevance here is VicHealth's Partnerships Analysis Tool [7
], which encourages partners to examine the reason for the partnership, map their relationships, and complete a checklist on a number of features of the partnership. While the map of the partnership has a similar focus to what is of concern here – understanding relationships – it is based on people's views of different types of engagement at an organizational level. This approach is straightforward to apply but more detailed views of relationships between people are required to understand what is happening beyond structures, and in accounting for the agency of individuals.
This paper attempts to walk the line between structure and agency, by combining network mapping and analysis with narratives, both of which are based on the observations of individual participants in partnerships. Pure description explains nothing, yet reflects the complexity of reality, while abstract theorising and modelling explains much but only by ignoring the complexity of reality [8
]. A seemingly fruitful way of examining both structure and agency stems from Gidden's structuration theory [9
]. He argues that structures constrain and facilitate actions, and also bind actions so that patterns are generated and reproduced. In other words, people work from within a set of structural constraints and opportunities, but also create and sustain these structures through their actions.
While Gidden's approach is to examine structure and action in isolation, Jessop's strategic-relation approach goes beyond this to examine structure in relation to action and action in relation to structure [10
]. He argues for combining structural and discursive approaches. This is what this paper attempts, by using an approach that examines social networks as a set of connections, as well as a narrative about those network connections.
A little explored set of concepts and analytical techniques useful for evaluating these partnerships is available from social network analysis, which focuses on analysing relational data. It encompasses tools for network visualisation and network analysis using graph theory, statistical and algebraic models [11
], and a range of concepts aimed at examining global network structure, network sub-structures, and the position of individuals within these networks (see these and other books dealing with these methods: [11
]). The second means for examining whether and how partnerships improve relationships, build trust and foster better collaboration and cooperation between agencies is to examine the use and value of relationships through narratives.
The aim of this paper is to outline a network approach for use in researching partnerships in health. In doing so, research based on Primary Care Partnerships in Victoria is used to illustrate how combining network concepts and methods with narratives can be used to answer important questions about partnerships. The approach used examines connections (ties) between people, through the use of network mapping and analysis, particularly looking at multiple ties between people. This provides information on whether there are connections between people, in relation to various purposes (structure), but uncovers little about how they use and value them (agency), which requires an exploration of the quality of relationships within partnerships. More information on this approach is contained in the methods section.
Primary Care Partnerships
Primary Care Partnerships (PCPs) were introduced in Victoria in 2001. The stated aim of PCPs is to improve the health and well being of a catchment's population by better coordination of planning and service delivery. A second aim is to improve the experience of and outcomes for recipients and reduce the preventable use of hospital, medical and residential services [14
The core agencies in PCPs are community health services, local governments, district nursing services, divisions of general practice, and aged care assessment services. In each locality, other agencies are also partners, based on local priorities. The initial PCP policy document emphasised consumer, carer and community involvement in the partnership [14
]. In establishing PCPs, the Department essentially provided funding for each to employ a network coordinator, and project workers who took on roles that reflect the main priorities of service coordination and health promotion. In general, all PCPs began with a steering committee, and committees to deal with service coordination and health promotion. Each PCP has a chair, often drawn from one of the partner organisations.
The state health authority, the Department of Human Services (DHS) centrally steers these partnerships. The DHS central office role is one of policy direction and advice, while DHS regional offices are responsible for monitoring and accountability. Local governments are an important partner and PCPs usually cover two or three local government areas. Some 32 partnerships were established across the state initially, and each of them received an establishment grant from DHS on signing a partnership agreement.
Combining considerations of structure and agency into one approach is no easy task. However, this is where network theories and methods provide great promise. To demonstrate the utility of social network analysis for examining partnerships, research on two of the original 32 (now 31) PCPs, is used to examine whether and how relationships between individuals and organizations changed and developed since the inception of these partnerships.
One of the PCPs is within the Melbourne metropolitan area, and one is in rural Victoria. The information presented is based on a survey of 19 people from the metropolitan PCP, and 18 from the rural PCP. Interviews in the rural PCP were conducted with the three people in the PCP office, nine of the 14 people from the steering committee, three DHS regional office personnel, and three members of the health promotion steering committee. Three of the people from the consumers and carers group were interviewed together but network information was not collected from them. Interviews in the metropolitan PCP were conducted with three people from the PCP office, 11 of the 15 people who were on the steering committee at the time, two DHS regional office personnel, and three members of the health promotion steering committee. This information is summarised in Table .
Information on the two PCP surveys
Members of the partnerships were interviewed using face to face or telephone interviews, and all were recorded and then fully transcribed. Name generators (that is, asking people who they would contact in relation to something) are commonly used to collect network information based on a range of relationships (see [15
] for examples). In network terms, people have multiple types of ties with each other. To capture these multiple relations, interviewees were asked the following:
1. Looking back over the last 6 months, who are the people you had the most contact with in order to do your work?
2. Over the last 6 months, who did you go to most when you wanted to get strategic information about something in the PCP?
3. Over the last 6 months, who did you go to most when you wanted to talk about policy in relation to this PCP or PCPs in general?
No set number of nominations was required, and a set of prompts was used if people were having trouble with recall (the prompts were: in your agency; in your PCP; in DHS regional and central offices; and elsewhere). The names were written into a form by the interviewer during the interview and the tape recording was used to check names later if they had been missed during the interview. While the second and third questions gave similar lists of people (with a number of respondents saying that list was the same), not all people nominated the same set of others for both. So many interviewees made a clear distinction between strategic information and policy ties.
The interviews provide information on both network structure, in terms of three different types of ties, and on agency, as described by people within the partnerships. The information on network ties forms the basis of the network maps and analysis. More people were mentioned than appear in these diagrams (as interviewees were free to nominate whoever they chose), but only interviewees are included here. That is, a larger number of people were mentioned in both PCPs, but those named but not surveyed did not have the chance to nominate people in return. Network analysis relies on people being able to both be nominated and to nominate others in return, so only the 19 and 18 who were interviewed are included in the analysis. This does not mean that the others are non-respondents in the traditional sense, it simply reflects that networks in effect have no boundaries.
During the interviews, open-ended questions were used to gather narrative descriptions of relationships. Questions were centred around:
• involvement with people in other agencies before the PCP was established
• level of contact since its establishment
• whether and how relationships had changed because of the PCP.
The narratives from the transcriptions were simply grouped under these three headings.