Alliances in Health Promotion Theory and Practice

Also by Angela Scriven

Health Promotion: Theory and Practice (with Judy Orme)

Alliances in Health Promotion

Theory and Practice

Edited by

Angela Scri yen

~ MACM I LLAN

Selection and editorial matter © Angela Scriven 1998

Individual chapters (in order) © Robin Douglas; Sally MarkweIl; Kathryn Backet­Milburn and Lindsay MacHardy; Angela Scriven; Andrew Wall; Meg Elliott and Debbie Jackson; Rachel Funnell and Katherine Oldfield; Maggie Rae; Viv Speiler; Davel PateI; Loraine Ashton; Doreen McIntyre; Anita Hatfield; Maggie Sims; Noreen Kickharn and Annette Rushmere; Helen Chambers; Helen Howson, John Griffiths and Ann Davies; Vanessa Walker; Marlene Inman; Linda Ewles, 1998.

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First published 1998 by MACMILLAN PRESS LTD Houndmills, Basingstoke, Hampshire RG21 6XS and London Companies and representatives throughout the world

ISBN 978-0-333-67769-8 ISBN 978-1-349-14297-2 (eBook) DOI 10.1007/978-1-349-14297-2

A catalogue record for this book is available from the British Library.

This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources.

10 9 8 7 6 5 4 3 2 1 07 06 05 04 03 02 01 00 99 98

Editing and origination by Aardvark Editorial, Mendham, Suffolk.

Contents

List of Figures and Tables VlI

The Contributors Vlll

Aeknowledgements XlI

Introduetion Angela Scriven Xlll

Section One: Current Issues and Future Trends 1

1 A framework for healthy allianees Robin Douglas 3

2 Exploration of eonfliet theory as it relates to healthy allianees Sally MarkweIl 18

3 Healthy allianees depend on healthy soeial processes Kathryn Backet-Milburn, Lindsay MacHardy 35

4 The influenee of government poliey on health promotion allianees Angela Scriven 44

5 The ethies of getting on with others Andrew Wall 53

6 Developing a strategie alliance using a soft systems approach Meg Elliott and Debbie Jackson 60

7 An evaluation tool for the self-assessment of healthy allianees Rachel Funnell and Katherine Oldfield 70

8 The eommissioning of healthy allianees Maggie Rae 77

9 Future developments of healthy allianees Viv Speiler 85

v

vi Alliances in Health Promotion: Theory and Practice

Section Two: Dissemination of Practice 95

10 Shared responsibilities: black community groups, black HIV specialists and the statutory sector working together in HIV/AIDS prevention and care Davel Patel 97

11 Ageing WeIl: healthy alliances to promote the health of older people Loraine Ashton 110

12 Glasgow: a smoke-free city by the year 2000? Doreen A1clntyre 120

13 Working together to reduce suicide in the farming community in North Yorkshire Anita Hatfield 132

14 Child accident prevention through healthy alliances A1aggie Sims 142

15 Alliance in secondary care: health promoting hospitals Noreen Kickham and Annette Rushmere 152

16 Arts in health promotion: a comparative overview of two health arts alliances Helen Chambers 160

17 Communities for better health: a healthy alliance between national and local agencies Helen Howson, John Griffiths, Ann Davies 168

18 Healthy cities: a preliminary analysis Vanessa Walker 176

19 Sea, sand and safer sex: an alliance for HIV/AIDS prevention A1arlene Inman 187

20 Working in alliances: an inside story Linda Ewles 195

Author index 203

Subject index 204

List of Figures and Tables

Figures

1.1 Recognising the initial position of the key players and organisations 10

1.2 Recognising elements that determine the potential in healthy alliances 11

1.3 Understanding the organisation 13 2.1 Model of conflict-handling behaviour 23 2.2 The Gods of Management 25 2.3 The Johari window 27 2.4 Stages in team maturity 31 6.1 Perceptual cobwebbing 64

13.1 Suicide as the tip of the stress iceberg 134 15.1 The Tannahill Model 155

Tables

1.1 Powell's seven dimensions for measuring healthy alliances 8

1.2 The extended framework: the nine areas for assessing potential performance and achievements of healthy alliances 9

6.1 Agendas of main stake-holders with respect to the Recipe for Health 63

12.1 Composition of the original steering group: Glasgow 2000 122

13.1 Suicide by occupation 133

vii

The Contributors

Loraine Ashton is employed by the Health Education Authority (HEA). She currently has apart secondment to Age Concern England to devel­op the UK Ageing WeIl programme, having previously developed the consultation process and networks for this overall European health pro­gramme. She has widely researched and written on the subject of the health needs of the 50 plus sector.

Kathryn Backet-Milhurn, formerly a Specialist Development and Evaluation Officer at the Health Education Board for Scotland, is now at the Research Unit in Health and Behavioural Change in the Department of Public Health Services at the University of Edinburgh. Previously a Research Fellow at the Research Unit in Health and Behavioural Change, she has published widely on family health, health behaviours, women's health, lay concepts, health promotion and qualitative methods.

Helen Chamhers is Senior Health Promotion Specialist for Sexual Health and HIV at Bath Health Promotion Unit. Her research has centred on the role of community artists in primary care health promotion.

Ann Davies is currently Director of Communications and Operations at Health Promotion Wales, aremit which gives her overall responsibility for the Authority's media and public relations work. A member of the Institute of Public Relations, she has contributed to a number of media and communication skills training courses and has managed the Communication Skills Module in an MSc course in Health Education and Health Promotion. She retains an active involvement in the devel­opment of youth and community initiatives in Wales.

Rohin Douglas is Director of Management at the Office for Public Management. Prior to joining the Office, he was a manager of children's services in the voluntary and local government settings. This was fol­lowed by five years' experience in consultancy and academic work of the National Institute for Social Work and as Fellow of the King's Fund for six years. He is the author of a number of books, articles and training packages on organisational change in public services. Robin has consid­erable experience in the design of intra-organisationallearning, particu­larly in the area of community services. He leads the Office's work with health service organisations and is responsible for the development of management learning.

Vlll

The Contributors IX

Meg Elliott is a senior lecturer in the Department of Management at Manchester Metropolitan University, working on a range of Masters and Diploma programmes. Her particular focus involves the MSc Management by Action Learning and Research and working with organisations in the development and delivery of corporate culture change programmes.

Linda Ewles is Health Promotion Commissioning Manager for Avon Health Authority. She has worked as a health education/promotion spe­ciahst for 25 years, in the NHS, in higher education and overseas. She is the author of many published articles, most notably, with Ina Simnett, Promoting Health - a practical guide, now in its third edition and trans­lated into four languages.

Rachel Funnell is a health promotion research officer for the Wessex Institute for Health Research and Development at Southapmton University with a first degree in Sociology and now completing a post­graduate degree in Research Methodology. Research and publications include sex discrimination and the areas of alliances and participative research ..

John Griffiths was Education Advisor to the Welsh Heart Programme (Heartbeat Wales). He moved with Heartbeat Wales into the newly established Health Promotion Authority for Wales in 1987 and since then has been involved in developing work targeted at children and young people, initiatives on tobacco, alcohol and drugs for the general population and, more recently, health promotion programmes devel­oped for local authorities, workplaces and the NHS. He is currently Chair of the UK No Smoking Day Campaign Committee and has under­taken work for the World Health Organization.

Anita Hatfield is a Senior Registrar in Public Health Medicine presently attached to the Nuffield Institute for Health, Leeds University, and for­merly with North Yorkshire Health Authority. Her research and publica­tions are in the area of mental health and rural issues.

Helen Howson taught before joining the South Glamorgan health pro­motion team. In 1986 she joined Heartbeat Wales as the Nutritionist and was responsible for developing and implementing the nutrition strategy up to 1990. Since this period, she has had responsibility for major project development and delivery as Community Projects Manager for Health Promotion Wales. Over the last three years this post has changed to include greater involvement with commerce and industry as the Commerce and Economic Development Advisor. She is currently the Senior Project"Officer for Health Promotion Wales and her responsibilities include leading the Communities for Better Health initiative and develop­ing training services.

x Alliances in Health Promotion: Theory and Practice

Marlene Inman is a freelance Health Promotion Consultant and design­er of the Happy Healthy Holiday pilot project and the Sea, Sand and Safer Sex project. She was formerly the Health Promotion Advisor and District HIV Prevention Coordinator for Plymouth and Torbay Health Authority. Her particular interest is in The Health of the Nation and strategy design. She has published widely on health promotion relating to HIV prevention.

Debbie Jackson is a Specialist for the Health Promotion Service of North Cheshire, part of Warrington Community Health Care (NHS) Trust. An experienced facilitator and trainer, she has successfully developed many multi-agency alliances including the Recipe for Health.

Noreen Kickham is the Director of Health Promotion for Portsmouth and South East Hampshire Health Authority and is lead purchaser for The Health of the Nation, health promotion and health alliance activi­ty. Her doctorate research focused on the development of a framework for intersectoral collaboration in the local authority setting.

Lindsay MacHardy is the Health Service Programme Manager for the Health Education Board for Scotland. She is responsible for initiating and developing health promotion in health service settings including the trainer-training resource pack Promoting Health through Teamworking in Primary Care.

Doreen Mdntyre is Senior Health Promotion Officer in Glasgow with special ist remit as the Coordinator of Glasgow 2000, a mUlti-agency tobacco control programme. She is also a course team member on Postgraduate Certificate and Diploma programmes in Health Education and Health Promotion at University of Strathclyde. Publications include manuals on workplace health promotion, smoking policy development and smoking cessation strategy.

Sally MarkweIl is the Health for All Coordinator for Winchester. She has undertaken research into effective strategies for health promotion with­in Romanian communities. Her current research, at Wessex Institute of Public Health Medicine, focuses upon the development of tools for effec­tive alliance working. She has a background in intensive care and com­munity nursing, and was Chair of the UK Health for All Network.

Katherine Oldfield is a research assistant at the Wessex Institute for Health Research and Development. She has a second degree in Health Psychology and has been involved in projects in healthy alliance evalua­tion and investigation of the issues in asthma management . .

Davel Patel is a consultant and formally worked as a Development Officer with the National AIDS Trust (NAT). Her work conducted at NAT formed the basis of her contribution to this book. Other publica-

The Contributors Xl

tions are in the area of sexual health, community development and fem­inism, and funding the voluntary sector.

Maggie Rae is Assistant Director for the Health Commission for Wilt­shire and Bath. Her research and publications are in the areas of prima­ry ca re led purchasing, health promotion and community development models of improving health.

Annette Rushmere is a health promotion manager in the Wessex Institute of Health Research and Development in Southampton University. She is responsible for the region-wide development of pro­jects to promote workplace health, including health at work in the NHS and health-promoting hospitals in South and West Region.

Angela Scriven is Head of the School of Health at Bath Spa University College. She is Programme Coordinator for the MSc in Health Promotion and for aseries of awards in Healthcare Management. Her research interests are centred on the influence of policy on health pro­motion. She has published widely and is co-editor of Health Promotion: professional perspectives.

Maggie Sims is a Senior Health Promotion Specialist for the Bristol Area Specialist Health Promotion Service (BASHPS) with aremit for accident prevention. Her previous experience includes secondary school teaching and local government health promotion based in an Environmental Health Department.

Viv Speller has worked in health promotion in the NHS for a number of years. She has published extensivelyon practice-related issues and is currently Senior Lecturer and Director of the Health Promotion Division of the Wessex Institute of Health Research and Development in Southampton University. She leads a va ried programme of research and development in health promotion with the overall aim of improv­ing quality and effectiveness.

Vanessa Walker is Assistant Director of Quality at Mid-Kent Healthcare Trust. Her previous work includes contributing towards Little Things Mean a Lot, a soft standards project published by South Thames Region and A Framework for Action: clinical supervision in the community trust (unpublished).

Andrew Wall is a Fellow at the Health Services Management Centre in the School of Public Policy at the University of Birmingham. He was pre­viously a general manager in the NHS. He has written widely on man­agement and ethics in the health services.

Acknowledgements

Special thanks to Ann Eade and the team from Bath Health Promotion Unit for their collaborative efforts in organising the three­day national research conference which established the foundations of this book, Tina JoHy for her sterling secretarial efforts, and Derek and Imogen Fry for proofreading the manuscript.

The Thomas-Kilmann Conflict Mode Instrument, © Copyright 1974, is reproduced with permission from Xicom, Tuxedo, New York.

XlI

Introduction Angela Scriven

The process of collaboration between different professional groups in the planning and delivery of health promotion initiatives has gained considerable credence and momentum over recent years. One explanation for this growth in interest and activity is that it is now widely believed that both the goals and processes of health promotion lend themselves to interagency working. The government, in acknowledging this synergy in their White Paper, The Health of

. the Nation (Department of Health, 1992), championed the establishment of healthy alliances between the various individuals, groups and organisations that promote health.

The perceived benefits of interagency collaboration for the promotion of health are generally considered to be numerous. They include a rationalisation of resources, including skills and finances; a reduction in the duplication of effort and expenditure; a more integrated, holistic and effective approach to health promotion problems and the creation of powerful coalitions that are able positively to influence policy. Despite the belief in these benefits and the increased emphasis on interagency collaboration, there is a lack of debate and evidence of the processes that enhance or obstruct joint working and a dearth of empirical research and theory-building on questions of intersectoral collaboration in health promotion. Moreover, there is little published on the disadvantages and pitfalls of working together across agency and professional boundaries. There is, therefore, a need for an increased understanding of the problems associated with the politics, structures and management of interagency working in the field of health promotion. The overall aim of this book is to increase the understanding of what it feels like to work in healthy alliances by offering an informed insight into a number of issues relating to alliance-working, illustrations of a range of different alliance structures and an explication of appropriate evaluative processes involved in measuring the effectiveness of alliance partnerships.

Because of its focus, the book will be of relevance to all who have an interest in and a professional remit for health promotion and who

X111

XlV Alliances in Health Promotion: Theory and Practice

wish to work in alliances. This will include policy-makers, politi­cians, educators, purchasers or providers, the wide range of practi­tioners confronting the realities of alliance-working and students of the same range of professional disciplines.

The authors in this edited text have been chosen to re fleet these multiprofessional interests and bases of alliance work. The book, therefore, contains contributions from a distinguished group of academics, researchers and professional practitioners drawn from a wide assortment of settings. The list of more than 20 authors includes representation from universltles, specialist health promotion, various sec tors in the health service, local authorities, voluntary organisations and education. Between them the authors bring together an impressive array of knowledge and experiences relating to alliance developments and this is reflected in the diverse nature of the chapters in each of the two sections that make up the text. This is one of the first books that seeks to provide such a wide­ranging review of health promotion alliance work. As healthy alliances are fairly recent phenomena, the discussion presented does not seek to be prescriptive but attempts to assess the significant features of, and issues around, alliance organisation. Relatively new territory, therefore, is being mapped out. Because of this, it is antici­pated tha.t the text will act as an appropriate stimulus for future activity, participation, debate and involvement in alliance work. The overall purpose of the book, therefore, is to open up an awareness of the potential for, and the drawbacks to, working in health promotion alliances. It will undoubtedly serve as a unique rec;ord of healthy alliance practice.

The meaning of terms

Several terms can be used to denote a multi-agency, co-ordinated approach to the promotion of health. Indeed, as increasingly diverse professional groups, organisations and sectors become involved in collaborative initiatives in health and health promotion, we have what one author refers to as a 'terminological quagmire' (Leathard, 1994, p. 5). Healthy alliance is the newest addition to the list. Much of the current emphasis on collaboration in health promotion is linked to Health for All by the Year 2000 (World Health Organization, 1984). This World Health Organization (WHO) initiative has intersectoral collaboration as one of its fundamental principles. It is not surprising, therefore, that specialist health promotion units have in their remits the liaison and co-ordination of health promotion within .their locali-

Introduction xv

ties. This has resulted in well-established traditions of collaborative work at both operational and strategic levels. Moreover, aseries of international and national initiatives has attempted to translate the principle of intersectoral collaboration into frameworks for action. Healthy Cities is one such initiative and The Health of the Nation is the national strategy that reflects our government's interpretation of Ijealth for All for England. A healthy alliance, therefore, is intersec­toral collaboration by another (grammatically incorrect) name! The grammatical ambiguity of the term has resulted in some authors of this book preferring to use the term health alliances or alliances for health. You will find that, interspersed with these variations, are terms such as collaborative or interagency partnerships. For the purposes of this book all of these terms refer to the same set of structures, which can be defined as pattnerships of organisations and/or individuals that have as common purposes the enablement of individuals or communities to increase control over and improve their health. Healthy alliances can operate at different levels: including community, district, city, regional, national and international. There are examples of each of these levels in the accounts of alliance practice in the second part of the book.

The organisation of the volume

The text is arranged into two sections. The first deals with a range of issues associated with the development and maintenance of alliances. This section will provide an essential backdrop to the professional accounts of alliance practice that constitute the second half of the book. Robin Douglas offers an overall introduction to the text in Chapter 1 with a detailed analysis and critique of healthy alliance processes and structures. The chapter provides an examplar of a theoretical framework that can be used for interagency health promotion work. In Chapter 2, Sally Markwell postulates that healthy alliances, by their very nature, can result in unproductive tensions and conflict. The chapter provides an extensive and interesting exploration of the possibilities for the application of conflict theory to alliance functions. Kathryn Backet-Milburn and Lindsay MacHardy continue this exploration in Chapter 3, basing their arguments on the premise that effective alliances depend on healthy social processes. This axiom underpins the discussion and identification of the process of collaborative working that surrounded the development of a health promotion training pack for primary care. Chapter 4 focuses on one possible constraint to alliances - the contradictory nature of government policies - and examines how

xvi Alliances in Health Promotion: Theory and Practice

these contradictions may result in difficulties in alliance formation and maintenance. Alliances between specialist health-promotion units and local education authorities and schools form the basis for this analysis. Andrew Wall covers an important issue in Chapter 5, the ethical principles that can help to stabilise alliance relationships.

Meg Eliott and Debbie Jackson evaluate a soft-system approach to the development of alliances in Chapter 6. A reflective account of a health promotion partnership between various health authority agencies and leisure services is permeated with their assessment of the value of the soft-system approach. The focus of Chapter 7 is evalua­tion. Rachel Funnell and Katherine Oldfield present a framework for the development and evaluation of healthy alliances and practical advice on the setting up of evaluative procedures. The commissioning of alliances is a relatively unexplored area. Maggie Rae explains the processes that one health authority went through to identify what alliances should be commissioned in the future. Chapter 8, therefore, might wel1 provide a model for other commissioning agencies. Chapter 9 concludes the first section of the book with an assessment of the key issues relating to the future development of al1iances. Viv Speller presents an illuminating and pertinent discussion of these issues around 10 themes that relate to the organisational structure and achievements of healthy alliances.

Section Two of the book is concerned with the dissemination of practice and includes a wide variety of examples of health promotion alliance work in England, Scotland and Wales, some of which are linked to international collaborative initiatives. The real value of this section of the book is in the diversity of alliances that it covers, all of which are described by the alliance workers based on their actual experiences. These should not be seen and understood as academic expositions but as empirical records of healthy alliances. Chapters in the second section of the text, therefore, are what McLeroy et al. refer to as wisdom literature (McLeroy et al., 1994). They are contextual, based almost entirely on the impressions of participants or external evaluators or observers, and contain some anecdotal elements. Notwithstanding, these contributions are an important addition to the implementation, maintenance, operational and evaluative problems and questions explored in Section One. They provide insider perceptions that, although not necessarily generalis­able to other alliances, act as case studies illuminating the develop­mental tasks and organisation al forms that are the essence of health promotion alliances. Section Two, therefore, moves beyond academic discourse, by il1ustrating, in real terms, the politics, principles, processes and actual context of examples of alliance work. The

Introduction XVII

various alliances differ in size, type, age and character, and because of this provide very useful insights into the diverse nature of alliance practice. Between them these case studies clearly identify the factors that affect the success or failure of alliance operations. These include the personal characteristics and interpersonal competencies of the alliance members, which embrace leadership qualities, decision­making, problem-solving and conflict resolution skills. Another factor to emerge that is crucial to the successful operation of the alliances is the organisational climate. Ir is clearly important that there is an appropriate balance of power, shared goals and agendas and a commonly perceived cost-benefit to the work of an alliance. These are highly political issues. Failure to achieve consensus around these questions frequently results in alliances floundering. In addition, cohesion is probably the result of all the factors listed above being operative, but it would also appear to be a fundamental requisite in relation to alliance viability. Finally, what Section Two illustrates is that there is no typical alliance structure or life history. The alliances in this book have been formed as a response to different external problems or stimuli and have evolved in a variety of ways. Some have fairly informal structures, others are more formalised, even institutionalised. In disseminating their accounts of their alliance the practitioners demonstrate these divergent features and organisation al arrangements.

The section begins with a discussion by Davel Patel of the issues surrounding the organisational development of an alliance whose focus is the prevention of HIV infection among black groups. This is followed by Loraine Ashton's account of a nationwide alliance initia­tive relating to health promotion with older people. This work is based on a European programme that encourages effective multi­agency approaches to promoting the health of the elderly. Chapter 12 offers an account of the well-established alliance, Glasgow 2000. Doreen McIntyre reflects on the way in which health agencies, local government and voluntary organisations are working together to make Glasgow a smoke-free zone. This is followed by an account of a regional alliance. Anita Hatfield explores the actions of a multi­agency group who are developing interventions to reduce the suicide rate among farmers in North Yorkshire.

In Chapter 14, Maggie Simms critically assesses the effectiveness of child accident prevention through a healthy alliance ap-proach. Noreen Kickham and Annette Rushmere follow on with a considera­tion of alliances in the secondary care sector, focusing specifically on the Europe-wide initiative for health-promoting hospitals. A proposed model for hospital-based health promotion along with the

xviii Alliances in Health Promotion: Theory and Practice

scope for alliance-working in this setting will be examined. An unusual alliance formation is explored by Helen Chambers in Chapter 16. She considers the role of arts in health promotion and provides a critical and comparative summary of two examples of health promotion initiatives facilitated through an alliance of a·rts and health. In contrast, Helen Howson, John Griffiths and Ann Davies explore an alliance that spans national and local agencies, led by Health Promotion Wales and based on Health for All principles. Similarly, Vanessa Walker evaluates the effectiveness of the alliances established for Healthy Cities, another Health for All initiative. Marlene Inman concludes the dissemination of the different types of alliance practice by describing the work of the nationally acclaimed alliance, Sea, Sun and Safer Sex.

It is left to Linda Ewles to bring Section Two, and the book~ to its overall conclusion. This is an experienced and seasoned health promoter at her best! She offers a highly personal, honest and reflec­tive account of her experiences of alliance-working, documenting the pitfalls as well as the pleasures. This is a fitting end to the second half of the text, which, in the main, has offered accounts of successful alliance practices written by enthusiastic and committed alliance members. It is also a suitable end to the book, because it challenges the reader to look beyond the hype and the rhetoric surrounding alliance work and face the realities of working collaboratively for health promotion.

Finally, there is still much to be researched and understood about the formation, implementation, operation, outcomes and termination of health promotion alliance work. What this edited text offers is a shared contribution to the body of work on this theme. It is intended to raise the issues around alliance-working and offer a snapshot of some of the alliances that have been formed to promote health. In doing this the authors hope their contributions will act as a stimulus and guide to future practice.

References

Department of Health (1992) The Health of the Nation. London: HMSO. Leathard, A. (1994) Going Inter-professional: working together for health and

welf are. London: Routledge. McLeroy, K.R., Kegler, M., Steckler, A. et al. (1994) Community coalitions for

health promotion: summary and further reflections. Health Education Research 9(1): 1-11 (editorial).

World Health Organization (1984) Health Promotion: a discussion document on the concepts and principles. Copenhagen: WHO.