Mapping public health networks Stephen Abbott and Amanda Killoran
This document is also published on the Health Development Agency website at www.hda.nhs.uk/evidence
Copies of this publication are available to download from the HDA website (www.hda.nhs.uk). Health Development Agency Holborn Gate 330 High Holborn London WC1V 7BA Email:
[email protected]
ISBN 1-84279-245-8
© Health Development Agency 2005
About the Health Development Agency The Health Development Agency (www.hda.nhs.uk) is the national authority and information resource on what works to improve people’s health and reduce health inequalities in England. It gathers evidence and produces advice for policy makers, professionals and practitioners, working alongside them to get evidence into practice.
ii
Contents
Acknowledgements
iv
Glossary
iv
Summary
1
A profile of public health networks
1
The context for public health network development
2
The process of setting up public health networks
2
Content and mechanisms of public health networks
2
Desired outcomes and network impact
3
The future
3
Policy context
4
Networks
4
About this report
6
Methods
6
Analytical framework
6
Findings
7
A profile of public health networks
7
The context for public health network development
9
The process of setting up public health networks
11
Content and mechanisms of public health networks
11
Desired outcomes
14
Discussion – the future?
15
References
18
Appendix: Research instruments
19
iii
Acknowledgements Thanks are due to all those who agreed to talk to the authors about public health networks. Stephen Abbott gratefully acknowledges the support of the following, who were members of his research support group: Ros Bryar, Martin Caraher, Yvonne Carter, Jenifer Chapman, Anthony Kessel, Roland Petchey, Sara Shaw. Amanda Killoran is grateful for the advice provided by the reference group that oversaw the full project. The work was commissioned by the Health Development Agency.
Glossary CPD DPH FPH HAZ HImP HPA LSP NHS PCT PHN R&D RDPH SHA
iv
continuing professional development director of public health Faculty of Public Health health action zone health improvement programme Health Protection Agency local strategic partnership National Health Service primary care trust public health network research and development regional director of public health strategic health authority
Summary
As part of the programme of NHS modernisation and reorganisation, public health services have been reconfigured. At regional level, the public health function is integrated within the nine government offices. The 302 primary care trusts (PCTs) are each expected to have a public health team, led by a director of public health (DPH). Strategic health authorities (SHAs) have the remit for monitoring their performance. Within the area of each SHA, public health networks (PHNs) are expected to ensure that the limited specialist public health expertise and resources are efficiently and effectively deployed to support PCTs. Health protection services are now delivered by a separate Health Protection Agency. The Health Development Agency (HDA), in conjunction with City University, undertook a study to investigate the nature and pattern of development of public health networks nationally, to help inform their further development. Networks are an important form of inter-organisational structure within the NHS, a means for collaboration between different players towards action on common goals. The creation of clinical networks and research networks are examples. Networks provide an alternative to managing through hierarchies, and can achieve collaboration by creating opportunities for the different players to identify mutual benefits and ‘win–win’ situations. Networks reflect the importance of relationships and partnership working in public health, and offer an opportunity to share resources and competencies across organisations and specialisms. Networks do, however, have possible disadvantages: significant investment is required to create and maintain them; they may be slow to deliver identifiable outputs; and they may experience tensions between network integration and the local interests of members. And whereas networks ideally are voluntary, PHNs are compulsory.
Mapping public health networks
The aim of this study was to explore the role and characteristics of PHNs, their process of development, and factors influencing progress. The investigation was based on semi-structured telephone interviews with DPHs (or nominated other/s) in all 28 strategic health authorities across the nine regions. In three of the regions, additional telephone interviews were conducted with a broader range of stakeholders.
A profile of public health networks There are different levels of public health networking within any region. Public health networks operate at least at the following four levels: • A single PCT – public health professionals engaging with each other and with a broader range of professionals and agencies • A group of PCTs (often covering previous health authority boundaries and/or coterminous with local authority boundaries) – public health professionals engaging with each other and with other professionals and agencies • Throughout the strategic health authority – public health professionals within PCTs in the SHA area engaging with each other and with other professionals and agencies • At regional level – public health professionals engaging across a region with each other and with other professionals and agencies. Respondents expressed different views about the purpose of PHNs, their value and potential benefits. PHNs were widely viewed as ‘the means of doing public health business’ and delivering on the PCTs’ agenda. They were also viewed as the key mechanism for supporting, developing and extending public health capacity and resources locally. At this stage they were thought to have a less direct role in tackling health inequalities and in linking to the wider health agendas of local strategic partnerships (LSPs).
1
Various doubts and reservations were also expressed about the rationale and potential of PHNs. For example, a minority viewed them as a fudged response rather than a workable solution to the fragmentation of a limited public health resource across PCTs. Different public health functions and tasks needed to be done at different levels, but as yet it was unclear which level would be best suited to which function. There was a tension between the immediate demands of the PCTs’ priorities and the need to understand and commit to a shared agenda. Public health networks were acknowledged as a significant and challenging shift away from traditional ways of working. A number of respondents stated that much would depend on a change in professional attitudes, as well as processes and structures to support multi-disciplinary and multi-agency networking. A minority were also sceptical about whether PHNs could significantly increase the overall limited capacity within public health.
The context for public health network development The turbulence of the NHS reorganisation as a result of Shifting the Balance of Power (Department of Health, 2001) clearly influenced the nature of network development. The history and capacity of the public health function locally, prior to the implementation of these changes, were important factors influencing progress. In many areas, limited capacity, new staff and unfilled posts meant that early progress was difficult. The requirement for PCTs to develop and deliver local delivery plans and targets was the dominant driver for PHN formation. The respective roles of regional directors of public health (RDPHs) and SHAs influenced PHNs in a number of ways – some positive, some negative. Where there had been early and rapid progress, this was related to a number of factors: preparatory work in anticipation of organisational change; the commitment and leadership of key individuals (eg DPH, PCT Chief Executive); clarity of focus; identified resource for investment in management capacity (eg business manager, administrative support, designated public health consultant time); and existing, well established patterns of networking and partnerships.
The process of setting up public health networks The study provided an early snapshot of the national development of PHNs, taken in March/April 2003. The
2
majority of PHNs were at a formative stage. The NHS restructuring, and the professional/personal changes that resulted, meant that progress had been gradual. In some cases, tensions and local politics needed to be worked through. A small minority of PHNs were at a more advanced stage of development, building on existing networks or early preparatory work. The process of setting up PHNs was typically collaboration between RDPHs, SHA DPHs, and PCT chief executives and DPHs. The formative stage involved discussions between these different stakeholders, and wider consultations. A bottom-up approach and grassroots ownership were thought to be the most appropriate way forward.
Content and mechanisms of public health networks The core stakeholders in most networks were based in the NHS, and comprised the public health function across the PCTs. However, the majority of respondents regarded potential membership of the network as comprising at least three groups of stakeholders: • The core of public health professionals – those with defined public health roles, including public health specialists, health protection/communicable disease specialists, health promotion personnel, and information specialists • A wider core of public health practitioners – including health visitors, school nurses, environmental health officers • A wider group of individuals – from a range of organisations with a recognised role in and contribution to public health, including diverse roles within local authorities, voluntary and community organisations. While the expressed intention was to adopt an inclusive approach, the need to limit membership initially was important in order to make early progress. However, most networks were undertaking activities at different levels, and did engage a broad range of professionals, groups and partnerships. Effective governance arrangements were viewed as vital. Many networks had, or were intending to establish, a network board or steering group as the focus of the network decision making and accountability. Representation by chief executives was critical to legitimise the network as a shared resource. However, PCT chief executives’ awareness and commitment to PHNs appeared variable, although it was increasing.
Mapping public health networks
Many respondents stated that ‘networks don’t just happen’, but need to be resourced and managed. The operation of the networks required an infrastructure, and the appointment of a business manager and administrative support were prerequisites for continuing progress. In a number of cases, public health consultants, registrars and specialists had designated a proportion of their time to providing leadership. Some networks had defined the time contributed by public health staff to the PHN. Others took a less formal and more flexible approach based on goodwill. A small number of PHNs saw themselves as centred on shared services that were already funded by a number of PCTs. These services included health information, library facilities, and specialist services such as pharmaceutical advisers. Most PHNs were still developing and agreeing their programme of work. Only a minority were already implementing the functions and tasks covered by their workplans. There was consensus that continuing professional development (CPD) was a key task, but there was less agreement on other priorities. The scope of functions and tasks covered by work/business plans was: • • • • • •
• • • •
Network governance, development and management Health information and knowledge management Health protection and communicable disease control Health surveillance and auditing; health impact assessment Contributions to planning and partnerships regarding national and local priorities and targets Specialist public health advice and/or management regarding prevention programmes, national service frameworks, clinical networks Advice on specialist commissioning Clinical governance and clinical audit Training and professional development and appraisal Workforce planning.
The designation of lead people to take forward work in particular areas was important. Many regarded making links with other partnerships, networks and groups as a central task. Links were being made at different levels, and for different purposes. In some cases the PHN saw itself as the hub, taking forward priorities by working through extensive links with other networks and partnerships. In this way PHNs could, it was hoped, manage a broader and more strategic agenda as well as public health operational business.
Mapping public health networks
Desired outcomes and network impact In general, PHNs were expected to be involved in operational business as well as more strategic and longer-term work. But while the need was recognised to demonstrate the added value of networks, there was little clarity about what this might mean, or how it could be measured and judged. The PHNs’ contributions to NHS targets and the wider public health agenda were implied by the workplan outputs, rather than articulated. Some consideration was being given to more systematic approaches to defining and managing performance, eg use of a balance scorecard approach or total quality management was being examined by the London networks. Continuing professional development was viewed as the primary mechanism over the longer term for increasing networks’ capacity to cope with the significant PCT public health agenda. Delivery of the immediate ‘must dos’ appeared to be regarded as a prerequisite before many wider public health issues could be addressed more systematically.
The future The development of PHNs is at an early stage, and it is clear that they will continue to develop and change. A range of national and local contextual factors have influenced the nature and pace of their development. However there was some indication that, over time, many PHNs may come to resemble each other more closely, and that many (but not all) apparent differences reflect the current stage of organisational development rather than enduring and substantial differences. It is clear that PHNs are in no sense a quick fix. Informants had mixed feelings about their likely success in solving the problems of capacity and fragmentation in the public health workforce. Conditions for their development have been less than ideal – indeed there is an apparent paradox. On the one hand PHNs are a response to a lack of capacity in public health and yet, at the same time, they cannot function effectively without adequate resourcing. It is possible that they will in time make an effective contribution to the delivery of the PCTs’ public health agenda, but at present such an outcome is uncertain without further support and nurturing.
3
Policy context
Shifting the Balance of Power: The Next Steps (Department of Health, 2002b) sets out arrangements for the national reconfiguration of the public health function. Important features of the new system are: • Integration of the regional public health function in the nine government offices • Establishment of public health teams in each primary care trust (PCT), led by directors of public health (DPHs) • Creation of public health networks (PHNs) within strategic health authority (SHA) areas to ensure that specialist functions are available to PCTs – the Regional DPH is responsible for overseeing the development of PHNs, and SHAs have a performance-monitoring role.
PHNs should help to maximise the utility of scarce resources, provide peer support for public health practitioners, and help sustain a sense of professional identity. A key task is the effective integration of health improvement and health inequalities work within LSPs, community strategies, local public service agreements, and local government scrutiny of health services.
The establishment of the new Health Protection Agency (HPA) in April 2003 has involved the reorganisation of the health protection function nationally and locally.
The term ‘networks’ has a variety of meanings. Three usages have particular relevance to public health: networks can refer to an organisational type; a delivery mechanism for a particular service or function; or a form of interorganisational collaboration.
The development of a multi-disciplinary public health workforce is now being actively promoted as central to the delivery of the new system. The Faculty of Public Health (FPH) is establishing a register of non-medical public health specialists who can demonstrate competence in the 10 key areas of public health work. It should also be noted that there are a number of public health and health promotion networks operating at European and international levels. These include Eurohealthnet, International Union of Health Promotion and Education, and European Public Health Alliance. These networks cover a range of functions including advocacy and sharing of experience. The public health community attaches considerable importance to the creation of PHNs (Shaw et al., 2002). The Faculty of Public Health (formerly Faculty of Public Health Medicine; FPHM, 2001) defined PHNs as:
4
‘Linked groups of public health professionals working in a coordinated manner across organisations and structural boundaries who will have a common agenda to promote health improvement and reduce inequalities.’
Networks
A well known typology of business organisations (Thompson et al., 1991) suggests that hierarchies, markets and networks are the three major organisational types. When the internal market was introduced into the NHS, these types were used to illustrate and understand the changing face of the NHS (Flynn et al., 1995; Ferlie and Pettigrew, 1996). The idea of networks was used to highlight how NHS organisations worked together, rather than in competition. Clinical networks aim to coordinate local outputs with respect to particular disease areas. The best known example is the national introduction of cancer networks (Kewell et al., 2002), but there are many other local examples, eg East London and the City HA (ELCHA, 2002) identifies seven local clinical networks in one former health authority area. Research networks provide an example of the organisation and delivery of a particular function across organisational boundaries. Mapping public health networks
Networks may be understood with reference to the range of broader terms used by the government to promote collaboration in pursuing policy goals across the public sector: partnerships, inter-agency collaboration, joinedup working, seamless services, etc. (Powell and Exworthy, 2002). Partnerships are viewed as the essential mechanism for engaging the diverse expertise and resources of many organisations to achieve both organisational and shared objectives. Kickert and colleagues propose network management as an opportunity to address complex problems that demand collaborative action by many different players, and where trust and diplomacy are central (Kickert et al., 1997). Organisations recognise the need to pursue a strategy of ‘collaborative advantage’ to create synergies and achieve organisational objectives better that they could alone (Huxham, 1993). Much of the literature indicates that the development and effective functioning of such collaborative arrangements depends on supportive conditions (eg Stewart et al., 2002). Insofar as the role of public health networks is to support PCTs in their public health tasks, they do not include the second type of network described above – the direct delivery networks such as cancer and other clinical networks. However, the other two types of network described above do appear relevant to public health networks.
may become talking shops – ‘all process and no output’ (Ferlie and Pettigrew, 1996). Networks require a nonhierarchical management style which leads and influences the relationships between players, creating mechanisms and opportunities for players to identify mutual benefits and ‘win–win’ situations (Kickert et al., 1997). This certainly contrasts with the prevalence of a much more hierarchical style in much of the NHS (Ferlie and Pettigrew, 1996; Kewell et al., 2002). Networks are likely to experience tensions between the drive for network integration and the local requirements of the organisations represented within them (Shanks, 2001). Above all, networks outside the NHS presuppose ‘the spontaneous, discretionary and above all voluntary engagement which gives network relationships their energy and creativity’ (Pedler, 2001); whereas the formation of PHNs, as with the cancer networks, was required by the government. As a solution to problems of dispersal and critical mass in the public health workforce, the notion of networks suggests a mixture of opportunities and threats. This report explores how far the developing reality of PHNs reflects this mixture, and therefore their potential contribution to the public health function and agenda.
Networks have some features that are particularly relevant to the public health function. Social relationships underpin network activity, and this social aspect is clearly important for a specialist function with a strong sense of professional identity and solidarity. Networks offer individuals and organisations the opportunity to access complementary resources or competencies (Harvey et al., 2000), which is critical given that many individual PCT public health teams lack certain specialisms. Expertise is limited and the concept of PHNs rests on the assumption that individual PCTs cannot go it alone to achieve their public health objectives. Also, Ferlie et al. found in research conducted in 1994–95 (Ferlie and Pettigrew, 1996) that public health departments in health authorities were already active networkers, establishing and maintaining links and joint working with a range of organisations inside and outside the NHS. However, the literature also directs attention to possible disadvantages of networks in the current situation. For example, networks require significant investment for their establishment and maintenance (Ferlie and Pettigrew, 1996; Harvey et al., 2000; Pedler, 2001). Public health networks may therefore absorb rather than unlock resources, at least in the short and medium term. There is a risk that networks
Mapping public health networks
5
About this report
The HDA is working in collaboration with the Department of Health and the FPH to support the development of PHNs. As part of this programme, the HDA and City University investigated the nature and pattern of development of PHNs nationally. The aim was to explore, at this early stage: • Role and characteristics of PHNs • Development and progress of PHNs • Factors that help or hinder progress of PHNs.
Methods Data were gathered by two methods: • Semi-structured telephone interviews with key PHN players across the country • Analysis of documents, including business plans provided by interviewees. The research comprised two distinct but complementary workstreams, each of which used the above two methods. The first workstream covered six government office regions, involving interviews at the level of SHAs. All DPHs and/or their nominated representatives were interviewed (including four public health specialists with a remit for PHNs, and three local PHN chairs). In total, 30 informants were interviewed. In the second workstream, key players in each PHN in the remaining three government office regions were interviewed, and also the corresponding three RDPHs or their representatives. SHA DPHs were asked to suggest the names of key players, who were then asked to take part. The three government office regions for the second workstream were chosen by the HDA to reflect diversity in PHN formation, and were the North West, East Midlands, and East of England (ie East Anglia). In all, 27 interviews were carried out in this workstream, a more detailed report of which is available at www.smd.qmul.ac.uk/gp/hsr/downloads/index.htm#mapping
6
Both interviewers took detailed notes during the interviews. The interview schedule is reproduced in the Appendix. Those interviewed included: PHN leads; PHN coordinators; PCT DPHs; PCT public health lead; PCT chief executives; health promotion specialists; health informatics specialist; HAZ coordinator; academics; SHA DPHs; and RDPHs or representatives.
Analytical framework Pawson and Tilley (1997) argue that the realistic evaluation of policies and programmes should seek to understand and define the relationship between context, mechanisms and outcomes. In the case of PHNs, the early stage of development at which the interviews took place meant that, for example, few mechanisms in Pawson and Tilley’s sense of ‘actions to effect change’ had been planned or articulated, let alone implemented. Instead, interviewees were preoccupied with the process of creating PHNs, and of establishing the network content (structure, membership, terms of reference, and so on) which would underpin the future planning and implementation of such mechanisms. We have therefore extended Pawson and Tilley’s framework to include the concepts of process and content, borrowed from Pettigrew et al. (1992). Thus the analytical framework is: context; process; content and mechanisms; desired outcomes.
Mapping public health networks
Findings
Findings from both workstreams are presented together. First, we present a profile of PHNs as they had developed by the first quarter of 2003, and how their purpose and rationale were viewed by respondents. Next, we discuss the context in which PHNs were being developed; the process whereby this was being done; their content and mechanisms; and their desired outcomes. We conclude with a discussion which suggests elements of a common framework for PHNs, and considers the extent to which their development reflects the characteristics of networks identified in the literature and summarised above. Respondents’ views were diverse, and this diversity did not reflect either differences in professional role or training, or geographical location. In the light of the ongoing development of PHNs in an ever-changing context, respondents were often tentative and provisional in offering their opinions. The result was an absence of consensus, with relatively few strongly held or definitive views being expressed.
A profile of public health networks Although the Department of Health (2002b) suggested a single PHN model (based on the SHA), we found PHNs operating on at least four levels: • A single PCT – public health professionals engaging with each other and with a broader range of professionals and agencies • A group of PCTs (often covering previous health authority boundaries and/or coterminous with local authority boundaries) – public health professionals engaging with each other and with other professionals and agencies • Throughout the strategic health authority – public health professionals within PCTs in the SHA area engaging with each other and with other professionals and agencies • At regional level – public health professionals
Mapping public health networks
engaging across a region with each other and with other professionals and agencies. Table 1 sets out the configuration of PHNs across England at the time of the research, providing a national snapshot at their early stage of development. Nationally, most appeared to be at the formative stage; however there were a number of well established and developed public health networks, such as South Yorkshire and Cheshire and Merseyside.
The concept and rationale of public health networks Respondents held different views about what PHNs meant, their value and their potential benefits. Public health networks were viewed variously as: • A way of doing public health business • A mechanism for delivering PCTs’ agendas, priorities and targets (one PCT alone was unlikely to have the expertise or capacity to deliver) • A way of maintaining and/or re-establishing the public health function of the previous health authority • A source of mutual support and focus for professional development for public health practitioners • A way of helping to develop wider networks at PCT level – this should be the basic building block for health improvement and tackling health inequalities. The first two of these were the responses most commonly offered. The role of PHNs in tackling health inequalities, and the need to link to wider health agendas via LSPs, were less frequently cited. Informants often perceived PCT agendas as more concerned with the delivery of NHS targets and priorities than with broader participation in multi-agency agendas. Public health networks had been formed because they were compulsory, but respondents did not necessarily think that
7
Table 1 Public health network profile Region
SHA
Scope of PHN
North east
Northumberland, Tyneside & Wear
6 PCTs, SHA, link to HAZ, HDA
Durham & Tees Valley
10 PCTs, SHA, link to HAZ, HDA
Greater Manchester
14 PCTs, SHA
Cumbria & Lancaster
13 PCTs, SHA; includes 1 local PHN based on 3 PCTs
Cheshire & Merseyside
15 PCTs, SHA, link to HAZ.
North & East Yorkshire & Northern Lincolnshire
Developing: 15 PCTs, SHA
West Yorkshire
SHA promotes local PHNs, eg pan-Leeds ‘managed’ PHN of specialist PH staff (5 PCTs), HAZ part of the network
South Yorkshire
SHA-wide (PCTs in 4 ‘health communities’) with links to other networks and forums, eg specialist commissioning
North west
Yorkshire and Humber
West Midlands
East Midlands
London
South east
South west
East of England
8
North Staffordshire South Staffordshire
4 PCTs, including communicable disease team, linked to health promotion team
Birmingham & Black Country
Pan-Birmingham (4 PCTs and HPA), link to local authority, and city-wide partnerships
Worcestershire & Hereford
3 PCTs and county-wide public health posts
Coventry & North Warwickshire
4 PCTs
Leicestershire, Rutland, Northants
9 PCTs
Trent
11 PCTs organised as 5 PHNs covering former health authorities; 2 likely to merge
North east
Developing: 8 PCTs, SHA
North central
Developing: 5 PCTs, SHA
South west
5 PCTs (all public health people), including Health Protection Agency, link to Public Health Observatory
North west
8 PCTs, SHA
South east
6 PCTs, SHA, academic units, link to HAZ
Hampshire & Isle of Wight
10 PCTs; emphasis on public health CPD
Surrey and Sussex
15 PCTs; with local networks developing
Kent & Medway
9 PCTs, aims include support to individual PCT, wider network development
Thames Valley
3 PCT-based county PHNs and 1 pan-Thames Valley network including Public Health Resource Unit, Oxford
South west peninsula
11 PCTs organised as 2 county-based PHNs for Cornwall and Devon, and an SHA-wide network with emphasis on CPD
Avon, Gloucestershire, Wiltshire
12 PCTs organised as 3 county PHNs
Dorset & Somerset
9 PCTs organised as 2 county PHNs; possibly 1 pan-Dorset & Somerset, aims including support to individual PCT wider network development
Cambridge, Norfolk and Suffolk
17 PCTs organised as 3 PHNs based on old health authorities/counties
Essex
13 PCTs, SHA
Bedfordshire and Hertfordshire
11 PCTs, SHA
Mapping public health networks
they were a good solution to the problems of public health fragmentation. Only a few were clearly negative, thinking that PHNs were a smokescreen for PCT underfunding of public health work. Many, however, were unsure. One PCT chief executive said: ‘Public health people would like to have thought through what was needed to be done at what level, rather than be told to have a network. We are not assuming that the network is the right level.’ One coordinator pointed out that: ‘We were networking anyway, so the network has been slightly disruptive.’ A PCT chief executive noted: ‘Good work is being done by PCTs, for example with local authorities. We might not gain from this being lifted to network level. Perhaps networks should be smaller and join up when necessary. What should be done at what level hasn’t been thought through for every issue.’ This theme frequently recurred in the interviews. In particular, different sorts of public health work would require work at different levels, in different groups, and with different partners: eg commissioning acute hospital care, or contributing to road accident prevention schemes. The existence of a PHN did not offer an easy way to decide such matters. Other areas of doubt included: • A top-down approach was inappropriate; people needed to explore and build on what worked locally • Tensions between the perceived need for a structured approach to managing a PHN (governance structures and workplans) and the wish to foster organic development • Tensions between the ‘professional club’ approach (meeting the needs of public health professionals) and a business approach (geared to delivering ‘must dos’) • Difficulties in demonstrating the benefits and outputs of PHNs • Tensions between the potential self-sufficiency of larger PCTs and the greater dependence on the PHN of smaller PCTs. Public health networks were acknowledged as a significant and challenging shift away from traditional ways of working and management within public health. The traditional, centralist management model was no longer appropriate. A number of respondents stated that much would depend on change in professional attitudes, as well as processes and structures, to support multi-disciplinary and multi-agency
Mapping public health networks
networking. Some respondents were sceptical about whether PHNs could significantly increase the overall limited capacity within public health.
The context for public health network development
NHS reorganisation A major contextual issue was the turbulence of the NHS reorganisation as a result of Shifting the Balance of Power (Department of Health, 2001). Virtually all individuals interviewed were in either new roles, or new organisations, or both. Informants reported that some staff were disappointed not to get the post of their choice, and this had delayed engagement with new structures and processes. In many cases there had been delays and uncertainties before new jobs had been agreed. In most areas there was insufficient public health capacity; there were many ‘single-handed DPHs’ (those working without the support of other public health consultants/ specialists), and some posts remained unfilled. Most PCT DPHs reported being drastically overstretched. There were many DPH vacancies, and many of those in post lacked qualified public health colleagues. This affected the ability to participate in PHN activity. ‘When new work comes, everyone ducks’, said one. ‘I can barely manage in my own patch, I can’t contribute to something bigger’, commented another. Informants pointed out that DPHs’ corporate duties for the PCTs meant that they could do less direct public health work. It was recognised that without non-medical public health specialists, the workforce problems would be even greater. The work of the FPH to provide a revised framework for training and qualification of a multi-disciplinary public health workforce was therefore regarded as important, being critical to the expansion and strengthening of local public health capacity. Some public health professionals were still mourning the loss of the cohesion formerly experienced in public health departments in health authorities. For example, many spoke of feeling isolated now that they worked alone, or in much smaller teams. Others felt that the period of mourning was over for them and their colleagues, and that they were able to embrace the future.
9
In a number of instances, the merging of old health authorities into new SHAs were perceived as ‘forced marriages’. For example, one SHA combined a deprived metropolitan area with a county perceived (not entirely accurately) to be very affluent and unchallenged by urban deprivation. Elsewhere, SHAs comprised two health authorities with very different traditions of delivering public health, health promotion and/or health information. These mergers could sometimes be tense. One respondent reported that disputes about merging different service models were delaying progress. On the other hand, one respondent reported that the determination to be polite, and not to hark back to the recent past, was preventing the PHN from taking important decisions. A number of respondents perceived an unhelpful lack of clarity about the respective roles of RDPHs and SHAs. A number of respondents felt that SHAs should have a role in supporting the development of PHNs, as individual PCT DPHs were snowed under with work, or not in post. Strategic health authority respondents emphasised that their role had to be as partners (or observers or facilitators), and that a topdown approach was inappropriate, although one respondent said that simply ‘being told to get on with it’ was helpful. A particular source of turbulence was the formation of the Health Protection Agency (HPA) on 1 April 2003 (Department of Health, 2002a). This turbulence derived partly from the usual issues of organisational change, such as individual uncertainty about new roles, career options, relocation, etc. But there were other concerns. Some PCT DPHs reported that they missed the opportunity to confer in person with HPA colleagues on health protection issues. Although PCT DPHs were expected to be on call for health protection, some felt less than competent in an area that was no longer their responsibility. Others pointed out that former colleagues, now in the HPA, had other areas of expertise than health protection, eg leading on screening programmes; these were now lost to PCTs and PHNs, which were left with the task, but with insufficient expertise. Several respondents said that the boundaries between HPA and PCT responsibilities had not yet been clarified locally.
Local geography and history As demonstrated in Table 1 (page 8), different solutions have been found to the challenge of organising a PHN over a wide geographical area. Some decided they should cover the former health authority area; others followed government guidance in creating a PHN at SHA level.
10
The local history of collaboration between key stakeholders was also important. For example, in a number of areas with health action zones (HAZs), PHNs had been able to build on well established inter-organisational working on priority areas. Elsewhere, concurrent changes in HAZ funding, in combination with the lack of coterminosity between HAZs and PHNs, meant that HAZs had not been an important factor. However, in one case HAZ money had been used to fund a coordinator to set up the PHN over an area far wider than the HAZ. Most respondents mentioned numerous groups, meetings and networks that already existed: these might be focused on needs (eg neighbourhood renewal); services (eg shared use of acute hospitals or therapy services); or professions (eg health promotion). Public health networks needed to relate to and work with these groups, and in some cases PHN events allowed time for meetings of particular professional groups. Public health networks are, in fact, being developed in the context of a plethora of already existing networks and collaborations. As one PHN document puts it: ‘We are building on a “brown-field” site not a “greenfield” site. There were networks. There are networks. People will develop relationships, contacts and networks. The task is to use this realistically to our advantage. We need to connect with networks, and link networks together. We need to network networks.’
Primary care trusts There was complete agreement that it was the function of the PCTs to lead local public health activity, and that the function of PHNs was to support them in doing so. Not unexpectedly, there were reservations about: • How far PCTs were willing to prioritise public health given the range of other targets they had to meet • PCTs’ understanding of public health as something wider than ‘just focusing on the national service frameworks’ • PCTs’ ability and willingness to fund adequate public health departments • PCTs’ willingness to devolve resources and responsibilities to PHNs. ‘Buy-in’ by PCTs, particularly chief executives, was regarded as vital in order to legitimise the PHN as a common resource to which all PCTs had to contribute, to gain benefits. The availability of funding to support the PHN’s management and administration was a major factor affecting progress.
Mapping public health networks
In general, relationships between public health personnel and PCTs appeared to be reasonably good. In one case, it was reported that: ‘The network has made a real difference to communications between PCTs and the public health community.’ Most PCTs had been willing to fund PHNs in the short term, but this was regarded as provisional and dependent on goodwill at this stage; PHNs would have to prove their worth to PCT chief executives if they were to continue. A few respondents noted that the PCTs’ wish for autonomy, eg in controlling resources, could cause disagreement. In one area, the public health community had wanted the PHN to continue the work of the previous health authority public health department on a shared services basis, but PCT chief executives had insisted that the public health function belonged to PCTs, and should be led by them.
The process of setting up public health networks The process of setting up PHNs was typically a collaboration between RDPHs, SHA DPHs, PCT chief executives and PCT DPHs. All of these had an obvious stake in the outcome, and it would have been unwise not to collaborate. Discussions about how PHNs should be formed took place in a variety of groups and meetings, in parallel with the emergence of relevant government guidance. Often, a stakeholder event was held to discover what those not hitherto included in discussions thought about, and hoped for from, PHNs. In most cases, PCT DPHs appeared to have worked together. In some areas, however, individual DPHs had undertaken preliminary work in anticipation of the changes; sometimes this was to ensure that existing pre-PHN arrangements which were highly regarded survived the reorganisation. The progress of the PHN had consequently been more rapid. For the most part, RDPHs and SHA DPHs had avoided leading from the front. Although they were charged with ensuring PHNs were set up, they were keen to promote bottom-up ownership of local arrangements. There were some examples of something more proactive: one RDPH had given a clear steer that PHNs should include non-NHS personnel from the start; an SHA DPH had ‘kick-started’ one SHA-wide PHN, but then ‘let go’. In general, progress does not appear to have been rapid, and many respondents emphasised that PHNs are still in their early stages. One person thought that the requirement to create a PHN had resulted in a hurried process; in particular,
Mapping public health networks
discussion had focused on its form, rather than first deciding its functions. This seems to have been true elsewhere, to judge from the lack of consensus about what, apart from continuing professional development (CPD), the core business should be (see page 14). A few PHNs appeared to have made slower progress than expected because of ‘politics’ – tensions between PCTs; or between public health professionals; or between public health professionals and PCTs; or between different health economies. In contrast, there were a number of examples of well established and developed PHNs where investment in management and administration support enabled more rapid progress.
Content and mechanisms of public health networks
Membership Primary care trusts and public health professionals were the main stakeholders in the majority of PHNs. Strong leadership and commitment by PCT DPHs were felt to be vital. However, significant competing demands on time could undermine this commitment, particularly where, as was common, there were limited senior public health staff. Other core stakeholders included the SHA and the HPA. Consequently, the core stakeholders in most PHNs came from within the NHS, and centred on those staff comprising the public health function across the PCTs. In some cases membership also included representatives from the local workforce development confederation, public health observatory and Health Development Agency, local authorities and universities. However, such links were not typical. Most respondents regarded potential membership of the PHN as comprising at least three groups of stakeholders: • The core of public health professionals – those with defined public health roles, including public health specialists, health protection/communicable disease specialists, health promotion personnel, and information specialists • A wider core of public health practitioners – including health visitors, school nurses, environmental health officers • A wider group of individuals – from a range of organisations with a recognised role in and contribution to public health, including senior managers, and with diverse roles within local authorities, voluntary and community organisations. Most reported that the first group formed the majority of PHN members, with some interested representatives from
11
the other two groups also attending: health visitors and environmental health officers were most often mentioned. However, these groupings were not universally agreed; some excluded health promotion and information personnel from the first group, while others excluded those not working at the level of consultant. Many thought that PHNs should begin by being restricted to the first group, with a view to expanding later. A common reason for this was that the first task was to make public health practice safe, which was the business of public health professionals; only then should they look to include a wider range of partners. There was a fear that too broad a group would lose focus. One PHN member said: ‘If you are too inclusive, you can’t address all the agendas in one day.’ Another had found that a membership of over 100 was already large enough for available administrative resources to handle. A third stressed that an SHA-wide PHN was the wrong organisation to be involved in the detail of partnership work: ‘The multi-agency work should be local, else it all gets too big.’ Others thought PHNs should be as inclusive as possible from the start: ‘If you don’t get people in at the start, they won’t get in at all.’ In one area where there was a very strong tradition of partnership, non-NHS personnel had felt aggrieved not to be included from the outset. There was no support for the view that PHN membership should always be restricted to public health professionals within the NHS. Most PHNs were, in fact, undertaking collaborative activities at different levels with a broad range of professionals, groups and partnerships.
Structure Many respondents stressed that if the PHN was to have sufficient ‘clout’, generate commitment and operate effectively, there needed to be effective governance arrangements. Most PHNs already had, or planned to have, a steering group – a group outside the PHN but to which it was to some extent accountable (as distinct from an internal management team). Almost all the steering groups included PCT DPHs, and chief executives were often included (some respondents emphasised the importance of their inclusion).
12
There was less frequent representation from SHAs, RDPHs, the HPA, etc. In most cases terms of reference for these steering groups had been, or were being, developed. A number of PHNs had set up standing sub-committees, usually around topics such as health promotion, health information and intelligence, health protection and CPD. Such sub-committees might well include a wider range of professionals and agencies than did the PHN itself. Most PHNs held regular meetings. These often comprised or included CPD events, and some found space to include other meetings, eg of particular professional groups. It was hard to give meetings broad appeal on the one hand, and a clear focus on the other: one SHA-wide PHN reported that: ‘Meetings are very well attended, so they tend to be unproductive’, – that is, large meetings may fail to make decisions and action plans. A few PHNs intended to have no regular meetings at all, because of either long travelling times or the prior existence of a multiplicity of meetings; their activity would be primarily web-based.
Management and leadership Numerous respondents stated that ‘networks don’t just happen’, but needed to be resourced and managed as an inter-organisational function. Many PHNs had created a coordinator post, though the formal title varied in some cases. Others invested leadership in a public health professional. The degree of engagement varied: one PCT DPH was contracted for half of the week to the PHN, while another professional lead ‘fitted it in with my day job’.
Service provision A minority of PHNs saw themselves as centred on ‘shared services’ – services shared and funded by a number of PCTs, and usually located within one. These included services such as health information; library services; individual public health professionals not employed by PCTs; pharmaceutical advisers; the Health Protection Agency (HPA), etc. (Such services also existed elsewhere but were not seen as part of the PHN.) In some cases the services had been kept together as a deliberate attempt to preserve something of the former health authority public health department. One respondent spoke of the PHN as a ‘home for orphans’ – the services not hosted by PCTs. Some PHNs could also call on designated time set aside specifically for PHN activity by public health staff in PCTs,
Mapping public health networks
Table 2 Scope of workplans Main functions
Examples of tasks
Governance and audit Development and management
Establish board and stakeholder involvement Convene steering group Appoint management and administrative staff Establish electronic communication system for members (email, web-based) Agree budget with PCT chief executives Extend membership to include local authorities
Health information and knowledge management
Maintain library and health information function for use by all Develop relationships with public health observatory and academic units Build/access evidence base for health policy and programmes Stocktake of public health skills and expertise across PHNs Share data for public health reports
Health protection and communicable disease control
Effective links to Health Protection Agency On-call rota
Health surveillance and auditing; health impact assessment
Needs assessment and preparation of health profiles, particularly with respect to health inequalities Local target setting and monitoring
Contribute to planning and partnerships regarding national and local priorities and targets
Contribute to local delivery plans Map existing partnerships Provide public health input to local strategic partnerships Coordinated responses to consultation documents from Department of Health and others
Specialist public health advice and/or management regarding prevention programmes; national service frameworks; clinical networks
Screening services Child protection services Sexual health strategy including teenage pregnancy Smoking; cancer; coronary heart disease; diabetes; drugs and alcohol; dental health; prison health
Advice to specialist commissioning Involvement in commissioning services from hospital trusts Clinical governance and clinical audit
Development of common protocols and procedures for prescribing, exceptional treatments etc.
Training and professional development and appraisal
Development and delivery of training and education programme Trainee placements Learning sets and events Peer review Personal appraisal and development plans
Workforce planning
Public health capacity planning in collaboration with Workforce Development Confederation
including DPHs. However, many PHNs relied on goodwill as a basis for the contributions of their members, taking the view that a formal commitment of public health time to the PHN should be avoided if possible. This was partly to preserve flexibility, and partly because it was unrealistic and unfair to expect DPHs within one PHN to contribute equally when their resources were not equal. DPHs had:
Mapping public health networks
• Different resources at their disposal in terms of both the number and type of staff (eg some had health promotion staff within their directorates, others did not) • Varying responsibilities within PCTs (eg clinical governance and prescribing were examples of DPH duties in some, but not all, PCTs) • Populations that differed in size and need.
13
It was acknowledged that goodwill might not always prevail, in which case more formal arrangements would have to be made.
Activities and tasks Only a few PHNs reported an extensive programme of work; for most, activity was still at the planning stage. There was a consensus that PHNs should be active in promoting CPD for those working in a public health capacity. In some cases the programme of events was already organised by other local groups or networks, and the PHN’s role was simply to support this work and to host sessions within meetings. In others, previous arrangements had lost impetus or disappeared, and it was up to the PHN to revitalise or replace them. Other than that, there appeared to be little consensus as to what the full scope of a PHN should be. This is not to say that PHNs did not aspire to set themselves a wider agenda – but in most cases, ideas about that agenda were not yet agreed and translated into plans for implementation. A small number of PHNs did include as explicit priorities the wider public health agenda, relationships with LSPs, and tackling health inequalities, although most did not. The designation of lead people to take forward work in particular areas was important, but had raised a number of concerns. There was uncertainty about what ‘lead’ meant in terms of accountability, particularly given the constraints on time and dependence on other members’ commitment and cooperation. In many cases, PCTs within a local health economy had already, prior to the formation of the PHN, allocated lead roles for areas such as the national service frameworks: in those cases the DPH working for the lead PCT would be likely to lead the relevant public health contribution. Making links with other partnerships and working groups was regarded as very important. Links were being made at different levels, and for different tasks. In some cases the PHN saw itself as the hub, taking forward local priorities by means of links with other networks and partnerships. In this way, PHNs hoped to be able to manage a broader strategic agenda, as well as public health operational business. In general, respondents thought that PCTs, rather than PHNs, should lead in making partnerships with local authorities, not least because these were intrinsically complicated: one PHN, for example, covered 13 PCTs and related to two county councils, 18 district councils and two unitary authorities. Adding yet another umbrella organisation to the complex pattern of dialogue and partnership was not thought to be productive, and LSPs in particular needed to be local.
14
Informants highlighted the importance of establishing effective electronic communications systems. Many planned, or had already begun to develop, electronic databases, email groups and web-based fora. These tools could be very useful in opening the PHN up to a broader range of practitioners and agencies. Some respondents assumed that public health professionals would work primarily in their own PCTs, and would develop links and networks appropriate for their particular needs and purposes. One was explicit about this – the PHN’s role was to facilitate such links but not to organise or to structure them, and members wishing to convene a meeting on a particular theme had used email to do so, rather than looking to the coordinator. Table 2 sets out the content of workplans more systematically, drawing on both documentary and interview data. Any one plan covered these functions to a greater or lesser extent, and the presence of some functions was dependent on the level of PHN. For example, SHA-wide PHNs were more likely to include workforce planning.
Desired outcomes Many respondents cited the need to demonstrate that PHNs added value in order to secure and maintain the commitment of PCTs and to engage other potential stakeholders. However, there was little consistent definition among respondents about what this might mean, or how it could be measured and judged. Delivery of the workplan tasks was seen as the main tool for assessing progress, as well as feedback from stakeholders (either ad hoc or systematic). In a minority of cases, more comprehensive ways of defining and managing performance were being considered. For example, the possible use of a balanced scorecard approach or total quality management was being examined in the London networks. However, there was agreement that PHNs should contribute now or later to a number of key areas: • Health protection – working with the HPA to minimise risks of disease outbreaks • Contributing to the evidence base for, and quality assurance of, services commissioned and provided by the PCTs • Tackling health inequalities in partnership with local authorities and other local organisations • Expanding and supporting the public health workforce.
Mapping public health networks
Discussion – the future?
The development of PHNs is at an early stage, and it is clear that they will continue to evolve and change. A range of national and local contextual factors have influenced the nature and pace of development. However, there was some indication that, over time, many PHNs may come to resemble each other more closely with respect to their content and mechanism. Many apparent differences perhaps reflect the current early stage of organisational development, rather than enduring fundamental differences, eg: • Some PHNs expressed an intention to strengthen their infrastructure if and when resources become available • Some posts had been created, but not yet filled • Workplans that currently focused on CPD were expected to expand and broaden • Some PHNs based on former health authorities were planning to merge • A PHN without a steering group was discussing the idea of forming one as part of the governance arrangements • Engagement of a broader range of organisations and professionals was planned. It remains to be seen whether PHNs will show the variety of development noted in the case of cancer networks (Kewell et al., 2002). However, the boundaries between what constitutes the network, and network activities, are not clear-cut. It may be that work undertaken by PHNs would have taken place without the creation of a network, via the pre-existing and less formal collaborations between PCTs and/ or public health personnel. Similarly, different decisions have been taken locally about which resources and activities are included in PHNs and which are not, therefore it would be difficult to determine differences in the aggregate resources and activities that exist locally.
features of PHNs which are likely to endure beyond this development phase. How far does the evidence we have found confirm the hopes and fears for PHNs discussed previously. • Social relationships underpin network activities and the sense of professional identity and allegiance within the public health community We found evidence for good relationships between public health personnel, and a strong sense of professional identity. In some cases the reconfiguration of the NHS had dislocated such relationships and impeded progress in PHN development, particularly where people were still mourning the loss of cohesion. In others, the desire to ensure the continuity of former relationships and structures had been a major driver for PHN formation. • Networks offer individuals and organisations the opportunity to access complementary resources or competencies Respondents were clear about the need to share resources and competencies. However, this need had been recognised before the requirement to create networks (eg PCTs leading on given areas of work on behalf of others), and just how this sharing was to be done was still unclear in many cases. • Public health personnel are already active networkers, establishing and maintaining links and joint working with a range of organisations inside and outside the NHS There was abundant evidence of the many networks and partnerships to which respondents were already committed.
Given this sense of underlying similarity, a suggested general framework for PHNs is presented in Table 3, setting out key
Mapping public health networks
15
Table 3 A framework for public health networks Context
PHN content and mechanisms
Desired outcomes
Public service agreements, targets and performance management frameworks
Definition of scope and nature of network and relationships
Risks of disease outbreaks or health damaging incidents are minimised, mechanisms in place for their effective management
Reconfiguration of the health protection Steering group/management board function engaging key stakeholders Public health faculty system for continuing professional development and qualification of public health specialists Pattern and priorities of health issues locally, including health inequalities Level of local support and legitimisation by key stakeholders including PCTs’ chief executives History of collaboration and relationships between key stakeholders including PCTs, as well as existence of other relevant networks and forums Competence and capacity of public health function locally Resources to support PHN development and operation
16
Terms of reference/vision statement of roles and functions Business/workplan defining priorities, activities, outputs, appropriate to level of network Investment in infrastructure: • Management, administrative staff • Communication systems • Stakeholder events and workshops Assessment of skills and expertise and designation of leads for specialist areas: • Multi-agency subgroup working • Development of health intelligence and knowledge management systems including links with PH observatories Professional development and training programmes for public health workforce, linking with local workforce confederation arrangement and academic bodies
Commissioned services are public health quality assured Consistent standards for quality and availability of treatments, new drugs and technologies (including rare cases) through protocols and procedures Public health integral to programmes delivered through clinical networks Decisions about strategies, programmes and investment informed by assessment of needs evidence of what works and assessment of health impact Health improvement and tackling health inequalities integrated within community strategies and neighbourhood renewal Efficient production of annual public health report to consistent standards, to inform investment strategies Competent expanded public health workforce through: • Continuing professional development and qualification of public health specialists • Expansion and training of public health practitioner workforce • Expansion and training of wider public health workforce
Mapping public health networks
• Networks require significant investment for their establishment and maintenance Resources were a matter of great concern to respondents – on the one hand, PCTs had to provide the costs of maintaining PHN infrastructure; on the other, PHN members had to find the time to undertake PHN work. Both these contributions were thought to be vulnerable because of the resource and time constraints endemic in the NHS.
respondents believed that further NHS reorganisation was inevitable, and that this would interrupt PHN development. It is clear that PHNs are in no sense a quick fix. It is possible that they will, in time, make an effective contribution to the delivery of the public health function of PCTs, but at present such an outcome appears uncertain.
• Networks may become ‘all process and no output’ Only a minority of PHNs could be said to be delivering at the early stage of their development. But as they mature as organisations it might be anticipated that workplans will be taken forward and potentially deliver desired outcomes. • Networks require a non-hierarchical management style, in contrast with a much more hierarchical style in the NHS There were some worries that PCT chief executives might not allow public health personnel to give time to the PHN if such work did not contribute directly to the PCT’s business objectives as set by central government. • Networks are likely to experience tensions between the drive for network integration and the local requirements of PCTs, etc. There were fears that PCT chief executives would expect PHNs to demonstrate what they had achieved at an early stage, even though this might not reflect a realistic assessment of the PHN’s current capacity and of the time required to develop a mature network. • Networks presuppose voluntary engagement Few of those interviewed could be said to be volunteers (those few included academics, health promotion specialists, etc., whose engagement across PHNs was very variable). However, we found little evidence that PHN members are reluctant recruits who are resisting PHN formation, although goodwill was combined with some scepticism. On the basis of this mixture of opportunities and threats, it is difficult to offer a definite prognosis for PHNs as an effective mechanism for development and delivery of the public function. Conditions for their development have so far been less than favourable. Indeed there is a paradox that on the one hand PHNs are a response to a lack of capacity in public health and yet, at the same time, they cannot function effectively without adequate resourcing. Furthermore, some
Mapping public health networks
17
References
Department of Health (2001) Shifting the Balance of Power. Department of Health, London.
Shanks, J. (2001) Managed public health networks: squaring the circle in London? Public Health Medicine, 3 (3): 107-11.
Department of Health (2002a) Getting Ahead of the Curve. Department of Health, London.
Shaw, S., Taylor, S., Petchey, R., Abbott, S., Carter, Y. and Bryar, R. (2002) Primary Care Trusts and the Public Health Function. Final Report. Health Services Research Unit, Queen Mary, University of London and City University, London.
Department of Health (2002b). Shifting the Balance of Power: The Next Steps. Department of Health, London. ELCHA (2002) Health in the East End. Annual Public Health Report, 2001/2002. East London and the City Health Authority, London. FPHM (2001) Statement on Managed PHNs. Faculty of Public Health Medicine/Health Development Agency, London.
Stewart. M. et al. (2002) Collaboration and coordination in areabased initiatives. Neighbourhood Renewal Unit, London. Thompson, G., Frances, J., Levacic, R. and Mitchell, J. (1991) Markets, hierarchies and networks. Sage, London.
Ferlie, E. and Pettigrew, A. (1996) Managing through networks: some issues and implications for the NHS. British Journal of Management, 7, S81-S99 (special issue). Flynn, R., Pickard, S. and Williams, G. (1995) Contracts and the quasi-market in community health services. Journal of Social Policy, 24 (4): 529-50. Harvey, J., Fenton, E. and Sturt, J. (2000) Evaluation of Primary Care R&D Networks in North Thames Region, Final Report. Warwick Business School, University of Warwick. Huxham, C. (1993) Pursuing collaborative advantage. Journal of the Operational Research Society 44 (66): 599-611. Kewell, B., Hawkins, C. and Ferlie, E. (2002) Calman-Hine reassessed: a survey of cancer network development in England, 1999–2000. Journal of Evaluation in Clinical Practice, 8 (3): 303-11. Kickert, W.J., Klijn, E.-H. and Koppenjan, J.F. (eds) (1997) Managing Complex Networks. Sage, London. Pawson, R. and Tilley, N. (1997) Realistic Evaluation. Sage, London. Pedler, M. (2001). Issues in Health Development. Networked Organisations – An Overview. Health Development Agency, London. Pettigrew, D., Ferlie, E. and McKee, L. (1992) Shaping Strategic Change. Sage, London. Powell, M. and Exworthy, M. (2002) Partnerships, quasinetworks and social policy. In: Glendinning, C., Powell, M. and Rummery, K. (eds) Partnerships, New Labour and the Governance of Welfare. The Policy Press, Bristol.
18
Mapping public health networks
Appendix: Research instruments
Interview topic guide
Activity
What is your role in the network?
What activities are currently under way, and planned?
Process
Strengths and weaknesses
How long have you been going as a network?
What is the network’s added value to public health work, particularly in addressing health inequalities? What are the added costs (money, time, commitment)?
Setting up mechanisms
Context
Who was responsible for leading its development? What was easy, what was difficult?
Existing activity
Progress to date
Content and mechanisms
What are the key local strategies for public health and health inequalities?
Aims and objectives?
What alliances among public health personnel existed prior to the network (including pre-existing networks)?
What are the network’s chief roles, functions, priorities? Is there a workplan? If so, could I have a copy?
Partners
Who?
Who are the network’s key partners in delivering the public health agenda in your areas?
Who are the members? What organisations and professional groups are represented? What is the profile within the network of non-medical public health personnel? Organisation How is the network organised (eg board/steering group (membership); relevant meetings, sub-groups (membership); means of information exchange – email/Internet communications; governance issues)? Do participants have defined roles and responsibilities? Do members have protected time for participation in the network? To whom is the network accountable? Is accountability formalised? What funding does the network receive?
Mapping public health networks
What is the network’s relationship with: SHA, public health observatory, RDPH, local government, HAZ, LSP, single regeneration budget, existing PHNs, research networks, HDA, etc.? Helps and hindrances Other aspects of local context that do/may/will have an influence on the role and development of the PHN?
Outcomes How will the network know if it has been successful? Does the network have performance criteria? How will the network add value?
19
