live from leeds

Health action zones and health improvement programmes, and the partnership approach which lies at their core, are receiving a great deal of attention. But there has been remarkably little comment on the management issues arising from these new ways of doing business.

This is surprising when the very purpose of these initiatives is to break the mould of current thinking about health policy. If the policy watchword is interdependence, then a consequence will be an erosion of structures of authority and modes of responsibility. For HAZs and HIPs to succeed, the management dimension is therefore pivotal. It is a critical matter, especially for the generation of managers and practitioners brought up in a context of new public management (NPM). Erroneously, NPM sought to emulate private sector management and ignored 'the distinctive tasks, purposes, and conditions of public sector management'.

1Without role models and tools for the new age of partnerships and interorganisational linkages, those responsible for making HAZs and HIPs work will grope for guidance. The bad news is that so little is being done to replace NPM with an alternative framework for managing health and healthcare. The good news is that help is at hand - but only if you look for it.

There are lessons to be learned from the past.

In the late 1970s and early 1980s, the Institute for Operational Research (IOR), part of the Tavistock Institute of Human Relations, produced a newsletter called Linkage . It was addressed to those who are concerned with practical problems of co-ordination which cut across organisational boundaries. Its aim was to help people cope better with co-ordination problems.

Looking through the contents of the few issues of Linkage which were published before funds ran out, one is struck by the startling relevance of concepts and practical illustrations which only a couple of years would have been ignored or dismissed as old-fashioned. But here they are once again in high fashion. Even allowing for considerable changes in organisations and structures, articles appearing in Linkage with titles like 'Multiple deprivation: a human and economic approach', and 'Joint working: a cautionary tale', resonate powerfully with the government's public management agenda.

A particular strength of the IOR's approach was the building up of a grounded body of knowledge about how to handle interorganisational relationships which was derived from the subtle interplay between experience and theory.

In the current rhetoric of partnerships, collaboration and integrated care, this is where there exists a major vacuum.

One of the difficulties about generalising from interorganisational relations is the context-specific nature of initiatives. Transferring experience from one situation to another therefore becomes prone to failure. A further obstacle is that the skill of the successful networker may be of such a subtle nature that it can only be made explicit with considerable difficulty. Persuading successful operators to reveal their tactics is one way of not losing their effectiveness, but creating the space to do this in a structured manner requires resources and commitment as well as a conviction that it is a worthwhile activity.

The IOR's work on understanding linkages produced other important insights. For instance, it is important to counter trends towards increasing functional specialisation since network skills are generalised rather than specialised skills. In the care of elderly people, for example, in terms of staffing, fewer rather than more powerful specialisms are required. Resources devoted to paying for increased professional competence could be diverted to paying for practical tasks and 'dirty jobs' to be done.

A further insight concerns the importance of identifying roles at the margins of organisations where crucial boundaries exist to be managed.

The important point about these marginal roles is that people working across boundaries cannot afford to become too immersed in a single corporate ideology, cultural framework or set of values.

Empathising with multiple cultures and managing 'cultural gradients' will be essential skills.

Crucially, it is not just the skills of those spanning organisational boundaries which are important, but also those at the top of organisations who possess the power to appoint people to boundary roles.

Network management carries with it profound implications for professional practitioners and managers, but unless these matters are confronted at the outset, then HAZs and HIPs are likely to join the list of worthy initiatives which have failed through a lack of detailed and sustained attention to their implementation.

In a welcome second edition of their seminal text, Planning Under Pressure , Friend and Hickling comment on the educational challenge which their work presents.

2The nub of the matter is how hard-won skills 'built on cumulative experience in working under real-time pressures of complexity, uncertainty and conflict' can be made widely accessible to others. Regrettably, 'obstinate gaps' in our educational systems are hampering progress. Schools of business and public policy have been slow to see the value of the strategic choice approach which is the basis of collaborative planning.

The NHS white paper contains many ambiguities and paradoxes. One of these is the government's desire to return decision-making to those who know best - the doctors and nurses on the frontline. This will not solve complex management challenges. If the professions are part of the problem, they are also part of the solution - provided, that is, they receive appropriate guidance and support in order to face, and manage, the future.

David Hunter is professor of health policy and management at the Nuffield Institute for Health, Leeds University


1 Rhodes R. 'Foreword: governance in the hollow state'. In: Blunden M and Dando M (eds) Rethinking Public Policy-Making. Sage Publications, 1995.

2 Friend J, Hickling A. Planning Under Pressure: the strategic choice approach . Butterworth/Heinemann, 1997.