and protection from many adverse health outcomes (UNICEF 2004). There are numerous opportunities to promote breastfeeding that go beyond the normal exposure that the midwife will have with the mother. By taking a partnership approach to offering continuous psychosocial and emotional support before the birth, during labour and in the months after, both professionals and appropriately trained and supported laypeople could assist the mother and promote the benefits of breastfeeding.
It has been well documented that smoking has many potential problems for the woman, the fetus and neonate, including raised blood pressure, reduced birthweight and increased risk of sudden infant death syndrome (Twigg et al. 2004). In the Independent Inquiry into Inequalities in Health, Acheson (1998) offers considerable evidence to suggest how a decrease in prevalence in smoking during pregnancy is followed by a decrease in women who smoke after pregnancy, with the obvious benefits to the mother, child and those sharing her home. Any professional who has worked with people attempting to quit smoking will be aware of the difficulties encountered by all parties; however, pregnancy is a prime opportunity to encourage women who smoke to give up (Health Education Authority 1994) and a good opportunity for the midwife to work in partnership with other agencies, especially the smoking cessation services. It is therefore essential that those responsible for the care of both mother and child be linked into LSPs and other relevant systems.
The Health Development Agency (HDA) compendium Tackling Health Inequa- lities(DoH 2003) offers 35 examples of projects tackling health inequalities in communities across England. The range of projects is considerable with examples including: practical parenting courses in Andover, which encourages families to feel positive about their ability to parent; promoting perinatal mental health in
Lincolnshire, which aims to reduce the incidence and impact of postnatal depression by working with parents before and after childbirth; and a scheme to tackle teenage pregnancy at Queen Elizabeth Hospital in London. This final programme aimed to improve teenagers’ access to midwifery services and outcomes for newborn babies by developing maternity services that meet the specific needs of teenage mothers.
The aim of the compendium was to feature ‘snapshots’ of projects tackling health inequalities in communities across England. There are a number of recurring themes common to meet projects; uppermost among these is the emphasis placed on partnership working. Key points or ‘learning points’ highlighted include the following:
• Get people and partners on board as soon as possible
• Give feedback to people and partners
• Develop partnerships: effective partnership working is when everyone knows where they fit into the picture.
CHALLENGES OF PARTNERSHIP WORKING
Activity – 1
Identify the challenges you see yourself facing when given the chance to work in a partnership.
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Across the public health/health promotion agenda, the effectiveness of partnership working is often questioned by practitioners struggling to make the leap from theory (‘it seems like it should be a good idea’) to the reality of practice (‘that worked well’).
I am sure that many practitioners struggling with numerous competing priorities and ever-increasing workloads would agree with Brown et al. (2004) that, although the perceived wisdom is that joint working must be beneficial, there is, even at this stage, little evidence to support the notion.
If a manager of a busy midwifery unit is experiencing the considerable challenges of recruitment and retention, it is unlikely that setting up a partnership meeting to discuss how to meet targets for health inequalities is top of the agenda. It is easy to see how partnership working gets marginalized when priorities revolve around issues such as how to access resources, securing ownership of shared goals and overcoming the lack of mutual understanding between organizations, often with very different organizational cultures. Within any health organization there are likely to be difficulties when attempting to address the multitude of competing agendas, especially in an environment dominated by economic restraint and when decisions are often taken with the medical model taking centre stage. Indeed when considering the challenging area of evaluation, partnership working does not lend itself well to what has been described as the ‘gold standard’ of evaluation, the randomized controlled trial (RCT), the method most preferred by the medical establishment.
Partnership working is not the panacea to addressing the organizational, structural and strategic inadequacies when attempting to address health inequalities. Indeed, despite the widespread support for integrated community care in the UK, inter- disciplinary working between health and Social Services staff remains complex and tentative (King 2003), and unlikely to achieve sustained success unless it is given greater emphasis. This is especially true in relation to the unmet potential that the midwife has to contribute to partnerships and public health.
Considerable human and financial resources are devoted to the success of partnership working, yet many tensions, conflicts and challenges are encountered by all of those trying to forge the perfect partnership. Achieving consensus about the significance of a partnership is challenging, not least because, although many will subscribe to the principles of partnership working, following through with the necessary commitment is less easy to achieve. One of the potential pitfalls when implementing a partnership initiative is the potential disinvestment that a worker may experience should she or he become disconnected or detached from the process, and in the extra work needed in delivering relationships with outside organizations.
Ownership of the process is therefore key as is clarity, of both purpose and method of delivery. This is where the concept of social capital in relation to organization development and partnership working becomes clearer.
It is important for midwives at all levels to engage in this process; to do so will require midwives to adopt what Edwards et al. (2005, p. 48) refer to as ‘a radical and openly social stance to health’. This works very well when taking a broad approach to tackling health inequalities but has to be considered alongside Furber’s (2000, p. 314) opinion that when looking at midwives’ attitudes to health promotion:
The patterns of views towards health promotion approaches were complex as midwives stated that they preferred societal approaches but worked in approaches that were focused on the individual.
Summary of key points 107
It takes time to build trust in any relationship (professional or otherwise). The current often-unwritten policy of ‘short termism’ does not allow for relationships to grow and therefore does not facilitate healthy partnerships. Just as an individual or agency needs time to develop resilience in a new environment or to work in a new way, so partnerships need time to embed themselves into the psyche of local structures. This need for a more human approach to partnership working requires a cultural shift in the structural development and organizational management.
Relationships between statutory health and social care services and the voluntary sector have their roots in past practices and separate agendas and, as Andrews et al.
(2003) recognize, partnership working does not emerge from a policy or service vacuum. In the study by Andrews et al. it was indicated that any partnership between the statutory and voluntary sectors in delivering packages of intermediate care would inevitably encounter challenges associated with multi-level, multi-professional and multi-agency collaboration. All of this takes place against a rapidly changing policy backdrop, where health providers and Social Services departments in England are attempting to develop partnerships in order to provide services effectively (Coleman and Rummery 2003).
All too often commissioners of programmes in health, community development, etc. are placed in a position where they are expecting agencies or partnerships to deliver solutions to complex health/social problems with limited resources, which are available for a fixed point of time (usually 1 year, occasionally 2, rarely 3 or more). We then ask for comprehensive evaluations that detail the impact of an initiative, this in itself being physically impossible.
The esoteric nature of the medical establishment can be an exclusive arena in which, even when patients’ self-help groups are allowed to enter, the different values, language, etc. can inhibit equitable partnership arrangements. What is the solution?
Look for the win–win scenario by using the principles and process behind a patient- focused approach. By embracing the concepts behind integrated care pathways and recognizing that the holistic reason for disease and illness require holistic solutions, an approach seen as positive by the medical establishment is much more likely to be successful than a process that is forced upon them.
Midwives play a significant role in reducing health inequalities and contributing to the public health agenda. The two areas of promoting breastfeeding and reducing the prevalence of smoking in pregnancy were indicated, but there are many others, especially in Sure-Start areas. In many areas of public health, professionals are still working in ‘silos’ where they remain isolated and disengaged from the broader public health debate. As Edwards et al. (2005, p. 48) have suggested, ‘midwives are ideally placed to develop their public health role, but many feel isolated and unsupported in their personal development’.
SUMMARY OF KEY POINTS
■ Midwifery is a profession already embedded in the ethos of public health. There is a broad professional consensus that maternity care should contribute to improving public health.
■ Much has been written about the links between poor health status and material deprivation. As part of the present Government’s attempt to address this issue,
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REFERENCES
Acheson ED (1998) Independent Inquiry into Inequalities in Health. London: HMSO.
Andrews J, Manthorpe J, Watson R (2003) Intermediate care: the potential for partnership.
Quality in Ageing Policy Practice and Research4: 13–21.
Baggott R (2000) Public Health: Policy and politics. Basingstoke: Macmillan Press.
Ballach S, Taylor M (2001) Partnership Working: Policy and practice. Bristol: The Policy Press.
Bennett N, Blundell J, Malpass L, Lavener T (2001) Midwives’ views on redefining midwifery 2.Public Health9: 743–6.
Brown L, Tucker C, Domokos T (2004) Evaluating the impact of integrated health and social care teams on older people living in the community. Health and Social Care in the Community11: 85–94.
Coleman A, Rummery K (2003) Social services representation in primary care groups and trusts.Journal of Interprofessional Care17: 273–80.
Department of Health (1999a) Making a Difference. London: HMSO.
Department of Health (1999b) Saving Lives: Our healthier nation. London: HMSO.
Department of Health (2001a) Making a Difference: Strengthening the nursing, midwifery and health visiting contribution. Midwifery Action Plan. London: DoH.
Department of Health (2001b) Tackling Health Inequalities: Consultation on a plan for delivery.
London: Department of Health.
Department of Health (2003) The HDA Compendium Tackling Health Inequalities. London:
The Stationery Office.
Department of Health (2004a) Choosing Health: Making healthier choices easier. London: HMSO.
Department of Health (2004b) Maternity Standard, National Service Framework for Children, Young People and Maternity Services. London: The Stationery Office.
Department of Health (2005) Creating Healthier Communities: A resource pack for local partnerships. London: The Stationery Office.
Edwards G, Gordon U, Atherton J (2005) Network approach boosts midwives’ public health role.British Journal of Midwifery13: 48–53.
El Ansari W, Phillips CJ, Zwi AB (2002) Narrowing the gap between academic professional wisdom and community lay knowledge: perceptions from partnerships. Public Health116:
151–9.
Elston J, Fulop N (2002) Perceptions of partnership. A documentary analysis of Health Improvement Programmes. Public Health116: 207–13.
partnership working has become one of the ‘fundamental principles’ in delivering on the agenda of health inequalities.
■ There are many benefits to working in partnership, such as the opportunity for successful collaboration across various agencies to tackle the roots of health inequalities.
■ The success of midwifery partnership projects within the Sure-Start and Sure-Start Plus programmes offer a strong practical example of the midwife’s role in public health.
■ The danger of midwives becoming excluded from PCTs and public health networks, from which local health improvement strategies are instigated, must be overcome.
■ It is vital for midwives to realize their full potential in partnership working and public health, and it is important for them to engage fully with those involved at all levels of strategic development and to get involved at the community level.
References 109
Field J (2003) Social Capital. Routledge: London.
Freudenstein U, Yates B (2001) Public Health skills in primary care in South West England – a survey of training needs, obstacles and solutions. Public Health115: 407–11.
Funnel R, Oldfield K, Speller V (1995) Towards Healthier Alliances. London: Health Education Authority.
Furber C (2000) An exploration of midwives’ attitudes to health promotion. Midwifery16:
314–22.
Gillies P (1998) Effectiveness of alliances and partnership for health promotion. Health Promotion International13: 99–120.
Health Education Authority (1994) Smoking and Pregnancy: Guidance for purchasers and providers. London: Health Education Authority.
Hillier D, Caan W (2002) Researching the public health role of the midwife. British Journal of Midwifery10: 545–7.
Improvement and Development Agency (2000) A Councillor’s Guide to Local Government.
London: HMSO.
Kawachi I, Kennedy B, Wilkinson R (1999) Crime: Social disorganisation and relative deprivation.Social Science and Medicine48: 719–31.
King N (2003) Professional identities and interprofessional relations: evaluation of collaborative community schemes. Social Work in Health Care38: 51–72.
Lewis M (2004) Working together to make a difference. Midwives7: 422–3.
Morgan A, Swann C (2004) Social Capital for Health: Issues of definition, measurement and links to health. HDA website: www.hda.nhs.uk (accessed April 2005).
Moss Kanter R (1994) Collaborative advantage: The art of alliances. Harvard Business Review July: 96–108.
NHS Confederation (2003) Prevention is Better than Cure. A report from a conference on joined-up thinking on public health. Nexus Report, Local Government Association and the Faculty of Public Health Medicine. London: NHS Confederation.
Nutbeam D, Harris E (2004) Theory in a Nutshell, A practical guide to health promotion theories, 2nd edn. Sydney: McGraw-Hill.
Piper S (2005) Health promotion: a framework for midwives. British Journal of Midwifery13:
284–8.
Putnam R (1993a) Bowling Alone: The collapse and revival of American community. New York:
Simon & Schuster.
Putnam R (1993b) Making Democracy Work: Civic traditions in modern Italy. Princetown, NJ:
Princetown University Press.
Rowe M, Devanney C (2003) Partnership and the governance of regeneration. Critical Social Policy23: 375–97.
Royal College of Midwives (2001) Modernising Maternity Care: Commissioning for primary care trusts. London: RCM.
Twigg L, Moon G, Walker S (2004) The Smoking Epidemic in England. London: HDA.
UNICEF (2004) Health Benefits of Breastfeeding: www.babyfreindly.org.uk/health.asp (accessed May 2005).
Wildridge V (2004) How to create successful partnerships – a review of the literature. Health Information and Libraries Journal21(suppl 1): 3–19.
Woolcock M (1998) Social Capital and Economic Development: toward a theoretical synthesis and policy framework. Theory and Society27: 151–208.
World Health Organization (1985) Health for All by the Year 2000. Geneva: WHO.
World Health Organization (1986) The Ottawa Charter for Health Promotion. Geneva:
WHO.
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World Health Organization (1997) The Jakarta Declaration on Health Promotion into the 21st Century. Geneva: WHO.
FURTHER READING
Baggott R (2000) Public Health: Policy and politics. Basingstoke: Macmillan Press.
Putnam R (1993) Bowling Alone: The collapse and revival of American community. New York:
Simon & Schuster.