Effective cross-sector collaboration and joint working among practitioners remains a Holy Grail that continues to elude us within health care. Networks such as collaboratives, alliances, taskforces and clinical leadership councils are examples of mechanisms that facilitate shared solutions design and implementation. Jade Hart challenges us to examine the goals of cross-sector collaboration and assess acceptable time horizons for the realisation of those goals.
Networks as a model of organisation in complex health systems
The Australian health care system, like most other systems internationally, is complex and lacking of a single authority. Despite an evidence-based medicine/clinical practice movement that has spanned decades, clinical care concerns and wicked issues necessitating comprehensive and innovative responses remain entrenched.
Networks emerged in the health system as a model of cross-sector collaboration. These networks are organised through relationships and self-selection, and have been applied where other forms of organisation, namely markets and hierarchies, have had limited impact (Pedler, 2012). Networks have been convened to stimulate collective resolution of issues that stem from system complexity but often cannot be corrected by market pricing interventions or command and control approaches. For example, responses to obesity (which is connected to factors such as diet, physical activity, genetics, transport, education, access to surgical intervention) that have relied on market and hierarchical approaches alone have been unable to deliver desired community change at implementation. Local community networks, through coalitions, action groups, and physical activity taskforces, have been offered as solution for finding a way to navigate a complicated and dynamic set of factors. Government agencies may also have a role in networks, through funding or provision of administrative support for network operations through which a dependency is created.
The cross sector network lifecycle as a product of goals
Structures such as local community networks for cross-sector collaboration generally follow a development lifecycle with a number of common activities that may not always occur in sequence. Goodwin et al (2004) describes these loosely grouped activities as follows:
i. Initiation of the network – Including selection and recruitment of members
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ii. Objective negotiation – The definition of collective goals and actions
iii. Design – Network design and preparation activities
iv. Environment management – Activities undertaken with external parties and stakeholders for the purposes of clarifying objectives and ensuring network legitimacy
v. Joint production – Collaborative conduct of network-oriented tasks
vi. Adjustment – The process of continuous review and adjustment of the network over time
vii. Termination, transfer, or fundamental change – The completion or suspension of network activities, or reformation of the network to undertake these activities.
Networks can have a range of goals, which may be related to constructs such as consumer or patient outcomes, cost-efficient service delivery, power and risk sharing, and professional or peer relationships. Each of these goals may be variably understood individually or collectively defined as part of group development, and each goal may have varying priority and time horizons for their realisation (Goodwin et al., 2004). Therefore, the network development lifecycle both influences and is a product of agreed goals over time.
A refocus on time horizons – How far is a cross-sector network looking ahead?
In reflecting on the network development lifecycle, the manner in which time horizons are understood as it pertains to goal attainment can bear influence on structure and approach. For example, time horizons related to relational goals may be short-term (i.e., building relationships among those with a vested interest in obesity prevention and control within six months), but those related to consumer or patient outcomes may extend into the longer term (i.e., reducing the incidence of childhood obesity by a defined percentage over five years).
Cross-sector networks can kick-off with great enthusiasm and sincerity. However, a lack of clarity in relation to individual and collective time horizons for the realisation of goals can result in cross-sector networks failing to plan and/or failing to structure goals that can be achieved within “acceptable” time horizons. This can result in missed opportunity and frustration where time horizons are considered prolonged, or confusion and mistrust among individual network members where time horizons are perceived as abbreviated. The time horizons of organisations must also be acknowledged. This includes those of government agencies or other funders of network management or project delivery costs (on a non-recurrent or recurrent basis), and whose decision to withdraw or suspend funding may subtly alter the network approach or result in its immediate dissolution.
In this context, factors such as individual employment terms, organisational funding schedule duration, and political cycles can influence perspectives of time. For example, a service provider with a one year funding contract would retain a different time horizon compared with that of a hospital which may operate with a level of ongoing funding security. Additionally, who has not paused to consider the potential impact of looming political elections? The absence of clarity as it pertains to goals and time horizons can contribute to uncertainty and cause networks to be seen as ambiguous and amorphous structures of variable relevance in a given context, both for those involved, funding network operations, and other stakeholders.
Cross-sector collaboration and joint working are the means and not the end. The tendency to examine time purely in relation to the time required to conduct work activities, and in the absence of recognition of individual and collective time horizons, will limit a network’s understanding of and capacity to meet shared expectations. The ultimate test of feasibility of network intent within our complex health system requires a humble pause at any stage in the network development lifecycle to earnestly explore and collectively deliberate on the question: How much time do we have to do things right?