Networks - a briefing paper for the Health Foundation - Centre for ...

Centre for Innovation in Health ManagementUniversity of LeedsNetworks – A briefing paper for The Health FoundationBecky Malby and Kieran MervynWith support from Health Foundation Faculty: Douglas Archibold,Murray Anderson-Wallace, Sarah Fraser.February 2012Contact:Becky MalbyCentre for Innovation in Health ManagementUniversity of LeedsMaurice Keyworth BuildingLeeds LS2 9JTTel: 07974777309E-mail: r.l.malby@leeds.ac.uk

ContentsSummary Page 1Table 1: Network Types Page 5Table 2: Examples of Networks Page 101. Background Page 111.1 Background to the Scoping Exercise Page 111.1.1 Introduction to the study Page 111.1.2 The context for this work Page 111.1.3 Scoping Methodology Page 121.2 Background to Networks Page 121.2.2 Introduction to Networks Page 121.2.2 Network Characteristics Page 141.2.3 Network Functions Page 151.2.4 System vs. Network: when is a network not a network? Page 202. Types of Networks Page 232.1 Managed Networks Page 232.2 Developmental Networks Page 262.3 Social Networks Page 281

2.4 Agency Networks, Policy Networks Page 312.3 Learning Networks Page 332.4 Advocacy Networks Page 363 Network Evaluation and Future of NHS Page 383.1 Network Governance3.1.1 How Organisations Function as Units in Networks and Integrative Governance3.2 Network Assessment and Effectiveness3.2.1 Evaluating Policy and Public Management Networks3.2.2 Evaluating Managed Networks3.2.3 Evaluating Development Networks3.2.4 Social Networks and Social Local Networks3.2.5 Evaluating Clinical Networks3.3 Network Failures3.4 Leadership3.5.1 Leadership behaviour in networks and Structural BarriersPage 38Page 39Page 40Page 41Page 42Page 43Page 43Page 45Page 48Page 49Page 494. Conclusion Page 51REFERENCES Page 53Appendix Page 642

SummaryNetworks are best understood as an evolving, under-developed inter-disciplinaryphenomenon that transcend strategic management, business and management,organisational theory and behaviour, administrative government, political science, physicsand health care (Provan et al., 2007). As a way of organising networks are relatively poorlyunderstood in the NHS, with multiple types of networks emerging across the healthcarelandscape.A network is a set of “nodes” or points connected by “links” or pathways. In social networks,the “nodes” are people or organizations; the “links” are relationships. Networks are seen asdistinct forms of social organisation which differ from the traditional organisation which relieson hierarchical, top-down powers to achieve strategic objectives Plastrik and Taylor, 2006.The distinctiveness of networks lies in:The distribution of power and leadership across membersReciprocity and exchange as the defining relationship between membersTheir ability to be innovative and creative and their reliance on diversityFluctuations in their engagement and impactTheir adaptability to survive and thriveThe centrality of the knowledge functionNetworks are essentially processes which organically evolve; they: “Form and re-form, inendless variation. Those who remain inside have the opportunity to share and, over time, toincrease their chances. Those who drop out, or become switched off, will see their chancesvanish” NHS networks.‘……networks …..are largely self-organizing, they require structuring that reflects theirknowledge seeking orientation. They need to be managed like organizations but incollaborative, non hierarchical ways. Indeed, the data – information – knowledge function ofnetworks is so paramount that their collaborative communities of practice across agenciesdistinguish them from more bureaucratically oriented hierarchies’ Agranoff, 2006Networks exist on a continuum from the ad-hoc to more established endeavours forprotracted sustainability and encompass: ‘coalition, partnership, alliance, union, league,association, federation (s) and confederation[s]’ There are a number of distinctive Types ofnetworks (see Table 1 below)Managed NetworksDevelopmental NetworksSocial NetworksAgency NetworksLearning NetworksAdvocacy Networks3

‘Networks can take many forms to deliver similar functions, depending on a broad range offactors. To determine a network’s capacity to deliver its functions, we should ask whether itsstructure is the most appropriate one.’ Mendizabal and Hearn, 2011. Many networks arehybrids between the above types, but need to determine their design based on theirtypology, ie their form needs to follow their function.Networks are good for:Community-building: The network functions to promote and sustain the values of theindividuals or groups.Filtering: The network functions to organize and manage relevant information formembers.Amplifying: The network functions to help take new, little-known, or little-understoodideas and makes them public, gives them weight, or makes them understandable.Facilitating: The network functions to help members carry out their activities moreefficiently and effectively.Investing/providing: The network functions to offer a means to provide members withthe resources they need to carry out their main activities.Convening: The network functions to bring together different, distinct people, orgroups of people with distinct strategies to support themMendizabal and Hearn, 2011Leadership of networks is different from leadership of hierarchies or systems. Networksorganise through cooperation and peer based relationships. Leadership to establish anetwork is often different from that needed to sustain it.Networks fail because of institutionalisation, over-management cementing relationships andstructures that need to be dynamic and evolving, mistakes in initial design or ongoingmanagement, over expectation of network member’s willingness or ability to collaboratewhich damages creativity of the parts; predicating network some members over others,constraining network member’s independence, not recognising when leadership needs tochange / rotate. Network leadership is facilitative, distributed, democratic and inclusive, whilstmaking the most of difference for creative ends. Network leaders need to focus persistentlyon membership and impact.Each type of network has factors that enhance its likelihood of success and predicate itsfailure. Networks in the NHS would benefit from understanding the range of network typesand how to design their network structure and architecture to enable successful startingconditions. Attention to membership, leadership and impact are clearly critical for allnetworks to succeed.The emergence of networks may enable healthcare systems to address wicked issuesbeyond the capabilities of single organisations, (Crommelin et al., 2010). Networks are anemergent form for innovation, delivery, learning, advocacy, and intelligence. The breadth ofdisciplines networks span, means that there is an emerging body of knowledge about hownetworks succeed and fail, but their overall impact on the healthcare landscape is untested.4

Table 1 Network Types has been created to simplify the literature on health and social care networks. There are significant differences (andsimilar characteristics) acoss each respective type. Some networks stick to their type, others a hybrids mixing for instance advocacy andsupport. Table 2 provides examples of Network Types.Table 1: Network TypesManagedNetworksDevelopmental NetworksSocialNetworksAgencyNetworksLearning NetworksAdvocacyNetworksType ofNetworkManaged (+submanaged policyDevelopmental/ HybridClinical& SocialMovementsAgency Enclave / Support /Coalition of InterestCommunities ofPracticeCommonto allnetworksAll networks have different ground rules and organising principles but have similar characteristic e.g. all too varying degrees are useful forcreative solutions; fill gaps that can’t be addressed via conventional systems and structures; and all to varying degrees are based ongenerosity; reciprocity; diversity; fluctuating involvement and distributed leadership.What thisnetwork isuseful forUseful wherecontrolled forms ofintegration of astrongly articulatedset of services arerequired.Enables lucidnessand complex workto be broken downacross differentorganisations.Coordination;brokerage;shared standards;improving practiceEffective atfocusing expertminds on activitiesthat have a widerbenefit to thesystem.Amalgamatinginspirationalleadership andmotivational powerof healthcareprofessionals withthe task focus ofco-ordinatingnetworksBringing hybridhealthcareservices to apopulationacross widegeographicalarea.Strategic use ofscarce resources(money,technology andexpertise) forgreater impact.Instigating policychange.Campaigning.Common Cause.Intelligencegathering.Buildingreputation.Visibility.Learning.Cooperation whenone partydelegates work toanother.Role advocacyandamplification.Shared services/and resourcemobilisation5Unregulated netstructures (e.g. enclaveuseful when voluntaryparticipation, majorcommitment and internalequality of status areexpected/needed)Creative solutions wherethere is shared purposeand no one regulator/organisation /person incharge.Instigates enthusiasticethical, honourable andcommitted activities,Learning aboutidentified practicethrough doing withothers.Role Learning, canalso be aboutdelivery or creationof new knowledge (intheir most matureform)Advocating forshared commoncause

of the parts.based uponintegrity.HowmembersparticipateFrequent meetingsbut with modestoutputBy focusing onspecific tasks(improvinghealthcare accessor standards ofcare for specificpatient groups)where themembers can learnand change.Connection oforganisations toprovide evidencebased healthcareservices,operating acrossdifferent levels.Communicationvia socialmediums.Fluid, dynamicinteraction(London riots viaBlackberryMessenger/networks onestep ahead ofsystem).Can work moreeffectively if sharedwith others.Act togetherthrough mutualinterest,commonality inpurpose and areasof work.Commitment to task,equality of status, andshared experimentingand learning.People embedded inCoP becausesomething needs tobe done and theyidentify with peerswanting to learnabout the same.Participate as mutuallearners.Usually participationis facilitated.Collection oforganisations orindividuals withcommon purposetaking leadershipas required, basedon need.Refinement of corepurpose andagreed impact.No one course ofaction - try, try,try again;LeadershipHierarchical, lessinclusive than othernetwork types,advocacy style ofleadership, withclear tasks andbudgets suits themanagedhierarchical model.Working below thecore hierarchy is inpeer task groups.Boundary spanner(intermediaryleaders)Contextdependant –leadership rotatesdependent onneedEntrepreneurialorTransformationalleadership style(can includesmall team basedleadership);No one leader.May have variousformal/informalleadersSituatedleadership,dynamic leadersmust know when topursue interagencycollaboration.Distributed leadershipInclusive leaders whoseek constructive andfacilitative approacheswork best with enclavetypenetworksRequires anecosystem thatinstigates netweaving across alllevelsRotational basedon issue,availability andneed.Leader open tograssrootsengagement(contextdependent)6

GovernanceUnambiguous,clearly definedauthority toregulate members(but strength ofhierarchy isvariable); Relativelystraightforward toperformancemanageA ‘professional’modelFinancial andClinicalaccountability is theresponsibility ofparticipantmembers andremains separateRobustarrangementsneeded fordifferent types ofclinical nets.Good whenseeking fewerstructuralsolutions.Little authority toregulatemembers; selforganising;membersregulate throughpeer pressure./Hard toperformancemanagePlural forms ofgoverningEnclave andindividualistic networksare often self-governingentities with limitedformalised accountability.Horizontal /non-existentManagement structureProfessional integrityand inculcation, andarranging forimprovisation andexperimentation.Self-governing.Accountable tomembers forimpactDemocraticWhy theywork whenthey doMandated networkwhich works whenmutually agreedobjectives andpriorities areshared whichconnect directlywith that of otheragents. Retainssignificantlegitimacy withmany clinicians.Used to develophub and spokemodels of care.Innovative, flexibleand adaptable tochanginghealthcare contextsbased on principlesof effectivepartnershipworking.Work well whenall parties engageincludingclinicians, otherhealthcareprofessionals andpatients/users/carers etc. convergearound apathway.Work well whensupported by anevidence baseNew ideas andways of doingthings may notcommenceimmediately, butspread via socialnets.Rapid access tolatest intelligence.Socialmovements canbe created withinshort space oftime so are veryresponsive.High Trust neededto succeed7They develop novel waysof working, and newsolutionsGood at ProfessionalDevelopmentGood at developinglegitimacy andauthenticity.Good at information &knowledge sharing;Succeed whenparticipants commitselves to ownership ofthe networks goals, inconjunction with activefacilitation by anonaligned party/agencyMembers share apassion and committo frequentinteractions.Where there iscommitment todeveloping expertise,and working togetherto solve problemsWork when havingclear impact anddemocraticengagement makesthe best of allparties.

Why theyfailIf it struggles toachieve support(&commitment)from the networksmembers.If it hampersprofessionalmember’sautonomy topractice.When there areproblems reachingobjectiveagreement.When there are suboptimal outcomes;Over-regulation;meagreproductivity;inability to createsufficient capital;high transactioncosts; congestionvia bureaucraticprocedures; staticdesignated rulesand roles; low(front-line serviceprovider) morale;gateway barriers tohigher authority.Limited success insolving theproblems ofcapacity andfragmentation.Complex decisionmaking process forimplementing newstructures andinnovation-basedservices.Tensions betweeninterests andprioritiesWhen they don’tmake agreementsbetween membersthat are binding.Need to negaterisk of littledictators ormonopolies orperhaps conflictof interest.Social capital notalways a publicgood.Institutionalisationand becomesmainstreamPart of theproblemGovernment andsocieties’incapability ofperceiving groupsas self-organisednetworksBreakdown in trust;if multi-agencycoordinating groupscannot agree aboutits desired results.Where specific andunique publicmandates are notalignedLow motivation viafatigue; rifts anddivisions.Unstable entities withweak negotiation powersand reliant on agentswho may be unable toprop up effective powerLow productivity via moreemphasis on distributionbased values rather thanproductive based values.isolation from largestakeholder groups.Breakdown of trustbetween agents (peopleand orgs)Community is acontested conceptWhy CoPs fail(Roberts, 2006)Neglects power;doesn’t acknowledgepre-existing socialcodes;.Dissolve ifmembers do notachieve the impactthey intended.Overly concernedfor democracy getsin the way ofaction.Too blinked on theirown remit and notconnected to widercontext.What ittakes toOver-regulationmay result inNascent solutions/need to be properlyProfessionalcredibility;High level ofsocial media, andHuge effort to run.Challenging to maintainenergy and participationChallenging tomaintain energy andCommitment todemocratic process8

un thesetypes ofnetworksextremebureaucracy (papermountains)Huge effort/HighResource(transaction costs)developed.adaptiveleadership;rotationalleadership.energy fromnetworkmembers.rates.participation rateswith a shifting set ofparticipants.and cause.9

Table 2: Examples of NetworksManaged Networkse.g. Diabetes Research Network: The NIHR Diabetes Research Network is part of the National Institute for Health Research Clinical Research Network, and forms part of the UKClinical Research Network. The Networks support and deliver high quality clinical research studies. (Managed Networks are governed like hierarchies; dedicated management;members as peers; division of labour; can get ‘stuck’.Development Networkse.g. Clinical Networks: The Leeds Managed Clinical Network is a local pilot-based service that embraces a whole-system working approach to supporting individuals withpersonality disorders (Shields and Mullen, 2007). (Developmental Networks are for collaboration and coordination; agreed task; boundary spanners).Agency Networkse.g. NAAPS/ Shared Lives seeks connectivity between the inter-dependant parts and involve acting together but with less diversity (Agency Networks act as single agents ofchange; Advocacy & Amplification (often policy networks) . Those coming together to undertake a shared activity or work programme)Support Networkse.g. AQuA – the Advance Quality Alliance is a network of networks, supporting individual members to innovate and support improvement in services. The aim is to support/actindividually, but receive support from network; learning and experimenting; collaboration between members etcSocial Networkse.g. Facebook/Occupy: Social – individuals for intelligence/support; power and influence; temporary space; Social Movements - Try, try again; diversity.Enclave Networkse.g. Dispov Leeds: The Disrupting Poverty in Leeds is a group of people concerned about the impact of poverty in Leeds and doing what they can to disrupt it. Individuals meet tolearn approaches that could help them reduce poverty through their work and community etc. (Enclave networks are generally self-directed learning associations: Informal butprofessional networks that seek to share clinical knowledge and expertise but without central authority)Communities of Practice .LD Programmes (for learning and practice development) Communities of practice take place in health organisations where groups of people come together to learn about aspecific practice together e.g. pain management. CoPs are also often integral to NHS learning and leadership programmes, where learners commit to learning about andimplementing new practices together.Advocacye.g. Parkinson ‘s Action Network – a united voice advocating for a cure.10

1. Background1.1 Background to the Study1.1.1 Introduction to this studyThis brief study was commissioned by the Health Foundation as part of its programme onSupporting Networks. The aim of the programme is to:Create productive relationships with networks doing work aligned to the HealthFoundation’s mission to build our collective insight and extend the reach of thelearning we all bring.Explore and develop the potential of network approaches to improve quality as part ofthe prototyping phase.It became evident that there were a plethora of type of networks operating in theNHS, a range of scales of networks and a range of stages of development. It alsobecame evident that networks require different types of support based on thesecategories. This brief review of the literature was commissioned to illuminate:(a) Successful network types(b) Issues that will help determine how best to support those networks.(c) What further evidence will be required in order to support the Network Programme?1.1.2 The contextMuch literature and theory exists about structures and strategies in Public Sector Networks(PSNs) (See Section 2.2.3) and Health Care Networks, however gaps exist in terms of hownetworks actually improve patient care (Huerta et al., 2006), and the reasons why the currentnetworks have formed. The DoH, (Department of Health., 2000) outlined a modernisationframework (NHS Plan) approximately twelve years ago, which, in a trade for more resources,stipulated that the NHS would reform to meet 21 st century challenges. Collaboration,learning, evidence-based practice, QI and diffusion of good practice were central policythemes in the NHS Plan. Another key theme was networking between different agencies(Ferlie et al., 2010). Since then the UK’s ‘Transformational Government’ white paper andconsequent policy reports foresees local authorities evolving from a rigidly structured andhierarchical model to a fluid, dynamic and boundless structure to facilitate multi-agencyworking, shared services, inter-operability and citizen participation. This has been labelled asa paradigm shift (Ho, 2002). The current NHS White Paper: 'Equity and Excellence:Liberating the NHS' 2010 provides an overall framework for Clinical Commissioning Groupswhich it could be argued are suited to a network approach of engaging multiple owners andstakeholders in decision-making. The NHS is moving towards network approaches in otherways for instance the work on integrating health and social care (Goodwin et al., 2012), andmost recently the McLean (2011) review of Clinical Networks and Clinical Senates (2011).11

1.1.3 The scoping methodologyA brainstorming session was held at CIHM in February 2012 in order to place this study incontext and to review the current state of healthcare networks.CIHM with researchers from Leeds University Business School synthesized the key issuesand challenges for participants around health care networks before embarking on a short butintensive literature review to determine what exists within the confines of health carenetworks and beyond. A list of network types emerged from this grounded approach whichcreated the foundation for a literature review.The brief literature review was then undertaken to determine network literature and theoryand to ascertain any evidence that may exist for successful network types. A fullysynthesized literature review was beyond the limited and rapid scope of this consultationexercise because of time constraints. Bibliographic databases were explored including Webof Science and The Social Science Citation Index (Google Scholar). Searches wereconducted across disparate domains, rather than reviewing the entire literature within a givendiscipline, although we did focus predominantly on healthcare networks. Articles werescrutinised and synthesised, however synthesis proved challenging because of theinterdisciplinary nature of this study. Donner (2008) notes how interdisciplinary literaturereviews differ from single disciplinary reviews because: ‘[Difficulties lie in identifying] clearboundaries for which sources should be included in the review. It’s difficult to assess therelative quality or importance of one work versus another. Anthropologists and economists,for example, bring quite different perspectives to bear on the same phenomenon’ (Donner,2008: p.142).Chapter 1 highlights the theoretical basis of networks per se and determines networkcharacteristics in terms of their structure, functions, role and purpose. We also seek to clarifythe difference between a network and a system. Chapter 2 then reviews each respectivenetwork by type. Chapter 3 explores the critical issue of network governance beforeevaluating each network by type in Section 3.3. A brief overview of network failures isprovided in Section 3.4, before Leadership is discussed in the context of networks in Section3.5.We acknowledge that the current scope is particularly large, but has been necessary tocapture all network types and learn how they work in the current healthcare climate. Weconclude by finding that a plethora of inefficient networks exist within health care which arenot being exploited to the benefit of their members, the NHS and wider society.1.2 Background to Networks1.2.1 An introduction to networksNetworks are best understood as an evolving, under-developed inter-disciplinaryphenomenon that transcend strategic management, business and management,organisational theory and behaviour, administrative government, political science, physicsand health care (Provan et al., 2007). Networks exist in one respect on a continuum(Goodwin et al., 2004) from the ad-hoc to more established endeavours for protractedsustainability (Swart and Henneberg, 2007), and encompass: ‘coalition, partnership, alliance,union, league, association, federation [and] confederation[s]’(Wilson-Grau, 2007: p.1).However this erroneously implies that networks are one-dimensional. Goodwin and12

IntegrationWeakStrongcolleagues (2004) identified four core types of health and social care networks: Informational,Coordinated, Procurement and Managed. Each contains distinctive characteristics in termsof network goals, management structures and overarching ideals. Litwin (1995) distinguishedbetween four different social network types: Kin Network, Family Intensive Network; FriendFocused Network; Diffuse Tie Network. Litwin also distinguished between grades ofperceived obtainable social support on four detached measures: 1. emotional; 2.instrumental; 3. affirmational support; 4. advocacy assistance. Carlsson (Carlsson, 2003)identified three types of inter-organizational networks: extra-networks; inter-networks; andopen networks.Perri and colleagues provided a typology of healthcare networks based on a four cell matrix(Also see last paragraph in Section 2.1.1) of networked forms (Perri et al., 2006 in Ferlie etal., 2010: p.40/41).:Regulation/Integration Matrix: Perri 6' Four Cell Matrix of Network FormsRegulationWeakStrongIndividualismIsolateEnclaveHierarchyPerri et al.then applied the matrix to current literature which: ‘suggests a ‘continuum’ ofnetwork forms ranging between ‘loose’ (e.g. learning and informational networks) and ‘tight’(e.g. managed clinical networks). A common assumption within the health care managementliterature that the ‘tight’ (most managed) form is desirable is to be investigated’ (ibid,). Aprofile of Public Health Networks, (PHNs) (as an example of health networks) from 2005illustrates the different planes of networks in English regions which operate across thefollowing levels and beyond: a single PCT, a group of PCTs, throughout the SHA and at theregional level. Network membership encompasses three or more areas including a nucleusof public health professionals (‘including public health specialists, healthprotection/communicable disease specialists, health promotion personnel, and informationspecialists’), a broader hub of public health practitioners such as health visitors, and a widergroup of individual stakeholders across the local authority, voluntary and third sectors (Abbottand Killoran, 2005: p.2). Public network literature is also considerably fragmented,encompassing a plurality of definitions, theories, methods and explanations (Turrini et al.,2010). This literature review is concerned with the type, structure, governance and future roleof networks in health care which encompass informational networks (education, guidelinesand research) to more co-ordinated forms of network including joint assessments, care13

pathways, managed clinical networks (or often no binding contract at all). Irani noted howhealth care networks broadly encompass:1. Clinical Association: this is an informal group that corresponds or meets to considerclinical topics, best practice or other areas of interest2. Clinical Forum: this is a more formal group that meets regularly, focuses on clinicaltopics and formulates jointly agreed clinical protocols3. Developmental Network: this is a clinical forum with broader focus other than purelyclinical topics, with emphasis on service improvement4. Managed Clinical Network: this network includes function of a Clinical Forum and hasa formal management structure with defined governance arrangements and specificobjectives (Irani, 2011: p.4).Other networks include client based networks (Provan and Milward, 2001) carer networks(Abel et al., 2011), personal clinical networks (Sokolovsky et al., 1978), person-centrednetworks (Wellman, 1999) and clinical education networks (Guilbert et al., 2004). There arealso procurement networks (Perri et al., 2006) and the traditional highly managed networksof partners who provide and co-ordinate care for whole populations (Smith, 2010). Allen andMervyn (Allen and Mervyn, 2012: forthcoming) validate the work of others (Pettigrew, 1999,Pettigrew, 2000, Pettigrew et al., 2001, Fisher et al., 2004, Counts and Fisher, 2008, Fisheret al., 2010, Chatman, 1991, Chatman, 1996, Chatman, 1987) who found that underservedpeople in complex environments are more inclined to embrace inter-personal networks andunconventional sources as opposed to hierarchical, top-down sources associated with publicservice providers.This literature review is proposed as a means of understanding the nature of networks, withinthe context of the public sector and healthcare, and their objectives, relationships andpremise in the current healthcare climate (with a particular interest in future trends), and mayinvariably help to enhance the value of investments in the various health programs (Maysand Smith, 2011). .Research has explored the emergence of networks with public, private partnerships (PPPs),(Angelopoulos, 2010), and a: ‘...PPP can be conceptualized as a network in whichstakeholders are interacting nodes that establish formal as well as informal relationships’(p.3). However: [CIHM] do not equate partnership working with networking as this may leadto erroneous conclusions. Neither do we intend to explore public health per se; rather,healthcare networks are of prime concern.1.2.2 Network Characteristics iNetworks are quite unlike random graphs; rather, real networks are ‘non-random in somerevealing ways that suggest both possible mechanisms that could be guiding networkformation, and possible ways in which we could exploit network structure to achieve certainaims’(Newman, 2003: p.9). Many observers have attempted to define networks through anadapted version of O’Toole’s (1997) explanation: ‘…structures of interdependence involvingmultiple organizations or parts thereof, where one unit is not merely the formal subordinate ofthe others in some larger hierarchical arrangement’ (p.45). O’Toole specifically defined anetwork as a: ‘... pattern of two or more units, in which not all the major components are14

encompassed within a single hierarchical array (O’Toole, 1997: p.3). Castells (1999b)defines a network as a set of interconnected nodes, hierarchical and/or organic and fluid, anddevoid of a centre. Networks are essentially relationships which organically evolve; they:“Form and re-form, in endless variation. Those who remain inside have the opportunity toshare and, over time, to increase their chances. Those who drop out, or become switchedoff, will see their chances vanish” (iv). Perhaps this presumes that they have movedsomewhere else to increase their chances – especially if the network no longer meets theirneed. Different people may create contrasting types of networks whilst simultaneouslybelonging to a variety of different networks (Angelopoulos, 2010: p.4).Networks encompass organisational type, delivery mechanisms (for services and functions)and forms of collaboration (Abbott and Killoran, 2005). Lloyd et al., (2001) describe the rangeof collaborative efforts as encompassing interagency, inter-professional, inter-sectoral,partnership and multi-agency (Warmington et al., 2004). Lloyd and colleagues acknowledgethe diversity of working definitions and attempt to define the pre-eminent structures andpractices from academic and policy literature.Interagency working: more than one agency working together in a planned and formalway, rather than simply through informal networking (although the latter may supportand develop the former). This can be at strategic or operational level.Multiagency working: more than one agency working with a client but not necessarilyjointly. Multiagency working may be prompted by joint planning or simply be a form ofreplication, resulting from a lack of proper interagency co-ordination. As withinteragency operation, it may be concurrent or sequential. In actuality, the terms‘interagency’ and ‘multiagency’ (in its planned sense) are often used interchangeably.Joined-up working, policy or thinking refers to deliberately conceptualised and coordinatedplanning, which takes account of multiple policies and varying agencypractices. This has become a totem in current UK social policy (Warmington et al.,2004: n.p).Conversely, intra-agency networks are associated with small work teams and groups withinsingle organisations (Lazer and Katz, 2003). Perhaps organisations such as the North EastLincolnshire Care Trust Plus may not merit the network label because of its status as anorganisation – a single employer and provider of integrated health and social care (whereadult social care commissioning and subsequent provision shifted to Primary Care Trust fromthe local authority). There are now integrated (joint) health and social care teams constructedaround a single care co-ordinator with pooled resources (budgets). One central leadermanages the complex care provided by disparate people and teams (Smith, 2010), but it hasdeveloped the Accord Membership Body as a vehicle to recruit the local community to bepart of on-going involvement network. Members were consulted about the care trust’sstrategic direction and priorities, and could also be more directly involved if they stood forelection onto one of the four Commissioning Groups (Miller et al., 2011: p.19).1.2.3 Network FunctionsNetwork classification is connected to network structure, the character of its nodes (e.g.technical, individual, group, and organisational) and its purpose (Newman, 2003). Networksoffer a contested option for agents seeking to influence policy and practice, and mayeventually become the fore-most collaboration mechanism. They do not exist in a vacuumbut are formed from an initial idea and constructed upon the priorities of participant members15

in terms of a shared vision, commonality of objectives, analogous history, interests andidentity (Hearn and Mendizabal, 2011). Various networks already exist, however issues havebeen raised in terms of their visibility and levels of formality.1.2.3.1 Network MembershipResearch developed through the Networks Function ii approach (Mendizabal and Hearn,2011) lists network membership as a critical factor in the accomplishment of a network’sobjectives.Participant membership takes many forms beyond a simple insider-outsider dichotomy which encompass the coreleadership who set strategy; active members who participate, contribute and represent the network beyond itsconventional boundaries; inactive members who retain a diluted form of association, and finally peripheral figuresthat are not associative members per se but perform critical brokering roles [(Mendizabal and Hearn, 2011)].Networks are often fluid and undefined: their form and structure evolve over time because ofthe turn-over of diverse members whose roles and relationships exist in flux (Angelopoulos,2010). Network membership compliments the development of a participant members’competency portfolio and enables the broadcasting of ‘individual performance towards anaudience that is ready to promote’ (Büchel and Raub, 2002: p.588). Membership preferencesplay a determining role in where the Secretariat seeks to deliver value (internally orexternally); it determines the availability of network resources through participant membersand determines the location of power. One should observe how the core:‘...characteristics of the internal and external environment affect the network’scapacity to deliver it’s roles and functions’ (Mendizabal and Hearn, 2011: p.20).Agency type participation and the construction of networks that incorporate a peer elementtender a sense of belonging to a collective community (Hardiman and Segal, 2003).Research (Balkundi and Kilduff, 2006) has noted how leadership is based on the delicatemanagement of social relationships. From the cognitive networks of the leaders mind (egonetwork) to the organizational network and inter-organisational network, social bonds (SeeSection 2.3 and Section 3.3.4) are created and maintained; activities are created or avoided:‘...and through these actions and interactions, the work of the leader is accomplished.Building on the idea that networks are both cognitive structures in the minds of individualsand actual structures’ (p.434). Community based organisations are accountable to their ownset of constituencies such as donors/funders, regulators and clients. These stakeholders areoften uncomfortable about inter-agency collaboration because it is not necessarily seen intheir best interest. This is particular true when the agency’s managerial independence andself sufficiency will be reduced and sparse resources are shared (Provan and Milward,2001).Reciprocity, generosity; diversity; fluctuating involvement and distributed leadership are essential to effectivenetworks. These relationships are critical to networks functioning well in any type of network (CIHM, 2012).16

1.2.3.2 Network StructuresNetwork structures can be fixed or endogenous (Young, 2006). Daugbjerg & Fawcett (2011)discuss the dissimilarity between power relationships on a state-society axis and interestintegration axis respectively. The former axis was referred to as forming the vertical powerrelations within a network and the latter as the horizontal power relations. It was reported thatnetworks that seek to formulate and implement public policy are typified by variation acrossthe two axes:The governance network school, with its primary interest in the changing nature ofstate-society relationships, has focused on the vertical axis. The policy networkanalysis school, with its interest in power relations between the various interestsaffected by the policy outcomes produced by a network, has focussed on thehorizontal axis. Neither school would reject the existence of either dimension ofpower but we would argue that each school does have a tendency to privilege oneaxis over the other (p.3).Slaughter (2004) also describes how network structures may be vertical and/or horizontal.The objective of vertical networks is the alignment of both national and supranational rules,norms and conventions via various modes of enforcement. Conversely, horizontal networksinextricably rely on knowledge and informational exchange in order to build capacity and alsoto construct and conform to global regulations and policies. A systematic literature review(Cunningham et al., 2011) noted how most studies used social network analysis to explorestructural relationships in networks. Structural network vulnerabilities were identified as smallgroups (including professionals) with special bonds who (perhaps) invariably exclude others,and over-reliance on centric agencies and/or specific individuals. Cunningham andcolleagues concluded that the most effective healthcare networks contain structuralcharacteristics including intermediaries, interpersonal bridges, social capital, trust, densityand centrality. Networks are articulated through their relationships and core roles andfunctions, rather than their structure per se (Mendizabal, 2006b): ‘Networks can take manyforms to deliver similar functions, depending on a broad range of factors. To determine anetwork’s capacity to deliver its functions, we should ask whether its structure is the mostappropriate one’ (Mendizabal and Hearn, 2011: p.19).Ferlie described how some healthcare functions in Scotland and Wales are outsourced tosecond and third sector providers such as long-term residential care and elective surgery.These functions are subject to appraisal and regulation but not vertical line management(Ferlie et al., 2010). Research is increasingly focusing on: ‘...collaborative work acrossdisciplines and organisations in accelerating implementation of best practices along thecontinuum of care, and how e-technologies influence access, sharing, creation, andapplication of knowledge’ (Poissant et al., 2010). Studies have explored structure andchange in child mental health service delivery networks (Johnsen et al., 1996). Johnsen andcolleagues found that, from a structural standpoint, two similar networks that originated atdifferent levels of systems development will evolve in a relatively similar manner over time(Johnsen et al., 1996). Most studies from the aforementioned systematic literature review byCunningham identified the characteristics of a network structure connected with betterperformance. Persisting success factors relate to understanding the network'scharacteristics, ensuring its smooth functioning and taking frequent steps to facilitate itsimprovement. Nonetheless, they conclude that precious time spent on nurturing networkdevelopment does not automatically equate with patient improvement. They note how17

Rangachari (Rangachari, 2008) took a different approach by connecting network structurewith quality outcomes. Rangachari used SNA to analyse relations between the knowledgesharingstructures within four organisations (Large US teaching hospitals) and their(hospitals) coding performance which was linked to quality: ‘Good-coding performance wasassociated with a knowledge sharing network structure rich in brokerage and hierarchy (withsenior leaders coordinating knowledge exchange related to quality and connecting theorganisation with the external environment), rather than density (with everyone connected toeveryone else)’ (Cunningham et al., 2011: n.p). Delivery networks within healthcare are seenas groups of:“...three or more autonomous organizations working together across structural,temporal and geographic boundaries to implement a shared population health orhealth services strategy that primarily exploits current research findings rather thanseeking new knowledge” (Huerta et al., 2006)Hearn and Mendizabal describe the premise (functions) of what a network actually does:‘Research by the RAPID programme at ODI has identified a number of non-exclusivefunctions across most networks: community building or coordination; filtering information andknowledge; amplifying common or shared values and messages; facilitating learning(research-based or otherwise) among the members; investing and providing resources, skillsand assistance; and convening different stakeholders and constituencies’ (Hearn andMendizabal, 2011: p.2). They conclude by highlighting the network form in reference toMendizabal’s earlier work (Mendizabal, 2006b), in the context of its structural andorganisational characteristics which encompass spatiality, thematic range, participantmembers, governance, the immediate context of the community and wider context of theexternal environment, strategic network capacity, adaptive network capacity and resourcesincluding funding, skills, meta-competencies and communication (Hearn and Mendizabal,2011). Although the advocacy role for non-profit leaders is under explored, experts in thenon-profit domain concur that advocacy is a core function of the non-profit sector (NonprofitSector Strategy Group., 2000).18

The Network Functions approach is itself constructed around six functions (below) thatnetworks execute in varying guises, and acknowledges that networks often offer a supportand agency role to participant members (Mendizabal and Hearn, 2011).Community-building: The network functions to promote and sustain the values of theindividuals or groups.Filtering: The network functions to organize and manage relevant information formembers.Amplifying: The network functions to help take new, little-known, or little-understoodideas and makes them public, gives them weight, or makes them understandable.Facilitating: The network functions to help members carry out their activities moreefficiently and effectively.Investing/providing: The network functions to offer a means to provide members withthe resources they need to carry out their main activities.Convening: The network functions to bring together different, distinct people, or groupsof people with distinct strategies to support them (Mendizabal and Hearn, 2011: p.19).The Network Functions approach stipulates the overlapping nature of these functions, anddetails how networks provide a blend of each function to accomplish their core role in both anagent capacity and/or as supporters of change. Turrini, Cristofoli and colleagues (Turrini etal., 2009) provide three groups of variables that help to understand network effectiveness(See Section 3.3): network structural characteristics, network functional characteristics andnetwork contextual characteristics, all of which in varying degrees control networkeffectiveness. Networks have spontaneous and informal characteristics which differ fromother organisational forms and which illuminate the importance of individual level outcomesthat are generated. Member participation is often correlated with public value and individualinterest (e.g one sees the value of participating) (Büchel and Raub, 2002: p.588). Turrini et al(2009) then identify four key functioning aspects of effective public networks:Buffering instability/nurturing stability: such as the capability to address problemsamong partners in order to enhance ‘bridges’ among participant memberorganisations. (May include negotiating adjustments to the structure and processes ofnetworks which are seen to be poorly functioning.Steering network processes: where public administrators plan the scope/direction andcreate network missions from above.Traditional managerial work: requires public managers (in context of networks) toeffectively implement systems and encourage employees and wider staff to performwithin the networked environment.Generic networking: entails effective interactions and relations with people frombeyond the confines of a manager’s direct line of sight (control).19

Turrini et al (2009) also raise four supplementary forms of network effectiveness. The firsttwo categories: community effectiveness and capacity to achieve stated goals are associatedwith those outcomes that are exterior to the network itself. Community effectiveness relatesto the capacity for community engagement capacity. Conversely, network ability (to achieveits stated goals/objectives) is realised through developing or taking control of the requiredcapability (and resources). The two final network effectiveness categories are associatedwith internal outcomes and reflect the sustainability and feasibility of the network, and alsothe ability of networks to innovate and evolve in a fluid and dynamic manner. The premise ofthe aforementioned outcomes and the methods used to achieve these are in contrast tomarkets and bureaucracies. Subsequently, in the light of these differences, the role of publicsector organisations and agencies tend to alter under network arrangements where thepublic administrators become a central agent within a top down arrangement.1.2.4 System vs. Network: When is a Network not a Network?Hierarchies, networks and markets are modes of social coordination: often appearsimultaneously and in dynamic blends within PSOs, healthcare and between thepublic-sector and non-state entities.Networks are quite unique and rely on reciprocity, purpose, forms of distributedleadership and trust.Newman refers to the web based technologies, the internet, social networks and also‘...organizational networks and networks of business relations between companies, neuralnetworks, metabolic networks, food webs, distribution networks such as blood vessels orpostal delivery routes, networks of citations between papers, and many others’ as systemswhich take the form of a network (2003: p.2). The literature distinguishes between networksas highly functional organisations and hierarchical institutions, or predetermined projects(Hearn and Mendizabal, 2011). However the distinction is not always evident. Networks areseen as distinct forms of social organisation which differ from the traditional organisationwhich relies on hierarchical, top-down powers to achieve strategic objectives (Plastrik andTaylor, 2006). A seismic change to full network modes must include process changes andthe replacement of vertical management by broader, tangential leadership (Martin et al.,2009). Agranoff & McGuire (2001) highlighted the difference between managing withinindividual organizations and managing in networks. Networks also differ from markets whichconsist of buy-and-sell transactions, because consumers often have no immediateconnection with one another. Buy-sell supplier networks tend to work quite well (Gadde andHåkansson, 2010) and perhaps have something from which healthcare can learn in regardsto commissioning.Beverland (2001) noted from a collaborative procurement perspective how latent (possible)benefits are correlated to a reduction in uncertainty experienced by each solitary organization(Bakker et al., 2008). (Section 2.2.1 describes how tensions within individualisticprocurement networks exist between consumer choice (Payment by Results) versus theforce for integrated care partly through managed networks). Paradoxically, networks maycontain essence of both (of the aforementioned hierarchical or laissez faire components),which subsequently contain network structures. Ferlie and colleagues encapsulated thedistinction: ‘Usually considered as an alternative to a market, or a hierarchy ‘...withinhierarchically based organisations [...] the command is the basic instrument of control. In20

markets, transactions between producers and consumers are governed through price 1 . [...] Innetworks, co-ordination is achieved through mutual informal contact, negotiation andadjustment within a high trust social community or ‘clan’, such as a profession’ (Ferlie et al.,2010: p.13). In a similar vein: Agranoff concluded that ‘An internal look at networks indicatesthat although they are largely self-organizing, they require structuring that reflects theirknowledge seeking orientation. They need to be managed like organizations but incollaborative, non hierarchical ways. Indeed, the data – information – knowledge function ofnetworks is so paramount that their collaborative communities of practice across agenciesdistinguish them from more bureaucratically oriented hierarchies’ (Agranoff, 2006: p.63).However networks already contain elements of structure, else they would have difficultystarting. Lovseth (Lovseth, 2009) notes how government must position itself at the heart ofsocial networks which will in itself garner its ability to structure actions, communication andknowledge flow. These call for a radical re-shift from its traditional role of determining anddriving actions (in order to bring about change) to becoming a facilitator and catalyst forcollective deeds. This can be undertaken by creating the space for human development, byincreasing awareness, nurturing innovative thinking and instigating cultural change in anattempt to garner grassroots participation. This change in emphasis requires novel forms ofleadership (Waterhouse and Keast, 2011).This section seeks to distinguish between an adaptive system and a network (CIHM 2012).Complex systems may perhaps be a collaborative resolution to teenage pregnancies.Adaptive system is a set of relationships between agents, interconnected with ashared and common purpose.Each agent continuously (consciously or unconsciously) affects the other on a sharedwicked issue.Boundaries of system are determined by the question: e.g. How to reduce teenagepregnancy? One would describe the agents related to that place/locality/community (CIHM, 2012).Adaptive systems organise through:Clarifying collective purposeGenerating guiding principles to shape behaviour within the systemBuilding relationships in order to make the most of each others’ potentialGetting clear together what is actually going on here and nowGenerating visibility for the knock-on effects of any action in part of the systemSurfacing and working with diverse/different perspectives – the system looks differentdepending on where you are in it.Feedback loops – agreeing what ‘better’ looks like and metrics to enable the whole tomake sense of the action it takesSense making: taking time to review what is working / not working and why? Thisincludes challenging assumptions held in parts of the systemConnecting the system to itself via multiple conversations and stories1 And quality, as a form of price is evident within public sector markets. Non-profit entities that ‘face the non-distributionconstraint’, are much less likely to reduce service quality ‘to funnel profits into directors’ pockets’ (Marwell and McInerney,2005: p.8)21

Trying things out: just taking some steps and collectively working out what happened,and doing this iteratively Being future focused (CIHM., 2012).Complex adaptive systems require the cooperation of service providers and users for betteroutcomes (Edgren and Barnard, 2012, Edgren, 2011). The boundaries of the system aredetermined by the question (CIHM, 2012). Interventions may be straightforward or complex,‘...but the complex systems approach makes us consider the wider ramifications ofintervening and to be aware of the interaction that occurs between components of theintervention as well as between the intervention and the context in which it is implemented.This includes the operations, structures, and relations that exist in each setting [...] and theimplications that contextual effects have for designing and evaluating interventions [...]’(Shiell et al., 2008: n.p). And a complex adaptive network can never been formalised, unlessthe adaptiveness is formalised (else a paradox). Analysis of several Social EcologicalSystems (Anderies et al., 2006) implied three core types of social-ecological network effects(in terms of their influence on resilience): ‘People connect ecosystems by information ormaterial flows; ecosystem networks can be disconnected and fragmented, or be increasinglyconnected, by the actions of people; and people create new ecological networks such asirrigation systems’ (n.p). Anderies and colleagues suggest that each type of network facesdistinct and different problems that subsequently manipulate their resilience, and that theaccumulation or deduction of network connections can also influence resilience.22

2 Types of Health NetworksA grounded theoretical approach was undertaken by CIHM which identified six over-archingnetwork areas (health care and beyond), which was then explored within the academicliterature. Further research has illuminated six broad categories. Section 2.1: Managed Hierarchical Networks Section 2.2: Developmental Networks, Section 2.2.1: Two sub-types ofDevelopmental Networks (Co-ordinating Networks and Individual ProcurementNetworks)Section 2.3: Social Networks/Media.Section 2.4 Agency Networks/ Policy Networks; Sections 2.4.1 and 2.4.2 NAAPS andTower Hamlets case studies Section 2.5 Learning Networks 2.5.1 Communities of Practice; 2.5.2 EpistemicCommunities 2.5.3 Support Networks 2.5.4 Enclave Networks / Individual Networks;2.5.4.1: three types of Enclave NetworksSection 2.6 Advocacy Networks; Section 2.6.1 Transnational Action Networks2.1 Managed NetworksEvaluation of managed clinical networks with summary list in Section 3.3.5Characteristics: Traditional Model; Mandated work; Hierarchical; Clear Allocation ofLabour; Competency (for creating pre-specified tasks)Leadership: Transactional; Autocratic / Hierarchical Leadership; Central leadershipmust translate vision into strategy and strategy into operational actions.Governance: Hub and Spoke Governance Structure: Not particularly network-centricor organization-centric. No distinct corporate shape but definitely has a top-downstructure and fails to offer anything unique in comparison to other network formswhich are more fluid and undefined.Failure: Authorized networks have a history of ineffectiveness because networkmembers may not recognize the authority required for their governance. Hub-and –spoke centralized networks must decentralise communications; outer layers unable toengage in meaningful discussion; hub and spoke structure is constrained if aneffective (high functioning and successful) leader leaves his postThe key characteristics of managed networks, such as those that result from policyinitiatives(Evaluation of managed networks in Section 3.3.2), often include the use of a forumand formal management structures. Governance is unambiguous and clearly defined, andthe hub has clear authority and power to regulate its members or member’s organisations(Mendizabal and Hearn, 2011). Arrangements for external accountability and targetedobjectives are linked to a written and agreed strategy, and they often consist of a: ‘...directsteering group and often accredit or inspect providers, specify requirements and manage atask to deliver change. This might be a contract with the responsibility of agreeing itsspecification and reducing transaction costs, or an agreement to produce a binding protocolor remodel a service. They have a dedicated manager and either budgets to manage or defacto determination of the use of budgets held by a host organisation’ (Harris, 2005: n.p). Thebenefits of managed networks include greater competency for completing pre-specified tasksand clarifying the division-of-labour element across different individuals/organisations.23

Success is attributed/dependant on the level of authority and power accorded/agreed at theoutset (see Ferlie et al., 2012). Conversely, managed networks are constrained by the needto reach objective agreement and clarification of the division-of-labour process (task anddecision-making) by the network host agency. Further pitfalls are related to their high levelsof bureaucracy and transaction costs; a tendency to over regulate and lack of professionalappeal (to engaging professionals). They also have a tendency to:‘...reach gridlock and can fail if there is a challenge to their authority where they denyaccess to the host superior body. There is a real tension between the managednetwork of this kind and the promotion of Choice and Diversity by the DH. As animposed or mandated network, this model will have sub optimal outcomes, unless theobjectives and priorities are shared and link directly to those of member organisationsand professionals’ (Harris, 2005: n.p).2.1.1 Examples of Managed NetworksManaged networks have been effective at purchasing cognitive health services in NorthAmerica, and for attaining integrated care pathways, ‘...but the evidence of theireffectiveness are not clear from the literature. The key lesson is that implementation of a newICP needs executive level decision making as well as a comprehensive educational andfacilitation programme to gain professional ownership and acceptance’ (Harris, 2005). TheUKs national health service (NHS) has witnessed an increase in managed networks as a toolfor streamlining and standardizing healthcare across organizational and professionaldomains, yet research fails to adequately support the notion that managed networks shouldcontinue to be the foremost management approach for the delivery of health-based services(Addicott et al., 2007). In managed hierarchical networks, a core team sets the agenda, orperhaps it is set centrally and the network responds, such as the National Cancer ActionTeams’ (NCATs) multi-agency response to the national cancer programme 2 . 28 NHS Cancernetworks in England offer specialist advice to GPs. These networks operate across PCTs,bringing together healthcare professionals to assess and make decisions about developingmedical treatment within certain areas (Burki, 2011). The national cancer programme andsimilar hierarchical approaches seek to improve the practice of the parts through propermeans, yet require a leader to coordinate delivery. The Diabetes Research Network 3 (DRN)is a managed network of primary and secondary care centres. DRN has a co-ordinatingcentre - a consortium between Imperial College (London), and the Oxford Centre forDiabetes Endocrinology and Metabolism which manages local research networks specificallydesigned to reach a broader demographic. Rosen, Mountford and colleagues (2011) reporthow North Lanarkshire Health and Care Partnership (NLHCP) is an assemblage of agentsincluding North Lanarkshire Council and NHS Lanarkshire who collaborate to deliver betterintegrated services to four care groups: older people, people with disabilities, addictions andmental health problems. This is a long-standing partnership which has solidified over timeand cumulated in a joint governance and accountability framework to formalise the networks’roles and functions. Subsequently, many service users now benefit from a single sharedassessment. Further impact emerged from a division-of-labour perspective through membersof integrated teams operating to shared protocols, seeking common outcomes, and in some2 See http://www.ncat.nhs.uk/24

espects, referring directly to fellow networked participant’s’ services without seeking third–party (GP) permission:The integrated governance framework establishes the mechanisms by which thestrategy is set and implemented across each care group, allowing adjustment forgeographic variations and creating accountable local groups (‘care partnershipgroups’) to operationalise integrated care locally. It also sets out the reportingarrangements through which each tier of the partnership is accountable for deliveryagainst the national community care outcomes framework and other locally agreedperformance standards and outcome measures. There is no emphasis on usingfinancial incentives. The result is integrated health and social care teams for olderpeople with mental health problems, and collaboration between community nursingand social care teams through shared standards and processes to improve quality(Rosen et al., 2011: p.20).Rosen and colleagues note how the enablers of integration included a joint vision shared bysenior decision makers in health and social care which was connected to a joint governancesystem to drive integration across the afore-mentioned (4) care groups and without spatialconstraint. The history of partnership working and joint planning led to the emergence of arobust and effective network consisting of: ‘...skilled leaders with the ability to ‘win the heartsand minds’ of front-line staff; staff commitment...; joint training and development including jobshadowing, joint education, and organisational development work; taking an incrementalapproach and seizing opportunities as they arise’ (p.21).Much can be learnt from matrix management as these networks are often little more thaninter-agency matrix organisations. Research on employee networks has found lots ofinformation and knowledge flowing through social and informal networks as opposed to ‘howlittle through official hierarchical and matrix structures’ (Bryan et al., 2007: p.1). Bryan andcolleagues also believe that formalised networks have a role and can effectively replaceobsolete and burdensome matrix structures. The governance of matrix organisations differsfrom networks because it organises work through authority and is founded upon amanagement hierarchy in comparison to formal networks with organise through a commonpurpose and are collaboration based (ibid). Davis and Lawrence (1977) explored hierarchicalreporting structures in organizations, and noted how in matrix organizations, employees oftenreport via command systems (two or more systems). One usually relates to a function (e.gengineering), and another relates to a product (e.g mobile phones) (Cummings, 2004). Thisform of organisation has several strengths such as enhanced communication options and‘flexibility of resource use’ [...], and the implication of having different reporting managers ingroups is that members have access to diverse social networks through their managers’(Cummings, 2004: p.353).3 See http://www.ukdrn.org/documents/DRNbrochure.pdf25

2.2 Developmental NetworksCharacteristics: Enhanced lucidity of professional identity (Dobrow and Higgins,2005). Interest encompasses professional training and development and informationsharing to include service improvement. Informal relationships between differentagents/bodies and driven by professionals from their stakeholder organisations. Oftenemerge from a forum and are interested in the system as opposed to topical issues.Leadership: Vision of decentralized leadership; distributed leadership; manystakeholders have important roles in developing and sustaining a network (+ keepingthe network productive); wearing different hats when required (vibrant and adaptableto changing contexts) key to network sustainability. Fiscal leadership may emerge asdistinct role in fluid networks.Governance: Relatively easy to agree on the network mission, objectives andpriorities. Principle levers: draw upon power and influence of clinical and specialistHealthcare champions (as opposed to contacts or service level agreements (SLAs).Failure: Not properly embedding leaders within a network to ensure that the coordinatordoes not get snowed under in a hub-and-spoke governance structure.Meta-theoretical studies have explored development in the context of human activity andlabour using networks of interacting and nested activity systems (Engeström, 1993,Engeström, 2005). Research has explored the role of personality in employee developmentalnetworks (Dougherty et al., 2008), the influence of leadership in developmental networks(Lauren and Karl, 2008, Ghosh et al., 2010), the development of Primary Care ResearchNetworks as tools for enhancing service quality (Thomas et al., 2006), and developmentalnetworks within the context of career development where both network resources andconventional mentoring relations cumulate in a person’s social capital (Dobrow and Higgins,2005). Following the work of Granovetter (1973) and others, Cummings and Higgins notehow ties that are elevated in psycho-social support tend to an elevated emotional proximitythan career ties (Cummings and Higgins, 2006).Harris (2005) discussed how the developmental networks approach (e.g. Social networktheory), is particularly salient for studying health care systems because its objectives areoften associated with service development and health care improvement (DevelopmentalNetworks evaluated in 3.3.3). Abbot and Killoran found that many PHNs (which have hadlittle impact and are not the focus of this review) may eventually resemble each other, ‘...andthat many (but not all) apparent differences reflect the current stage of organisationaldevelopment rather than enduring and substantial differences. It is clear that PHNs are in nosense a quick fix. Conditions for their development have been less than ideal – indeed thereis an apparent paradox’ (Abbott and Killoran, 2005: p.3). Developmental networks are quiteflexible and adaptable to changing healthcare contexts, and their principles of effectivepartnership working can have powerful ramifications. They advocate the role of BoundarySpanners: dynamic, neutral, locally knowledgeable and highly literate intermediaries to liaisebetween organisations and network groups:Another organization-specific factor relevant for the understanding of intergrouprelations is the nature of collaboration between organizational groups. Boundaryspanning theory notes that a group’s boundary spanners—those who engage insignificant transactions with out-group members—rather than any individual within agroup, facilitate intergroup transactions and manage intergroup conflicts [...] (Richteret al., 2006: p.1252/53)26

Boundary spanners are effective at focusing on specific tasks (e.g. improving health careaccess or standards of care for specific patient group), and have been: ‘...used to develophub and spoke models of care. They can be innovative and flexible and cultivate appropriatemembership. Changes in individual professional attitude and practice might be achieved andthe commitment to an agreed integrated care pathway might be a tangible outcome’ (Harris,2005: n.p). In this respect, individuals forming the core of the network and who aresubsequently deeply embedded in the network structure are more inclined to keep their tiesestablished in comparison to those on the margins. The core-periphery structure of the wholenetwork provides a greater authority and hence more opportunities to engage (Cummingsand Higgins, 2006). Nonetheless, developmental networks include the complexity of thedecision making process for implementing new structures and innovation services: ‘Thewider the definition of their target group, the more difficult effective decision making. Thesenetworks often throw up conflicts between interests and priorities’ (Harris, 2005: n.p).2.2.1 Co-ordinating Networks and Individualistic Procurement NetworksHarris (2005) discusses two types of developmental networks: co-ordinating networks andindividualistic procurement networks. Co-ordinating networks (Sasieni et al., 1996, Goodwinet al., 2004, Bodenheimer, 2008, Gerwin, 2004) are a blend of enclave (See 2.3.4) andindividualistic networks. Gerwin (2004) explored new product development (NPD) andstrategic alliances, (the latter of which plays a commanding role in NPD within biotechnology),where exterior organisations often seek external artefacts including equipment,knowledge and risk sharing affiliates. Harris notes how an agent (individual/organisation)actively develops a body of members to achieve a certain task: ‘The experience ofbiotechnology firms is that their success depends on successful transfer of tacit knowledge inthe heads of experts and its entrepreneurial application, but that it does not work well througha classic managed hierarchical or individualistic network and requires this hybrid type’(Harris, 2005: n.p). These networks differ from enclaves in silo because there is a specifictask which emerged from a connection with other organisations which express a solidinterest in the task outcome. Network participants broadly understand the legitimacy of thisinterest and hence a form or accountability to an organisation ensues. ‘The task is usuallyeither focused on a hospital to deal with specialisation issues such as clinical standards oraccess, or is in the area of health and social care e.g. protocols, pathways of care’ (Harris,2005: n.p).Individualistic procurement networks are another sub-set of developmental networks which iseffectively a ‘coordinating network with procurement, commissioning or contracting role’(Harris, 2005: n.p). These networks are best developed in the US where health insurancehas driven contracting by integrated care networks. In essence, control of access toresources is: ‘...not originally in the hands of the host organisation as consumers exercisechoice and the network, by its relationships, facilitates greater organisational control over theresource, concentrating that choice in the way that the organisation prefers’ (Harris, 2005:n.p). Conversely, in conventional procurement networks, where multiple commodities aresourced through a common network of suppliers, ‘...allocating capacity appropriately amongthe several commodities assumes great importance in determining the profitability of theentire system’ (Chandrashekar and Narahari, 2011, in Agarwal and Ergun: p.2). Tensionsexist within individualistic procurement networks between consumer choice (Payment byResults) versus the force for integrated care partly through managed networks. In a nutshell:individualistic procurement networks are initially attractive to develop but have significant27

transaction costs. Also: ‘...the lack of sufficient institutionalisation can allow severe conflictsbetween individuals and demotivation of weaker groups’ (Harris, 2005: n.p). A ten yearreview (Dobrow et al., 2011) of developmental networks illuminated a number of issuespertaining to the clarification of the development networks boundaries: ‘...categorizing extantdevelopmental network research into four streams, and identifying new avenues for futureresearch... of primary importance, we highlighted the need for developmental networkresearch to take the viewpoints of all members of the developmental network into account—that is, to adopt a mutuality perspective’ (p.28). Various other guises of developmentalnetworks exist including mentoring networks and social networks. Researchers from bothpersuasions ‘often refer to a number of constructs as being almost interchangeable withdevelopmental networks [...]’ (Dobrow et al., 2011: p.3).2.3 Social NetworksCharacteristics: Those that offer personal support on a broader plane; Horizontal;Mutuality/Collectivist/PurposeLeadership: Tendency in social movements to retire away from leadership or takingthe lead. Charismatic leader sometimes frowned upon, but acceptance of need tohave some sort of leadership competencies and meta-competencies in place. Needto manage connectivity networks (e.g. Weaver: enable people to engage, to meetwith each other, facilitate information seeking); help to socially construct a form ofshared identity; and to manage, co-ordinate and deliver joint actionsGovernance: Bypass central authority; Less Governance Board Structure is MoreFailure: inability to sustain new initiatives; difficult to controlThe norms for defining social capital encompass reciprocity ‘between two friends, all the wayup to complex and elaborately articulated doctrines like Christianity or Confucianism’(Fukuyama, 1999: Section 1). Field, Schuller and Baron (2000), attributed the idea of socialcapital to three key authors: Bourdieu, Putnam and Coleman. Bourdieu defined social capitalas: ‘The aggregate of the actual or potential resources which are linked to possession of adurable network of more or less institutionalised relationships of mutual acquaintance andrecognition…which provides each of its members with the backing of collectively-ownedcapital’ (1997: p.51). In regards to the acquisition of educational credentials in America;Coleman took issue with the dominance of human capital theory over conventional policythinking (Coleman, 1988). He particularly emphasised the value of bonding within localisedsocial ties. Coleman later suggested that social capital was a culmination of resources thatreside in family relations and in community social organisation.These were seen as useful for the cognitive and social development of a young person(Coleman, 1994). Fukuyama took issue with Coleman’s assertion that social capital was apublic good which would be ‘under produced by private agents interacting in markets. This isclearly wrong: since cooperation is necessary to virtually all individuals as a means ofachieving their selfish ends’ (1999: section 1). Field and colleagues were also critical ofColeman’s interpretation of social capital; a point encapsulated by the following quote. ‘Whilewe agree with Coleman on the importance of social capital to the creation of human capital…we have tried to show that he seriously understated the complexity of this relationship. Aboveall, social capital can be used to exclude, or to limit participation, as well as to promote it’(Field et al., 2000: p.261).28

The coalition government’s Big Society agenda 4 has been based on the premise oflocalisation and grassroots participation in contrast to state-led approaches to civil societyand social exclusion. Part of this strategy seeks to transfer power from Whitehall to localpeople and communities, to encourage broader (private and public) ownership of publicservices and to reduce bureaucratic regulation. The Conservative Party’s Green Paper(2009) outlined plans to reconstruct the way central government activities and finances areadministered at a local level under five pillars of change:1. Giving local communities a share in local growth2. Freeing local government from central control3. Giving local people more power over local government4. Giving local people more ability to determine spending priorities5. Removing regional governmentThe Green Paper noted the centralism of New Labour policy and how local governmentspending was connected to national programmes that restricted expenditure decisions.Central Government had also previously specified all Local Authority objectives from aperformance targets perspective. Conversely, the Conservative’s plan to offer local peoplemore power over central government spending in their locale; to liberate Councils frominspection regimes and to eventually eliminate the policy of ‘ring fencing’, implies thatcouncil’s and citizens will have a say in how local budgets are spent (ibid: pgs. 3-4). Howeverthe Big Society agenda is perhaps a false dichotomy (Wells et al., 2011). Drawing upon theRSA Connected Communities report (Rowson et al., 2010), Wells and colleagues note howengagement and participation were now a lower priority in comparison to cost savingmeasures and the drive for externally set targets. The RSA report argues that policies suchas Area Based Initiatives (ABIs) would be significantly enhanced through greaterunderstanding of social networks. ABIs would be solidified if social networks were properlymeasured, and through actively engaging with social networks during the implementation ofpublic policy (Wells et al., 2011).Social networks are of growing interest because of their influence on social processesincluding information processing and diffusion of social influence (Kossinets and Watts,2006). They have long been of interest as dynamic processes per se: ‘Over time, individualscreate and deactivate social ties, thereby altering the structure of the networks in which theyparticipate. Social network formation is a complex process in which many individualssimultaneously attempt to satisfy their goals under multiple, possibly conflicting, constraints’(Kossinets and Watts, 2006: p.88). Open source software developers and insurgent groups(Figure 2) have been compared as interacting agents in a complex web or network (Cui etal., 2011). Cui and colleagues sought to identify the core concepts or self-organized localrules, norms and conventions that add to the global emergence of social behaviours in thenatural world. Their agent based model was created to symbolize insurgent organisationssuch as Al Qaeda using ideas from conflict studies and swarm insect intelligence associatedwith the concept of emergence.4 The UK Coalition Government’s Big Society agenda and localism bill has been proposed as the basis of for apolitical economy and civil society (albeit in the context of current austerity measures). This agenda seeks todevolve power from Whitehall to local areas, to outsource services to private and community/third sectors; tochange the planning system and provide more local control over housing decisions. Also, all national processtargets set for local government will be eradicated.29

The authors acknowledge that the model is flawed in the sense that humans are irrationalbeings, however it ‘...offer[s] powerful and counter-intuitive insight even though it is highlyidealized’ (p.3).Figure 1: Self-organized social organization model takes place in both theinsurgent groups and Open Source Software developer communitiesThis ideological model illuminates the complex form of human-centred, self-organizedinsurgent movements and in an analogous vein, fluid and dynamic organizations, bydesignating each as networks of interacting agents. What appear like conflicting domains areactually the opposite, portraying common patterns of association and organisation throughtheir network structure and purpose. Cui and colleagues also describe how Valverde et al.,(2006) demonstrated common statistical patterns of an organization in both a colony ofwasps and in open source software (OSS) developer based communities: ‘In their research,the agents involved—whether they are social insects or humans—have limited knowledge ofthe global pattern they are developing. Apparently, insects and humans differ significantly inwhat the individual agent can be aware of the overall designing goals’ (Cui et al., 2011: p.3).Social healthcare networks (See 3.3.4.2) are growing in significance (Mudry et al., 2010).Chatman (1992) described the variance and depth of social networks for tackling theinformation needs of retired women in North America who were categorised as informationpoor. Chatman connected social network theory ‘to coping information’ (1992: p.1), in anattempt to frame the study around people in the same social space, and reported how thewomen often thought and acted alike, after conformed to specific social structures from theirimmediate environment. Their activities were shaped according to conventions, whichsubsequently determined the conduct of their co-inhabitants. Chatman concluded that socialsupport systems must exist before people engage in the process of sharing information.Networked social movements including patient groups often use the web to socially constructalternative information sources or to enhance public participation (Ferlie et al., 2010). Winkeland colleagues (2005) found that greater interaction by social networking participantsinterested in the topic of suicidal youth has been correlated with ‘reductions in theparticipant’s self ratings of reductions in suicidal intent’ (Seeman, 2008: n.p). Research insocial networks tackle issues of centrality in the context of which individuals are best linkedto or have most persuasion over others, and connectivity in terms of how people interactthrough network mechanisms (Newman, 2003). Social media technologies are actively30

supporting, developing and solidifying networks: ‘However, surprisingly little has been writtenon their strategic development and management, and even less is known about how capacitycan be built’ (Serrat, 2009: p.12). Research has also identified the challenges of gatheringdata on large scale social network structures (Kossinets et al., 2008).2.4 Agency Networks, Policy NetworksPolicy network literature is often confused with Network Governance: the former is anelement of policy analysis that is based upon a condensed version of conventional /hierarchical forms of governance. Network governance (See 3.1) is associated with aparadigm shift from conventional to plural forms of governing (Blanco et al., 2009)Policy NetworksCharacteristics: policy inspired agents engaging in knowledge sharing; restrictive;closed shop;Leadership: Little dictators in daily process of policy-makingGovernance: Hierarchies remain dominant as policy networks meet the legal andpolicy-based functions of government.Failure: Resistance to change; Democratic Accountability; Shape behaviour ofstakeholders through rules and regulationsAttempts have been made to construct a typology of policy networks, with differentiatedmodels encompassing policy/territorial communities; professional networks;intergovernmental networks; producer networks and issue networks (Rhodes, 1997, Marshand Rhodes, 1992, Rhodes, 2006). Policy networks (McPherson et al., 2006, Rhodes, 2006)encompass agents (individuals and organisations) with a particular interest in policy, andpublic management networks (Ferlie et al., 2011) transcend: ‘...studies of informal andintraorganizational networking among individuals to include interorganizational...[and]intergovernmental— entities that emerge from interactions among formal organizations’(Agranoff, 2006: p.56). McPherson et al., (2006) describes how policy networks provide themeans for knowledge transfer and exchange-based activities to enhance evidence-basedpolicies and systemic change. Knowledge sharing often develops through memberinteraction, thus leading to jointly constructed solutions. Public sector knowledge networks(PSKNs) for example encompass a complex blend of interorganizational relations, policies,information-based content, professional knowledge and expertise, work-based processes,and technological artefacts which are connected to achieve a cooperative public purpose(Dawes, 2005).Agency theory is used by Provan and Milward (2001) as a theoretical lens and analyticalframework for the primary network-constituent groups, by proposing that agents situated atone plane may be a principal on another plane. Each respective group is more concernedwith effectiveness at a specific level of network analysis. The paradox is that networks oftenconsist of long-established programmes and participating organizations that may beculturally disinterested or fearful of change. In contrast with individual organisations, anoverriding dilemma with any attempts to appraise public networks is that external stakeholdergroups seldom subsist for networks (Provan and Milward, 2001). In the USA, most federal,state and philanthropic funding for public health activities is directed through local publichealth organisations, who are tasked with mobilising and directing public health activities ofhospitals, health-plans and neighbourhood-based organisations (Mays et al., 2010).31

Research has explored regional clusters (Sydow et al., 2011), and determinants of networkeffectiveness (Turrini et al., 2009) the latter of which reviewed international journalpublications on the efficiency and effectiveness of public-service networks. Mendizabal foundin reference to his prior research on Ethiopian networks in 1997 that the conventional notionof networks is problematic because ‘...they do not operate as networks at all’ (2008: n.p).Sections 2.4.1 and 2.4.2 discuss two hybrid network approaches. The first briefly exploresthe findings from a review of various agency based approaches and the second exploresnetworks of GP practices which are the basic building blocks for investing in primary care(Ham et al., 2011).2.4.1 NAAPSAgency networks such as NAAPS (Shared Lives) are based upon a need for connectivitybetween the inter-dependant parts and involve acting together but with less diversity. Fox(Fox, 2011) explored a number of initiatives and networks including NAAPs (Shared Livessince 2011), ASA Lincolnshire's At Home Day Resource for people with dementia,Homeshare, KeyRing and various micro-enterprises, and found that a hybrid networkapproach which embraces social networking in conjunction with formal support structures ledto greater impact and outcomes at significantly lower costs.2.4.2 Tower HamletsTower Hamlets was a pilot site for the DoHs Health Integrated Care Programme in 2009which sought to construct new ways of redirecting diabetes care from hospitals to the localcommunity. Tower Hamlets PCT aligned itself with this pilot by establishing coalitions ofpractices 5 (networks). The Tower Hamlets network is now a service funded by a hybridenhancednetwork service arrangement. Tower Hamlets PCT consists of networks of GPpractices which provide the basic building foundation for investing in primary care. This is aninteresting hybrid network model which commissions integrated diabetes to residents inareas of high social deprivation. The network has a contract with the local PCT which issigned by each general practice and subsequently enables practices to be managed as agroup. This grassroots approach enables outcomes 6 and renumeration to be measured atthe network level rather than in silo, so the sum is greater than the parts. Care packages arenow components of a wider alternative provider of medical services contract which enablesvarious services to be managed and scrutinized at the network level. At a wider contextuallevel, the PCT has detached contracts with others including the community diabetesconsultant and the ‘PCT provider arm for the community nurse input. Only the networks haverisk-based contracts. The PCT did consider contracting through a lead provider arrangement,but felt it was too much too soon, preferring instead to integrate provision first’ (Ham et al.,2011: p.42).5 Diabetes care forms part of a wider integrative work programme that incorporates participation in thenational ICO pilot programme instigated by the Department of Health (HAM, C., SMITH, J. &EASTMURE, E. 2011. Commissioning integrated care in a liberated NHS. London: The NuffieldTrust.). Also see http://www.integratedcare.londondeanery.ac.uk/integrated-careinitiatives/diabetes/integrated-working-networks-in-tower-hamlets6 Commissioners often designed contracts connecting a significant element of funding to performancemetrics. Approx 30% of the contracts’ value was dependant on the network of practices meeting theoverall diabetes outcomes indicators such as patient experience, care-planning and ensuring thedelivery of stratification data. (Ibid.)32

Additional support for patients has been discussed in the form of small support groups withinnetworks and there are now multi-disciplinary team meetings in networks iii with support fromconsultants.The PCT faced a number of challenges when attempting to develop the network system,such as aligning community (health) services with the network of practices, and finding alevel of apathy to change, with one high-performing practice averse to sharing its data. Thereare no current incentives for secondary care to support the network of practices; howeverlevers for secondary care to support the practice networks will soon be embedded insecondary services contracts. ‘The networks are currently exploring options for their legalstatus and are keen to clarify arrangements for employing staff, liability and insurance’ (Hamet al., 2011: p.43). Overall, it was reported that the networks have been extremely positive forPCT and GP relations: ‘The managers have been at the PCT for a long time, and thecontinuity of support for the development of networks and investment in primary care hasbeen crucial to their success. The PCT is very conscious that good relationships between thePCT and GPs will be essential in the future’ (Ham et al., 2011: p.43).Health social networks enable client/patients to find others with similar health dilemmas andshare information about health conditions and treatments (Swan, 2009): ‘The collectivelearning and experience of others can be leveraged and shared to help individuals makedecisions. Health social networks are primarily directed at patients but caretakers,researchers and other interested and knowledgeable parties may be able to participate’ (p.495). Client-patient networks can be as formal as Diabetes Association 7 which the UK’sleading diabetes charity, through to the breast cancer patients in Bristol who organisedthemselves and had a huge impact on services in their local area. Shaw and colleaguesfound that while a small number of asthma patient-clients were referred to the NHS’shomeopathic hospital by their family doctor or accessed subsidised therapy through thesame channel, complementary therapies were principally accessed via networks of informalpersonal contacts, beyond the remit of the NHS (Shaw et al., 2006).2.5 Learning NetworksCharacteristics: Identified practice development as shared goal; learn through doingwith others; temporary; soft networking.Role: Learning, can also be about delivery or creation of new knowledge (in theirmost mature form).Leadership: Distributed; requires an eco system that instigates network weavingacross all tiers/levels.Governance: ‘professional integrity and bench-marking, an ecology of weak ties,objects of transversal alignment and inculcation, and arranging for improvisation, formpart of the interactive and governance architecture of successful innovation in expertcommunities’ (Amin and Roberts, 2006: p.20-21).Failure: Breakdown of trust; fatigue; neglects power; CoPs do not acknowledge preexistingsocial codes; weak negotiation powers.7 http://www.diabetes.org.uk/About_us/33

Networks are essentially a form of governance which enables the rapid diffusion of learningand good practice. Network level change is naturally equated with network level learningopportunities (Knight and Pye, 2002). Brown and Duguid (Brown and Duguid, 1998)originated the concept of networks of practice (COP) in deference to work on communities ofpractice . (COP) by Lave and Wenger (Lave and Wenger, 1997 ). Brown and Duguid definethe COP as: ‘A group across which such know-how and sense making are shared - thegroup which needs to work together for its dispositional know-how to be put into practice -has been called a ‘community of practice’ (Brown and Duguid 1998, p. 96). A culture ofknowledge and learning should form the basis of network development (Mendizabal, 2008).Brown and Duguid (2001) suggests that shared practice is the basis on which knowledge isdeveloped in networks, whilst Podolny and Page stated: “network forms of organizationfoster learning, represent a mechanism for the attainment of status or legitimacy, provide avariety of economic benefits, facilitate the management of resource dependencies, andprovide considerable autonomy for employees” (Podolny and Page, 1998).2.5.1 Communities of PracticeThe current healthcare environment has been described as: ‘communities of practice andnetworks, as another popular KM strategy in the health arena, require attention in terms oflong term sustainability’ (Kothari et al., 2011: pgs 6-7). Practice networks and COPs are seenas novel ways of organising and improving health care (Mallinson et al., 2006). (For instancesee NHS Quest 8 and Advancing Quality Alliance 9 ). Client-patients are actively constructingand producing information before making it meaningful and accessible, ‘...by organizingthemselves and the information into knowledge communities’ (Swan, 2009: p.520/21).Warmington and colleagues found that the learning processes that occur within inter-agencysettings and also the learning processes that perhaps could form a precondition to effectiveinter-agency working are largely unexplored (Warmington et al., 2004). Kothari andcolleagues (2011) explored the use of knowledge management (KM) strategies inhealthcare. They criticise the narrow functionalist tendency of focusing on ICTs (in thecontext of KM) which are often static, ignore the wider context required to make an effectiveclinical diagnosis and hinder knowledge sharing and knowledge development. They suggestthat: ‘Communities of practice knowledge-sharing strategies have been used to promoteinteractions among health practitioners. These strategies can be ICT based [...], narrowlyfocused on practice improvement and/or broadly defined as networks involving multiplestakeholders and objectives’ (Kothari et al., 2011: p.1).2.5.2 Epistemic CommunitiesHaas (1992) conceptualised communities of specialised knowledge workers as an epistemiccommunity to describe an alliance of observers including public administration experts,scientists and politicians who convene with similar interpretations of the scienceunderpinning environmental problems and the policies that emerge in response.An epistemic community which seeks to drive through political objectives was defined byHaas as: ‘a network of professionals with recognized expertise and competence in aparticular domain and an authoritative claim to policy-relevant knowledge within that domainor issue-area . . .they have (1) a shared set of normative and principled beliefs . .. (2) shared8 http://www.quest.nhs.uk/9 http://www.advancingqualityalliance.nhs.uk/34

causal beliefs, which are derived from their analysis of practices leading or contributing to acentral set of problems in their domain . . .(3) shared notions of validity . . .(4) a commonpolicy enterprise.’ (p.3).2.5.3. Support NetworksCharacteristics: coming together to share experience sometimes as a result ofworking in some isolation: Not inter-dependant; Focus on Innovation; Sharedpurpose; CreativeLeadership: DistributedGovernance: The opinion leader is now a very contested concept; May disregard orbypass central authorityFailure: Breakdown of trust; Weak negotiation powers; FatigueSupport networks (Mudry et al., 2010) provide services, new products and focus strongly oninnovation. They are not inter-dependant. Their focus is experimental in nature. It is alsolearning based and embraces knowledge sharing within Communities of Practice (CoP).Innovation discourse highlights the need for systems to have the ‘absorptive capacity to takeinnovative inputs and create useful outcomes [...]...This absorptive capacity may bedependent upon prior accumulation of knowledge [...]... the ability of different role players tointeract effectively [...]... and the structure of social networks within the adopting system [...](Begun et al., 2003: p.275). Further attributes relate to interactions shaping and advocacy.Distributed leadership is a core ingredient of support networks. Grimshaw (2006) noted howthe: ‘setting of an opinion leader intervention may be important for its success e.g. thatopinion leader interventions in secondary care may be more effective than in primary care,due to more complex social networks in the former (Flodgren et al., 2011: p.4).2.5.4 Enclave Networks (Individual Networks)Characteristics: Competent at professional development, developing authenticityand legitimacy and information and knowledge sharing; building trust between agents(individuals and organisations) and developing novel ways of working.Leadership: Variable and unpredictable nature: substantial leadership skill and metacompetenciesneeded for self sustainability.Governance: Enclave and individualistic networks are often self-governing entitieswith limited formalised accountability. Disregard/bypass central authority. Horizontalor often have a non-existent management structure.Failure: Fatigue; apathy; rifts; weak negotiation powers; Isolation from largerstakeholder groups. Failure also correlated with peer apathy and disillusionment, orwhen their understanding of ‘...principle is challenged by another rival group ornetwork. They may find it hard to sustain negotiation with outsiders’ (Harris, 2005:n.p). Also, if voluntary/third-sector participation is refused, problems committing totask or if equality of rank is questioned (ibid).Enclave networks (Thomas et al., 2006) are cohesive groups with a flat structure, whereparticipant members interact to share information, knowledge and strategies (NHSNetworks., n.d). A study of enclave networks by Bauer and colleagues (2002) described howimmigrants with low literacy, numeracy and English language deficiencies tend to migrate togeographical areas with larger networks of migrants with a similar ethnic makeup. Harris(2005) describes the characteristics of sharing and learning (enclave) networks as having35

significant social bonds and joint commitments. Trust is an essential aspect but they tend toexclude the participation of others. Harris identifies three types of Enclave Networks: Selfdirected learning networks, Association and Forum.2.5.4.1 Three types of Enclave Networks1. Self directed learning networks reflect a cluster of self-governing professionals whointeract with one another and share mutual experiences. Group output is zero: benefitis measured solely through the educational benefits of participant individuals. Noexternal accountability and differ from structured networks which are facilitator drivenor may have mutually agreed educational goals.2. Association networks are also informal groups who goals are also education-basedand focus on mutual sharing; however agreed group-learning objectives are instilledin certain areas. Accountability is internal: no expected external output; selfgovernance.3. Forum: formalised learning (and sharing group) who regularly interact & use a formalagenda and minutes. It mainly contrasts with an Association type through its creationof group outputs (e.g. agreements to share and appraise and also create mutuallydeveloped policies and protocols etc). In this respect, ‘...Governance remains internalbut there is an informal wider accountability, characterised by agreements to reachgroup positions or produce group protocols, or advise on requirements to meet onNSF. Thus an external body might have a legitimate expectation of a report from thenetwork, including a particular topic, but no capacity to specify the content or natureof the output’ (Harris, 2005: n.p).2.6 Advocacy NetworksCharacteristics: Open, dynamic complexLeadership: DistributedGovernance: FlatFailure: Fusion of functions that typify an advocacy network lead to three challengesfor evaluation:Activities and outcomes are difficult to ascertain because of their complex, dynamic andopen nature. Traditional management approaches for enhancing operational effectiveness,efficiency and growth (towards meeting objectives) are impotent. Nonetheless, they have thepotential to be pro-active and innovative in an attempt to gratify the donor’s expectations.Unique Networks - methodological challenges: ‘The concern for democracy is everpresent in advocacy networks. Methodologies based on the assertion that certain networksshould be directing programmes rather than facilitation are fundamentally flawed as they arefocusing on differing functions of that network’Blinkered world view: Participant members tend to consider the advocacy network fromwithin their own narrow remit (such as government or political agency, civil societyorganization or business) (Harris, 2005: n.p).Individualistic networks are constructed by a single actor (individual or organisation), creatinga coalition of affiliates to achieve a certain objective. More flexible and dynamic thanhierarchical networks, but consequently free of formal constraints (NHS Networks., n.d) iv . In36

a similar vein, research has explored advocacy networks (Carpenter, 2007) and transnationaladvocacy networks (Sperling et al., 2001). Carpenter (2007) highlighted a lack of knowledgeabout the initial process through which advocacy v type networks identify and select issuesaround which to activate and mobilise. Advocacy Network evaluations are Janus faced: ‘Thesolution is to focus on the results that are upstream from impact – on outcomes understoodas changes in the behaviours, actions, and relationships of social actors within the advocacynetwork’s sphere of influence. For advocacy networks that wish to focus on outcomes, andnot simply on their advocacy network activities, it is vitally important to take full account of themessy, multi-level and multi-directional causality of the process and environment whenevaluating its achievements’ (Harris, 2005: n.p).2.6.1 Transnational Action NetworksWilson-Grau (2007) highlighted the complexity of articulating the impacts of advocacynetworks in international social change networks. International networks consist of clusters ofautonomous organisations and individuals in different countries or continents ‘...who share apurpose and voluntarily contribute knowledge, experience, staff time, finances and otherresources to achieve common goals’ (Wilson-Grau, 2007: p.2). Transnational ActionNetworks was conceptualised by Keck & Sikkink (1998) in reference to any type of fluid,boundless form or network of activists linked to national and international/global politicalarenas who interact in an attempt to persuade national governments to adhere to theactivists demands, and also comply with international conventions and human rightsprinciples. Keck & Sikkink’s survey of the exchanges and interactions between networkactors illustrated interesting themes, such as the boomerang pattern, where local activistsrestricted from influencing policies through their national political institutions seekinternational collaborators who can convey their concerns to international bodies (Keck andSikkink, 1998). McAdam and colleagues (1996) propose a structuring framework based onthree decades of significant global developments that seeks to elucidate a social movements’emergence, development, and subsequent outcomes (Garrett, 2006). They do so byaddressing three correlated factors: Mobilizing structures, Opportunity structures andFraming processes. Mobilizing structures relate to the means/mechanisms that enablepeople to organise and participate in communal action (included social structures and tacticalnous); social structures include both formal and informal configurations; Opportunitystructures relate to the environmental conditions that support social movements’ goaldirected activities such as ‘relative accessibility of the political system, the stable orfragmented alignments among elites, the presences of elite allies’ (Garrett, 2006: p.3).Research has noted how a grassroots innovations model can frame social movements asagents of transformation (Seyfang and Haxeltine, 2010). They note three ways in whichflourishing niches can influence the establishment: ‘they can replicate, bringing aboutaggregative changes through many small initiatives; they can grow in scale and attract moreparticipants and actors; and they can translate their ideas into mainstream settings’ (p.5).Paradoxically, social movements often push against the mainstream, yet habitually becomemainstream after official recognition and power is accorded (Seitanidi and Crane, 2009).37

3 Network Evaluation and Future of NHS3.1 Network GovernanceNetwork governance as opposed to policy networks reflects part of a strategy to illuminatethe decision making process to interest groups and to local citizens. “Sometimes, hierarchy isused to stimulate network and market governance, in other cases, network governanceprepares the floor for a hierarchical finish” (Meuleman, 2008: viii).Immediate reaction: is to bring order to the chaos and complexity. Involves howdecisions are made, and how to accomplish things/develop policy or make strategicdirectives for the group.Network Scenario 1. Return to a conventional governing board (GB) structure as inpolicy networks restricts network potential.Network Scenario 2. Perhaps require just enough structure to enable conversationand make important decisions; (and structure can often be fluid).Dilemma: Role articulation may broaden view of options/possibilities for engagement(including the deeper functions of network collaboration.Leadership (in Network Governance): In comparison to policy networks, dispersedpower: leadership of the many is healthy, and raises opportunities for development ofunique talents.Governance: Ideally a direct democracy model.Cautious attempts have been made to systematize literature on governance and governancenetworks (Blanco et al., 2009). Research is currently exploring the notion that a new form ofhealthcare organising will take shape and transcend the conventional / professional versusNew Public Management (NPM) dichotomy (Ferlie et al., 2012). Drawing upon Foucault'sresearch on 'governmentality', they illustrate how the governance in two distinct case studiescan be illuminated through a 'governmentality' lens (ibid). Daugbjerg and Fawcett (2011)distinguish between two overlapping strands of literature: governance and networks. Theydifferentiate both schools of thought and highlight how each conceptualizes their contrastinggovernance arrangements. They also note their influence on metagovernance outcomes.Governance takes forms including Traditional, Multi-level, Network and Digital Governance,Governance for Human Development, Governance and Dispute Resolution, and alsoAccountability and Leadership (Wilikilagi, 2009). Collaboration replaced Competition (withinthe context of networked governance) as a guiding principle, and new policy implementsincluding pooled budgets and shared governance were initiated to help cross boundaryworking (Ferlie et al., 2010). Research (Provan and Kenis, 2008) has explored thegovernance of organizational networks and identified three forms of network governancewhich focus on their structural characteristics: Efficiency versus Inclusiveness, Internalversus External Legitimacy, and Flexibility versus Stability. They conclude that by focusingattention on ‘...collectively generated, network-level outcomes, the form of networkgovernance adopted, and the management of tensions related to that form are critical forexplaining network effectiveness’ (Provan and Kenis, 2008: p.19 ). Section 3.2discussesintegrative governance.38

3.2. How Organisations Function as Units in Networks and IntegrativeGovernanceThe NHS has a tendency to regress towards linear solutions to complex problems that arisewithin healthcare (Keasey et al., 2009). The under-researched area of network management(perhaps because network management is an oxymoron in all but the hierarchical types) isparticularly relevant in complex networks that tackle wicked issues which involve first, secondand third sector agents (Klijn E.H. et al., 2010). Network Governance was discussed in abriefing paper (NHS Service Delivery and Organisation R&D Programme., 2005), whichnoted how all regulators beyond the boundaries of a network faced similar challengesassociated with authority (to enforce power). Addressing the governance gap requiresincentives (when associated with individual networks), or developing pre-formed and sharedprinciples, within enclave networks, to enable participant members to adhere to a system ofself-regulation and subsequent governance (NHS Service Delivery and Organisation R&DProgramme., 2005). Research has largely focused on the structural components of healthnetworks (Provan and Kenis, 2008), however more recent studies have expanded this unit ofanalysis to gauge the dynamics of network emergence that cumulate in the outcomes ofprocess improvement interventions (Papadopoulos et al., 2011).Papadopoulos and colleagues drew upon the conceptual and analytical framework of ActorNetwork Theory (Latour, 1996) to trace how stakeholders change work roles and networkallegiances over time. Klijn (Klijn, 2008) illuminates North American and Europeanapproaches to public networks, and suggests that future studies should focus on greaterlevels of integration. Mendizabal cited the lack of investment in the central communitybuilding function where participant members often engage with the network secretariat in aservice-to-provider capacity, ‘...but do not deal with each other. This threatens thesustainability, as well as the effective fulfilment, of the network’s roles’ (2008: n.p). In somecases, networks actually compete for funding and policy influence with their fellow members,however Mendizabal cautions against viewing networks as mere funding mechanisms perse. Networks that are grounded in the use of contracts (eg via a care pathway) may perhapsengender compliance, however these networks are less successful in integrating careprovision than the more managed networks or singular organisations, and: ‘Governmenttargets, audit and incentive arrangements need to be harmonised to promote and rewardworking in networks (NHS Service Delivery and Organisation R&D Programme., 2005: p.3).Future studies must broaden their unit of analysis from mere descriptions of networkedactivities and human behaviours, to how organisations function as units within networks. Thisrequires an intricate analysis of whole networks, including their governance structures (howthey are governed) (Provan et al., 2007, Provan and Kenis, 2008). Rosen et al (2011)explored four organisations in the USA (2), UK (1) and Holland (1) notable for providingeminent and cost-effective integrated care. It was reported that their knowledge andexperience of integrating health and social care services illuminated six operational actions(integrative processes) to be enacted in network development (beyond mere structures), thatcan help to support incentives and manage healthcare delivery across team andorganisational boundaries.Organisational processes in the form of governance arrangements betweenparticipating organisations which: ‘...encompass: the relationships betweenorganisations, such as partnership; structural integration through merger or39

contractual relationships; the arrangements in place to define and implement goalsand objectives; and the assurance frameworks to ensure that agreed objectives areachieved’ (Rosen et al., 2011: p.11).Informational: e.g. shared recordsClinical e.g. care co-ordination Administrative e.g. shared support across practices and training anddevelopment/educationFinancial (risk-sharing budgets, monetary incentives for achieving QoS) Normative (role of professional leaders, social networks) (Rosen et al., 2011)The notion of ‘Integrated governance’ reflects both the arrangements and agreements asvehicles for organisations to a) manage (organise) and control their respective functions; b) itcan also depict the type of governance arrangements that span organisational boundaries(Rosen et al., 2011) 10 . The former refers to relations between patients and partnershiporganisations (still an under-developed area):A key role of the governing body is to support the creation of shared goals, valuesand understanding of professional roles across participating organisations, teams andindividuals. With numerous partnership and network arrangements across health andsocial care, many different governance arrangements are already in place. Researchis needed to assess which are most effective for driving the development of highqualityintegrated services that improve quality, patient experience and efficiency(Ibid. pgs 39-40).3. 3 Network Assessment and EffectivenessChapter 2 drew upon evidence to illuminate the breadth and impact of networks which seekto develop better co-ordinated healthcare. Network scrutiny takes many forms (Rhodes,2006), and categories exist on a continuum from formal managed to emergent socialnetworks (Hearn and Mendizabal, 2011), within which research has focused on their coreforms and functions, the external context in which networks are constructed, together withthe interests of participant members (Serrat, 2009). We explained how network discourseencompasses social networks, learning networks, delivery networks, organisational networksand beyond, and how different networks have different ground rules and organisingprinciples. Chapter 3 seeks to illuminate the factors that make networks effective andsustainable. Further evidence about effectiveness and incidence within healthcare willilluminate the review. It is now necessary to review the effectiveness for each categorybefore highlighting the leadership task and behaviours per type.Network assessments frameworks can assist in developing a deeper understand of thenetworks effectiveness. Goodwin and colleagues (Goodwin et al., 2006) offered ten lessonsfor successful network management vi . However: the complexity of measuring network impactis well documented (Wilson-Grau, 2007), because ‘Networks are not magic bullets. They cando what they have been designed to do, but to adopt new functions they need long-term10 See the NHS Integrated Governance Handbook, where integrated governance is described as:‘Systems, processes and behaviours through which trusts lead, direct and control their functions inorder to achieve organisational objectives, safety and quality of service and in which they relate topatients and carers, the wider community and partner organisations [...]’ Rosen et al., (2011: p.40).40

investments’. (Mendizabal, 2008: n.p). An Inter-Agency Network for Education inEmergencies (INEE) case study (Mendizabal and Hearn, 2011) explored whether thenetwork structure as opposed to individual participant members or certain network projects oractivities was responsible for creating value that in turn meets the network’s objectives.Drawing upon the theory of value by Allee (2002), who argued that value was tangible orintangible, Mendizabal and Hearn noted how a variety of actors supplement and sociallyconstruct the networks by adding novel value, re-distributing value between participantmembers, or by converting one form of value into another. In this respect, mere engagementis not a recipe for success, regardless of whether it in itself defines the network. The criticalissue is related to how the relations that form the network infrastructure are responsible forcreating and adding value. Mendizabal and Hearn (Mendizabal and Hearn, 2011)subsequently propose the value network analysis (VNA) model, within which a network isseen in terms of value creation and exchange among the networks actors. The VNAproposes:1. Exchange analysis: What is the overall pattern of exchanges in the system?2. Impact analysis: What impact does each value input have on the participatingmembers of the system?3. Value creation analysis: What is the best way to create, extend, and leverage value,either through adding value, extending value to other participants, or converting onetype of value into another? (Mendizabal and Hearn, 2011: p.20)The potency of each VNA approach enables the observer to identify how the networkfunctions approach could be enhanced: ‘by a better understanding of the members of thesystem (through [social network analysis/SNA), and how their interactions may or may notcreate value (through VNA). This will allow us to conclude whether the evolution of INEE hasled to the development of the most appropriate network structure for the fulfilment of itsfunctions and roles’ (ibid).3.3.1 Evaluating Policy and Public Management NetworksFrom a policy networks perspective, (Provan and Milward, 2001) argue that networks shouldbe evaluated across three overlapping levels: community, network andorganization/individual. Each element contains a distinctive level of effectiveness criteria ofinterest to three types of network constituents: principals, agents and clients. The corecriteria of effectiveness relates to the gratification of groups that represent an array ofcommunity interests (e.g. advocacy groups). In such cases, effectiveness: ‘depend[s] onwhat specific service providers either do or do not do, rather than how well services areprovided as a result of network activities’ (Provan and Milward, 2001: p.422). It thus impactsupon community and network-level decisions made at the ‘expense of network participants’(Ibid). Public management networks (PMNs) are effectively collaborative endeavours on apar with social networks because they consist of participant members and representatives indisparate organisations, however they differ by moving ‘...beyond analytical modes. They arereal-world public entities’ (Agranoff, 2006: p.56). Saxton (1997) notes how public-sectornetworks are different from those in the for-profit world, where the financial feats of memberfirms is often the most practicable method for assessing network effectiveness (Provan andMilward, 2001). Research findings from Agranoff’s (2006) study of 14 North American publicsector networks find that regardless of notions of a network culture and network society (alsosee Castells, 1996, Castells, 1997, Stalder, 2006), hierarchies remain dominant and continue41

to meet the legal and policy based functions of government. Agranoff (2006) highlighted thediversity of public sector networks, which are rarely alike, but differ through what they do andlevels of power and command (some have much less powers than others).In essence, all networks should be voluntary entities, however PHNs are compulsory (Abbottand Killoran, 2005). The Teaching Public Health Network (TPHN) initiative, a unique regionalnetwork model funded by the DoH, was developed in response to the call for enhancedaccess to (and provision of) public health focused education and training, and as amechanism for developing specific work on a broad curriculum encompassing highereducation, services and voluntary/third sectors (Sim, 2007). However the construction of aregional network was an immensely complex phenomenon which had not been undertakenbefore (ibid).3.3.2 Evaluating Managed NetworksNHS managed networks have existed for almost a decade but are in urgent need for reform(Addicott et al., 2007). Managed Networks theory is based on the concept of hierarchicalnetworks that emerged from beyond the health sector remit. Harris (2005) noted howmanaged networks are based on hub and spoke service arrangements, and their aim is tomaintain a high standard of service or if delivery of change is needed. They are based onformal collaborations/partnerships with instilled accountability and governance arrangements(Rosen et al., 2011). Managed networks undertake a number of strategic functions includingcommissioning, implementing service-level agreements (SLAs) and/or contracts, and oftenhave the power to agree service re-design/reconfigurations. They also have delegatedfunctions from their respective host organisations and possess supra-organisationaldecision-making powers and strategic roles in service development. Managed networksusually have specific external objectives, and also the power to regulate (Harris, 2005,Addicott et al., 2007, Guthrie et al., 2010).Most collaborations and clinical networks in the UK follow the managed approach whichentail formal partnerships driven by professionals; constructed with aim to change service (orfor network interventions to improve health care).The managed network in North Lanarkshirefaces significant challenges to successful integration through variations in national policy,socio-technical problems in developing a supportive ICT system and inconsistent progressacross different locales and care groups, thus highlighting the need (dependency) on localleadership (Rosen et al., 2011). The North East Lincolnshire Care Trust Plus provide onecentral face (senior leader) to the network who manages the complex care provided bydisparate people and teams (Smith, 2010). Section 2.1.1 described how the NorthLanarkshire partnership (collaboration between health and social care (H&SC) staff) hadfused governance arrangements which outlined the responsibilities and accountabilities ofthe respective H&SC teams (some were integrated and others entailed workingcollaboratively) at different network levels across localities and care groups (Rosen et al.,2011). Drawing upon Dickinson and others, (2007) and Glendenning, (2003), Rosen notedhow ‘Normative integrative processes were crucial for integration across partnerships andnetworks, and particularly across health and social care, as underlined by [North Lanarkshirepartnership] [who] had to devote a lot of ongoing effort to achieve this’ (Ibid: p.36).42

3.3.3 Evaluating Development NetworksInter and intra-organisational networks differ from social networks consisted of nodesconnected by social arrangements and relations (Mudry et al., 2010) and recurring and oftenentrenched relationships (Granovetter, 1973 ). Hearn and Mendizabal (2011) note that theoverarching principle of the Network Functions approach states that ‘...the form of a networkshould follow its functions because its organisational arrangement is crucial to its capabilityto deliver them’ (p.2). The evaluation of a Scottish Cancer network reported that ‘more clearlydefined understanding of outcomes, corporate support in building of trust and relationshipsand seed money were needed to be effective. Experience from network reviews suggest thatthe reluctance of partner organisations to cede interests and autonomy through joint deliverymethods restricts the success of such networks. The ending of central or experimentalfunding often leads to the demise of such networks’ (Harris, 2005: n.p). A study of 100 UScontracting networks suggested that Development Networks were not as effective as moremanaged and hierarchical networks (or single organisations) in the integration of servicesathwart a care pathway (Harris, 2005).Developmental networks in healthcare often advocate the role of specialist intermediaries(boundary spanners) for cross-silo functions by liaising between organisations and networksand undertaking specialist tasks. Dobrow and Higgins (2005) noted that the ‘dynamic natureof developmental networks has not been examined, and accordingly, the role that anevolving developmental network may play in enhancing the clarity of professional identityremains unexplored’ (567). Further, Harris noted that they often lack formal (or haveincomplete/ambiguous) external accountability & governance arrangements, and that a finebalancing act is needed between the manner in which developmental type networks arecreated (between governance and professional autonomy) and the expected outcomesconferred in relation to these and the accessible resources (adapted Harris, 2005: n.p).Developmental networks also tend to change and evolve which results in the development ofnovel relationships to the detriment of others (Sweitzer, 2008). Dobrow et al., (2011) notedhow ‘Developmental networks are considered “egocentric” because the focal individual orego, instead of the researcher, identifies the developers [...]. They are considered “contentbased” because the relationships that compose them are based on the type—or content—ofsupport provided (e.g., friendship, advice) as opposed to being based on structuralrelationships (e.g., supervisor–subordinate;...])’ (Dobrow et al., 2011: p.28). Further tensionsrelate to the power and responsibility of the host organisation when attempting to implementor enforce policy changes ‘Yet the more top down the objectives, the greater risk ofdisharmony. Indeed the loose ties that keep the network together are such that continuing tosustain it may not seem worthwhile to its members’ (Harris, 2005: n.p).3.3.4. Evaluating Advocacy NetworksAdvocacy networks are effective [in comparison to more managed networks] by recognizingachievements in a swift and candid manner; ensuring learning is disseminated aboutaccomplishments or problems/failures; evaluating the collective endeavour towards thepolitical rationale and also through the augmentation of the network itself (Harris, 2005).Strengths of advocacy networks in appendix vii .3.3.5 Evaluating Social Media NetworksThis literature review avoids the technical aspect of a networked infrastructure where Public43

Sectors Networks (PSNs) are understood in the context of a secure wirelesstelecommunications infrastructure. PSN brings together various PSO IT networks to reduceduplication and for uniformity purposes viii .We have however included the non IT literature onnetworks. Community empowerment initiatives take a variety of forms, requiring a greater orlesser degree of commitment from local citizens and led optimists to suggest that highlyparticipative community empowerment may rejuvenate the democratic process (Norris,1999). Social networks (Litwin, 1995) . tend to evolve over time and are motivated by themutual activities and affiliations of participant members, and also through the similarity ofone’s attributes, and the ‘closure of short network cycles’ (Kossinets and Watts, 2006: p.88).Social networks are a critical aspect of context, and all activities are embedded in socialrelations, whereby human interactions continually reshape conventions, norms, beliefs andsubsequently actions. Certain forms of governance arrangements (e.g policy makinginstitutions) may result in the creation of networks that subsequently ‘promote theendorsement of social capital and grease the wheels of altruistic collective action’ (Dietz andHenry, 2008: p.13189).Putnam defined social capital as features of social life that enable participants to act togethermore effectively to pursue shared objectives (Putnam, 1996). Putnam (Putnam, 1993)viewed social capital as a reflection ‘...of social organisation such as networks, norms andtrusts, that facilitate co-ordination and operation for mutual benefit' (p.2). The concept is oftenarticulated as the tangible existence of, and participation in, groups or networks, and lesstangibly, social trust, civic sharing, local democracy and solidarity. Putnam later presentedempirical evidence through a comparison of American states. His research found that wheremore social capital existed (shown by indicators of association membership, trust andcharitable giving), children performed better in schools, watched less TV, less violent crimeexisted, people were generally healthier, tolerance was higher, and more equality existed(Putnam, 2000) 11 . Blanchard and Horan (2000) proceeded Putnam’s thesis by surveying 342US citizens (in California) that were about to receive ICTs and partake in a community basednetwork. The aim of this study was to investigate which issues appeal to local people andexamine whether virtual communities could recompense for a reduction in social capital dueto a reduced level of participation in face-to-face communities. Their findings were largelypositive, in that community based networks may facilitate community integration andcohesion through participation in government based activities or local politics, sharing andaccessing education resources for children, community bulletin boards and enhanced virtualcommunication between family networks.Research has illustrated how social media technologies such as blogs and social networkscan improve health care provision (Hawn, 2009, Paul and Dredze, 2011). Twitter is amicroblog service used by many health care professionals who share short messages(Tweets) with followers on the social media platform. Flu outbreaks, situational awareness indisaster zones, and ‘aggregate sentiment about items/people/concepts can also be inferredfrom tweets’ (Dabeer, 2011: n.p).11 Putnam makes an important distinction between ‘bonding’ and ‘bridging’ social capital. In respect of socialexclusion, bridging social capital may reduce exclusion but bonding could ultimately increase it.44

3.3.4. Evaluating Social NetworksFrom a Social Local Networks perspective, The Big Society policy and legislative agenda,proposed as the basis for a political economy and civil society, advocates less public sectorinvestment and intervention yet greater levels of civic activism, with power dispersed fromWhitehall to town-halls, local councils and communities. The strategy behind the newlocalism bill is based on community empowerment, opening up public services, andendorsing social action to bring about change. The methods used to realise this strategyinclude redirecting power and authority to the lowest possible levels; providing greatertransparency and creating new planning laws permitting more direct action from citizens. Thecoalition has taken a number of measures including the creation of the Big Society Bank, BigSociety Network and Vanguard type communities; Office for Civil Society; creation of 5000community based organisers and various other structural reforms to support the Big Societyinitiative (Coote, 2011, Goodchild, 2010, Conservative Party., 2009 ). Abel and colleaguesexplored the role of compassionate community networks in Weston-super-Mare whichsupport terminally ill patients at home (Abel et al., 2011). They illustrate how communitiesmay be successfully mobilised in such respects. A community development model was usedin favour of a service delivery model associated with traditional community developmentinitiatives because mentor participants were grassroots volunteers as opposed to healthcareprofessionals. However the Social Local Network objective of the Big Society has had littlesocial effect, and led Wells and colleagues to conclude that ‘Civic Ties and Social Action MayImprove Policy, but are not the whole solution’ (Wells et al., 2011: p.18).3.3.5 Evaluating Clinical NetworksFormed: Clinical professional networks initially formed in an enclave mode (Harris,2005).Characteristics: Assemblage of willing stakeholders including active healthcareprofessionals and active citizens/residents (as opposed to traditional and completelycentralized model)Functions: supporting improvements in pathways and outcomes of care. Need tounderstand new clinical senates & function of new clinical networks in the newhealthcare system. Well established and consist of groups of experts andprofessionals, including patient and carer intermediaries, who converge aroundcertain pathways or conditions.Leadership: distributed and emergent leadership emanates from a variety of willingstakeholders who want to engage; to weave and sustain communicationsGovernance: communication is essential to good governance; members conversingand constantly seeking to sustain the networks’ dynamism and promotion of values.Here-within, good leadership should ensue.Failure: All coalitions/collaborations have the potential to breakdown, so require aneffective and aspiring leader to take the reins (and maintain momentumThis section briefly explores current networks emerging in healthcare such as clinicalnetworks and CCG Networks of GPs. Managed Clinical Networks (MCNs) have evolvedrapidly since the Scottish Office DH (1999) defined it as: “...linked groups of healthprofessionals and organisations from primary, secondary and tertiary care, working in a45

coordinated manner, unconstrained by existing professional and organisational boundaries toensure equitable provision of high quality and clinically effective services” (Baker andLorimer, 2000: n.p). Harris (2005) questions the usefulness of this definition because itencompasses a number of contrasting networks. Clinical or health service delivery networksencompass an assembly (three or more) of autonomous organizations that connect toprovide evidence-based health care services (Huerta et al., 2006). Hybrid networked formssuch as the NHS itself exists within the three overarching types, whereby the managednetwork encompasses a blend of hierarchies and networks (e.g NHS managed networks).Experts are increasingly seeking knowledge beyond the confines of organizational levels ofanalysis pertaining to inter-organizational networks (whole networks at the networked level ofanalysis) (Provan et al., 2007).Whole networks relate to solidity, centralization, and the continuation of sub-networks orfactions (Provan et al., 2007). Examination of the impact of ‘whole networks’ is relatively rare[...], although there are examples in the literature using network professionals’ perceptions ofimpact or single case study examination of change in clinical process and/or outcome [...].The range of impacts that could be examined is large, and their perceived importance islikely to vary across stakeholders [...]. (Guthrie et al., 2010: p.113). It was reported thatclinical networks should be retained and strengthened in the new NHS system, and thatnetworks should have a stronger role in commissioning, in support of CCGs and the NHSCommissioning Board. Payne (2011) noted how several types of networks will be required inthe new healthcare system including NHSCB supported networks; CCG supported networksand Professional Networks. Some future networks will be determined by NHSCB, somedetermined by CCGs in adherence to local priorities and modes of working and somedetermined by professional networks (the restructured NHS will still need professionalnetworks). McLean contrasts clinical networks and clinical senates:Although they can take many forms, clinical networks are usually specific to a clientgroup, disease group or professional group. Networks can undertake a range offunctions, including supporting improvements in pathways and outcomes of care.Clinical senates, however, are intended to bring together a range of experts,professionals and others from across different areas of health and social care to offeraccess to independent advice about improvements in quality of care across broadgeographical areas of the country (McLean, 2011: n.p).Much interest has been raised since the Coalition Government’s response to the FutureForum Report in response to proposals for new clinical senates, and the function of clinicalnetworks in the new system (McLean, 2011). National clinical networks are well establishedand consist of groups of experts and professionals, including patient and carerintermediaries, who converge around certain pathways or conditions (e.g cancer care). Thecoalition government seeks to strengthen current networks and provide them with the meansto envelope additional areas of specialist care. Subsequently, clinical networks will have amore robust role in commissioning to support the NHS Commissioning Board and localCCGs (Irani, 2011). Managed Network effectiveness is often correlated with centrality ofauthority and power; however:In reality, for any network to be effective, it will need some degree of goodmanagement, but it does not need to operate at this level of maturity. It is suggestedthat the term managed clinical networks is reserved for the specific type ofhierarchical network described in the literature. In reality most clinical networks do notconform to the characteristics of a managed hierarchical network (Harris, 2005: n.p).46

3.3.5.1 The NHS Heart Improvement ProgrammeManaged clinical networks are used to deliver quality health care to a population across awide geographical area. The objectives of MCNs include the expansion of access to careand decline of waiting lists; ‘...the increase in the qualitative level of services; and the betteruse of scarce resources, including finances, technologies and clinical expertise” (Lega andSartirana, 2011: p.725).The NHS Heart Improvement Programme is part of NHS Improvement 12 - a nationalimprovement programme working with clinical networks and a variety of other NHSorganisations in an attempt to change, deliver and maintain QoS across the completepathway in cancer care, cardiac care, diagnostics care, lung and stroke service care.A separate MCN for cardiac services in the UK (Hamilton et al., 2005) successfully pooled agroup of clinicians, patients and managers to redesign cardiac services: ‘Its primary “modusoperand” was the development of a myocardial infarction pathway and associated protocols.Of sixteen clinical care indicators, two improved significantly following the launch of thenetwork and nine showed improvements, which were not statistically significant’. (p.1). It wasreported that the lead role of a clinician was critical to its success, who served as a ‘‘coordinatorand boundary spanner’ (someone who works across existing professional enclavesor with isolates in historically established practice), using interpersonal relationships, workingcontacts to gain information, understanding values and undertaking negotiations’’ (p.9). TheMCN changed the traditional boundaries of the service, used the same level of resourcesand impacted (albeit modestly) upon patient care. However, they concluded that the networkfaced significant start-up problems (2 year set-up), found improvements to be sluggish andincremental and that MCNs in general required a central energetic leader: ‘...however this isnot without its problems: ‘If the organisation depends too heavily on single individuals, or ifthe leader does not have access to significant leverage, this model may not be sustainable,and investment in multi-professional leadership teams may provide more stability’ (p.9).3.3.5.2 The Vermont Oxford NetworkFenton (Fenton, 2012) notes how neonatal networks encompass multiple networked formsrather than being solely based on the MCN model. Fenton cites The Vermont OxfordNetwork as a voluntary endeavour of over 800 neonatal units which offer a variety of clinicaldata to Network members (users). Users now compare their own local outcomes withcomparable units of analysis in other areas which may cumulate in local qualityimprovement. The Vermont Oxford Network also serves as a coordination centre forcollaborative research between participating units.3.3.5.3 Dumfries and Galloway NetworkHamilton and colleagues discussed the Dumfries and Galloway network which includedclinicians and professionals encompassing a variety of backgrounds and sectors workingacross traditional boundaries. Through a broad based coalition (working group activity), thegeneral public (including patients) were heavily involved in service redesign and networkfocus. Crucially, the Dumfries and Galloway network had ‘broad aims rather than explicitgoals and proceeded organically, responding to locally identified needs and making the mostof opportunities’ (Hamilton et al., 2005: p.10).12 Retrieved from www.improvement.nhs.uk 14.2.201247

Research has shown that there is no preeminent means of evaluating the impact andinfluence of clinical networks (Guthrie et al., 2010). In a review of nine nationally managedclinical networks, it was reported that the impacts from such networks were difficult toascertain because of their intangible nature in comparison to that of a service. This negatesand invalidates the analysis of activity levels (NHS Scotland., 2010). Ramsay, Fulop andEdwards, (2009) highlight the need to develop a stronger evidence base to measure theimpact on client (patient) experience. It is evident that no one-size-fits-all solution for everynetwork that exists in the UK healthcare sector (Fenton, 2012):Service provision for a widely scattered population [neo-natal patients] requires adifferent approach to that needed when dealing with issues relating to services, forexample, in and around London. Issues regarding capacity and communication are,however, common to most if not all networks and the forthcoming tightening of theNHS budget mandates the most efficient use of the resources that networks offer:reconfiguration for delivery of high-risk perinatal care is inevitable. For this to succeedclinicians and managers in individual Trusts will need to take a broader, networkbasedview of how the service they provide suits their patient population. Furtherevolution of the network concept will undoubtably be required (n.p)3.4 Network FailuresEvidence from the US hospital market stipulates that networks under-achieve in comparisonto ownership-based hospital systems, and are often unable to out-perform hospitals that arelargely unconnected from any system or network (Friedman and Goes, 2001). Networkfailure is also associated with institutionalisation, as grassroots networks often becomereintegrated into the bigger system from which they originally emerged (Seitanidi and Crane,2009). The raison d’être for their initial formulation is invariably lost as the network becomesbogged down in governance arrangements and essentially become institutionalised.Goodwin et al, found that some members of networks may have local organisational stylesthat are in stark contrast to the ‘institutional style of the network-wide institutions (2004:p.132). Others (Miles and Snow, 1992) predict that network organisations fail due tomanagerial mistakes in initial design or in ongoing management particularly the impact ofover-expectation of cooperation (limiting the creativity of the parts of the network); resortingto command mechanisms of management; predicating some network members over others;constraining the operating independence of the network members. The relative success ofnetwork members is essential to network effectiveness; conversely, ‘network success can beenhanced through the failure of individual members, resulting in some interesting evaluationproblems’ (Provan and Milward, 2001: p.420). Government’s incapability of perceivinginsurgent groups such as Al Qaeda as self-organised networks has increased the publicthreat (Wheatley, 2007). Cui and colleagues (Cui et al., 2011) concluded that conventionalmethods are ill suited for analysing the construction, development and evolution of insurgentgroups. Perhaps the same can be applied to healthcare? Research has explored why anemergency alert system was not adopted by students on a university campus (Wu et al.,2008). Wu and colleagues found that: '...the adoption of ... an alert is not just a simple actionof “opt-in”. The use of the technology is situated in a complex socio-technical environmentwhich greatly shapes students’ perceptions and intention of action' (104).48

3.5 LeadershipHealthcare leaders face unparalleled challenges: The leadership required to establish anetwork is often different from the leadership needed to sustain a network. In contrast tohierarchies and markets, networks organise through cooperative means (Thompson et al.,1991) based on trust.Leaders connect members, and leaders emerge within the networks based on thespecified task/issue. Leadership is more fluid – it passes from person to persondependant on what’s needed over time (CIHM, 2012).Dearth of professional leaders: Evidence suggests that formal leaders deliver lessthan informal leaders (leading change and improvement in health and social care)and the health field has not fully embraced a culture of leadership development(Rosen et al., 2011). Research (Ghosh et al., 2010) is starting to explore relationsbetween developmental networks and leadership (Dobrow et al., 2011).Much resource is available to develop the leadership skills and competencies in GPsand other professionals, although they fail to adequately promote professionalleadership of integration work (Rosen et al., 2011).The message from the US medical groups is however unequivocal: without arelentless focus on securing and sustaining high quality leadership andmanagement of local services and clinicians, many of these GP consortiacould struggle. This would not only be a failure for the clinicians committingtime and energy to GP commissioning but, more importantly, a lostopportunity for both clinically-led service improvement and a reduction inavoidable hospital admissions. (Thorlby et al., 2011: p.17)In the NHS, whilst the policy drive is towards integration, Rosen argues that actuallywhat is needed for senior clinical leaders is the ability to integrateIn the NHS there are, as yet, very few clinicians leading such networks ororganisations, although the introduction of clinical commissioning groups mayhelp to develop a new generation of leaders. Leaders’ attention should befocused on developing a full set of integrative processes, with mutuallysupportive links between clinical, organisational, informational and financialprocesses, in order to enable the delivery of integrated care for patients(Rosen et al., 2011: p.39).3.5.1 Leadership Behaviour in Networks and Structural BarriersLeadership in networks differs from that of traditional organisations because it requires adynamic and innovative approach to instigating and realising change in complex interoperablecontexts (Huxham and Vangen, 2000). Network leadership is widely seen ascollective, emergent, distributed and facilitative. Umble and colleagues concluded thatnetworks provide the ‘collective creativity and broad support needed to enact system andinfrastructure changes’ (Umble et al., 2011). Research has found that that individual networkleadership does not automatically emerge without embeddedness in significant andcooperative processes of dialogue and discourse (Weibler and Rohn-Endres, 2010). Thosetasked with leading networked collaborations must concentrate on membership (coalition)infrastructure and its functioning, and concurrently understand both the immediate contextwithin which they are working and the wider context of the external environment(Wandersman et al., 2005). Health care networks help to address ‘wicked’ problems (or49

perhaps are used as a way to avoid solving the tough/challenging issues) which encompassa variety of agencies and professions and provide alternative forms of care configuration andservice delivery. Studies have shown that such networks can achieve significant levels ofclinical support, authority and legitimacy when supported by an evidence based approach(Ferlie et al., 2010). However, Networks have also been known to augment complexity,eventually consisting of small groupings of policy elites (little dictators) to the exclusion ofothers, and may lose vigour and purpose with the leadership element becoming populated(Ferlie et al., 2010). SNA data was used by Webster and colleagues (Webster et al., 1999) toanalyse differences across eight US mental-health (case management) teams in a municipalmental health system. Male supervisors were seen as key figures for advice-based andsocial relations than their females counterparts, with the former displaying autocraticleadership styles in comparison to the more democratic style of women supervisors(Cunningham et al., 2011). Heroic and hierarchical forms of leadership that focus on aleader’s competencies and behaviours are increasingly unsuitable in the current networkedenvironment (Collinson and Collinson, 2009). Leadership is largely context dependant andoccurs in situ: hence it’s intractable nature ensures that it cannot be condensed into variousconstituent elements (Bolden and Gosling, 2006).Leadership behaviour in hierarchies are set to the direction, the expected behaviours, the rules for doing business,behaviours expected, and exercising positional power (power over) (CIHM, 2012).Leadership behaviour in networks is perhaps the difference between the different types ofpower and how they relate to structural types (Cook, 1977). One should consider theleadership capacities of participant organisations where capacity can be found in theindividuals and also the structures that are created to enable collaborative relations.Subsequently, top down and hierarchical models of leadership are inappropriate for dynamicnetwork arrangements. Research has explored successful leadership models for effectivemental-health treatment (Cleary et al., 2011). They found that transformational anddistributed leadership models were harmonious with the values embedded in mental healthcare 13 . Cleary et al, drew upon literature which highlights the overarching and covert natureof organisational power within healthcare settings, but queried whether transformationalleadership (practiced within certain clinical contexts), can impact upon patient care beyondthose boundaries. Cleary and colleagues conclude by acknowledging the fact that patientsand nurses will continue to engage within these socio-spatial configurations, hence the needfor deeper knowledge about effective leadership. Martin and colleagues concluded fromtheir research on leadership within public service networks that structure provides thefreedom for individual actors (leaders) to perform their roles and functions and that therelationship between structure and agency is inextricably aligned (2009). Effective leadershave the potential to enact change through structures and processes (of a network), yet thenetwork itself contains other network forms which inhibit one’s ability to achieve certainobjectives (i.e. change) without harmonizing action beyond the confines of the network(Martin et al., 2009). This reflects the perspective of Williams and Sullivan who acknowledgethat actors may still construct outcomes, yet the parameters of their faculty to act (e.g13In contrast to Cleary and colleagues’ literature review findings where both models weremore idealised than experienced.50

arriers and opportunities) is defined by the structured context in which they engage(Williams and Sullivan, 2009). Davis (Davis, 2009) identifies that generating collaborativeinnovation relies not just on the design conditions (governance, social embeddeness) but onthe development of relationships over time facilitated by appropriate processes. In particularshe explores the role or rotational leadership (or shared leadership), and adaptive changesto all the partners strategies and ways of working.4 ConclusionThere has been a growth of network base organisations in the private sector, the UK publicsector and healthcare, however the shift to network organisations that transcend traditionalprofessionalized policy networks are largely unknown or misunderstood (Ferlie et al., 2010).Networks are increasingly gaining prominence as the NHS seeks more innovative solutionsthat cross public, private and third sector boundaries. The development of healthcarenetworks remains in its infancy, but some networks are more advanced than others and willcontinue to develop. The emergence of networks may enable healthcare systems to addresswicked issues beyond the capabilities of single organisations, and deal with the fact thatsociety is becoming increasingly risk averse (Crommelin et al., 2010). Perhaps networksform to fill the gaps in healthcare provision that officious organisations cannot fulfil. A seismicshift has occurred from the formal and often bureaucratic network to the informal, selfmanaged,self-organised and often self- funded models. It was also reported that networkscan add further layers of bureaucracy, are often difficult to performance manage and oftenhave significant transaction costs. Further flaws are associated with high frequency meetings(and meetings-about-meetings) with modest output.Networks are high maintenance, highcreativity forms.We attempted to distinguish between clinical networks and other network types. Theresearch suggests that clinical networks come in all shapes and sizes and transcend all ofthe above types in Chapter 2, and reflects research (Bazzoli et al., 1999) which found thatsignificant similarities exist across evolving networked environments. Ferlie and colleagues(Ferlie et al., 2011: p.322) discuss the managed networks model as a public policyexperiment which has thus far seen a ‘partial rather than radical transition from hierarchicalto network forms, yet the case for them to handle a pervasive ‘wicked problems problem’remains compelling. They are a nascent solution that needs more time to develop. Our studyprovides a (qualified) defence and cautions against a wholesale tilt back to quasi markets’(ibid).Effective networks function across strategic, operational and service delivery levels: ‘Thesuccessful operation of networks requires a very different approach to bureaucracies andmarkets. In particular, the nature of the boundaries between organisations in networks isunlike those found in other governance modes” (Waterhouse and Keast, 2011: n.p). Global,national and local contextual factors have influenced the form of network development,particularly in respect of the current Health and Social Care Bill. We have explored how theidea for a network emerges, and how managed networks are most prevalent withinhealthcare. Agranoff (2006) used the term, broadcast within the context of a ‘network:(broadcast, supply service, professional, friendship)’, and managed networks could bereframed as a broadcast approach (p.56). Nonetheless, most healthcare networks emergefrom the hub rather than spokes, and have political drivers; however this trend is changingthrough the role of grassroots endeavours and use of social media platforms. We have also51

attempted to determine (section 1.2.4) when (at what stage) a network is not a network? Thedistinction between networks and complex systems is blurred because they often possesssimilar characteristics. Nonetheless, they are distinct. In a similar vein:Complicated interventions can take on the characteristics of complex systems, sinceit is impossible to separate the intervention from the human agency required for itsdelivery [...] However, it is important to recognise the differences between the twoapproaches and to identify when each one is being applied ... (Shiell et al., 2008:n.p).Chapter 3 explored the mechanisms that make networks effective and sustainable, withevidence about effectiveness/incidence within healthcare explained throughout the report.One can also determine how different networks have different ground rules and organisingprinciples. Consequently, one can continue to determine their varying needs and foci. Thebreadth and depth of findings suggest a lack of prescriptive solutions for network success.Guthrie and colleagues (2010: p.6) found that there were no specific ‘origins and trajectoriesthat are more or less conducive to sustained Managed Clinical Network engagement andimprovements in patient care’. This review illustrates the shift from traditionalprofessionalized networks to the new Managed Network Form. Networks objectives andavenues for judging performance levels are discussed throughout Section 3.3. Many servicemarkets including healthcare embrace mixed-form markets which are ‘markets for goods andservices in which for-profit, nonprofit, and government providers coexist’ (Marwell andMcInerney, 2005: p.7). Ferlie and colleagues concluded by discussing the role of relationalmarkets in healthcare, symptomatic of an impending shift towards free markets and a mixedeconomy (Ferlie et al., 2010). In such a scenario ‘...there would be relatively few ‘spotcontracts’ and instead a reliance on long term relationships such as preferred providers ornew public/private hybrid organisations’ (p.193). Further: the expected complexity ofcommissioning and wider provision of: ‘...specialist services in a resource limited system,while ensuring that quality of clinical care, accountability and regulation are integral elementsof the service across the provider landscape, requires robust arrangements for differenttypes of clinical networks’(Irani, 2011: p.4). Networks are an emergent form for innovation,delivery, learning, advocacy,and intelligence. The breadth of disciplines networks span,means that there is an emerging body of knowledge about how networks succeed and fail,but their overall impact on the healthcare landscape is untested.52

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AppendixPrinciples of engagement (MENDIZABAL, E. 2008. Supporting networks: Ten principles.Overseas Development Institute.,.)‘Recommendations can often be confused with keys to success: I do not think these exist.But there are principles that decision-makers should consider:1. Networks are complex and there are no templates for success. Expect setbacks.2. Work with networks to agree on their functional balance and support that balance.3. Interventions to develop a network cannot be conceptualised as ‘logical framework’projects – other approaches such as outcome mapping can provide a better alternative.4. Support networks to function as networks with and through their members rather than todeliver specific services that could be delivered by their members or other types oforganisations.5. Do not treat networks as traditional NGOs or civil society organisations, and do not allowfunds to undermine community building functions.6. When networks carry out a funding role, ensure they have the necessary skills and thatother functions are not affected.7. Network support timeframes should take into consideration the different stages of networkdevelopment.8. Provide appropriate support for the network and its members to develop the rightcompetencies and skills to collaborate.9. A culture of knowledge and learning is a cornerstone of network development.10. Sustainability should be judged against the need of the members for the network’.Networks Function ApproachThe Network Functions approach emanating from Stephen Yeo’s typology of functions (YEO,S. 2004. Creating, Managing and Sustaining Policy Research Networks. Unpublished paper.)was used by Mendizabal to determine the core components of a network (HEARN, S. &MENDIZABAL, E. 2011. Not everything that connects is a network. Overseas DevelopmentInstitute.). A network contains four overarching elements: purpose, role, functions and form.The purpose entails the network objectives and validates its existence. However purposeand the strategy undertaken to achieve it are distinct. The purpose encompasses long termgoals ‘Millennium Development Goals’ (HEARN, S. & MENDIZABAL, E. 2011. Not everythingthat connects is a network. Overseas Development Institute.,) instrumental goals: ‘deliveringgoods and services to a particular population or group’ or fluid: ‘improving a policy debate’(ibid.). The networks purpose is concerned with promoting value amongst participants. Rolesare paradoxically split between support and agency, yet with one persistently affecting theother The former determines that participants act alone as change agents but connect withthe network to obtain support that enhances their work capabilities. [although it’s much moreintricate than that]. Conversely, participants in agency networks co-ordinate and collaborate64

with fellow participant members and perform as ‘...single agents of change’ (HEARN, S. &MENDIZABAL, E. 2011. Not everything that connects is a network. Overseas DevelopmentInstitute..) Support and Agency denote two alternative ways (of many) of operating within anetwork including the form and shape of human interaction, their division of work tasks andalso with the supporting entity. Most networks are situated between Support and Agency, butlimited awareness exists about the trade-offs or organisational impacts and influences (ibid).Tower Hamlet PCT Networks“In Tower Hamlets, for example, the PCT contracted for a new integrated diabetes servicewith networks of practices, rather than with individual practices, as would usually be the casein the NHS. The PCT was thus acting as the overall integrator of diabetes services, lettingparallel contracts with local community health and specialist services run alongside thosewith general practice networks, and ensuring that the overall mix of contracts added up to theintegrated care pathway agreed for people with diabetes in Tower Hamlets. At the time ofwriting, only the general practice networks have risk-based contracts, which may act as anincentive for practices to exert pressure on community diabetologists, community nursingand allied health professional staff to play their part in enabling overall achievement ofpopulation health outcome targets” HAM, C., SMITH, J. & EASTMURE, E. 2011.Commissioning integrated care in a liberated NHS. London: The Nuffield Trust..‘Each network consists of three to five practices from the same locality, with commissioningoccurring across networks rather than through individual practices. The networks werecommissioned to deliver an enhanced care package for diabetes. Care planning, training,patient education and an annual review with results sent out beforehand are all intrinsic partsof the commissioned diabetes care package’.http://www.diabetes.org.uk/upload/Professionals/Year%20of%20Care/YOC_casestudies_web.pdfImmunisation and vaccination‘Following the roll-out of the diabetes programme, networks were encouraged to roll-out apackage of care for immunisations and vaccinations. The focus of the programme has beento implement a call/recall system across the network. As there are issues with literacy levelsin Tower Hamlets, people are also contacted by telephone or in person. An IT system wasdeveloped to support roll-out of the programme. The system was developed with clinicalassessment groups (who are responsible for data entry). The PCT has found that thereporting of results motivates the networks and provides an opportunity for recognitionamong peers. The information is trusted and considered to be useful because it is:• frequently updated – not live, but everyone can see the impact of activity on the indicatorswithin a week• clinically led (the indicators were developed and agreed by clinicians)• obtained by an honest broker ’ (HAM, C., SMITH, J. & EASTMURE, E. 2011.Commissioning integrated care in a liberated NHS. London: The Nuffield Trust.)65

NHS Networks: The document (NHS NETWORKS. n.d. A suggested framework for the selfassurance of service delivery networks.) explores formal groupings of networks from theclinical fields which operate within hierarchical and individualistic models (or a blend of both)and which span a number of HC organisations, (e.g across primary and secondary care,seeking to provide clear patient pathways & quality assured care).Network-Centric AdvocacyThis is seen as a hybrid of the: ‘individual determination and participation typical of direct andgrassroots models with the efficiencies and strengths of the organizational model. The hybridis only possible because of the increased density of communications connections amongpotential participants and the ability to scale those connections to meet demand. Thenetwork-centric advocacy focuses on supporting individual engagement by connected gridresources (that may reside with individuals or organizations). The network-centric approachrelies on dense communication ties to provide the synchronizing effects, prioritization anddeployment roles of the organization. The potential for network-centric advocacy increaseswith each advancement in connectivity technology (web meetings, phone wi-fi,teleconference, voice mail, cell phones, voice over IP, etc.) and drop in transportation cost(flights, low cost shipping, etc.)’ Seehttp://activist.blogs.com/networkcentricadvocacypaper.pdfWhat needs to be done if these networks are to achieve better integrated care?(GOODWIN, N., PECK, E. & FREEMAN, T. 2006. Managing networks in 21st centuryorganisations, Palgrave Macmillan.)1. Achieve a position of centrality and leverage2. Have clarity of purpose and goals3. Be inclusive in their design and development4. Avoid very large networks and inertia5. Develop cohesion – the role of the ‘boundary spanner’ and IT6. Avoid over-regulation and mandating7. Engage professional leadership8. Avoid capture by an elite (managerial or professional)9. Stay relevant and worthwhile10. Provide the mandate for managersStrengths of Advocacy ApproachThe strengths of advocacy approach include the involvement of external evaluators, whichcan facilitate participation and ensure checks, balances, and the objectivity of the process.Even in the formal, summative evaluations, the greater the involvement of the advocacynetwork’s staff, members, allies and donors, and the more the evaluators serve as‘facilitators in a joint inquiry rather than experts wielding “objective” measuring sticks’, the66

greater will be the quality and validity of the evaluation. Perhaps most importantly, throughtheir participation the stakeholders, and especially the advocacy network’s member, willdevelop the understanding and the commitment to implement the conclusions andrecommendations (Harris, 2005: n.p).Public Sector Networks: The PSN Programme team, led by the Cabinet Office, is workingclosely with industry and other public sector groups, in six distinct workstreams, to define anddeliver PSN standards, practices and governance. This work is in its early stages67

iPrinciples of engagement (MENDIZABAL, E. 2008. Supporting networks: Ten principles.Overseas Development Institute.,.)‘Recommendations can often be confused with keys to success: I do not think these exist.But there are principles that decision-makers should consider:1. Networks are complex and there are no templates for success. Expect setbacks.2. Work with networks to agree on their functional balance and support that balance.3. Interventions to develop a network cannot be conceptualised as ‘logical framework’projects – other approaches such as outcome mapping can provide a better alternative.4. Support networks to function as networks with and through their members rather than todeliver specific services that could be delivered by their members or other types oforganisations.5. Do not treat networks as traditional NGOs or civil society organisations, and do not allowfunds to undermine community building functions.6. When networks carry out a funding role, ensure they have the necessary skills and thatother functions are not affected.7. Network support timeframes should take into consideration the different stages of networkdevelopment.8. Provide appropriate support for the network and its members to develop the rightcompetencies and skills to collaborate.9. A culture of knowledge and learning is a cornerstone of network development.10. Sustainability should be judged against the need of the members for the network’.iiNetworks Function ApproachThe Network Functions approach emanating from Stephen Yeo’s typology of functions (YEO,S. 2004. Creating, Managing and Sustaining Policy Research Networks. Unpublished paper.)was used by Mendizabal to determine the core components of a network (HEARN, S. &MENDIZABAL, E. 2011. Not everything that connects is a network. Overseas DevelopmentInstitute.). A network contains four overarching elements: purpose, role, functions and form.The purpose entails the network objectives and validates its existence. However purposeand the strategy undertaken to achieve it are distinct. The purpose encompasses long termgoals ‘Millennium Development Goals’ (HEARN, S. & MENDIZABAL, E. 2011. Not everythingthat connects is a network. Overseas Development Institute.,) instrumental goals: ‘deliveringgoods and services to a particular population or group’ or fluid: ‘improving a policy debate’(ibid.). The networks purpose is concerned with promoting value amongst participants. Rolesare paradoxically split between support and agency, yet with one persistently affecting theother The former determines that participants act alone as change agents but connect withthe network to obtain support that enhances their work capabilities. [although it’s much more68

intricate than that]. Conversely, participants in agency networks co-ordinate and collaboratewith fellow participant members and perform as ‘...single agents of change’ (HEARN, S. &MENDIZABAL, E. 2011. Not everything that connects is a network. Overseas DevelopmentInstitute..) Support and Agency denote two alternative ways (of many) of operating within anetwork including the form and shape of human interaction, their division of work tasks andalso with the supporting entity. Most networks are situated between Support and Agency, butlimited awareness exists about the trade-offs or organisational impacts and influences (ibid).iiiTower Hamlet PCT Networks“In Tower Hamlets, for example, the PCT contracted for a new integrated diabetes servicewith networks of practices, rather than with individual practices, as would usually be the casein the NHS. The PCT was thus acting as the overall integrator of diabetes services, lettingparallel contracts with local community health and specialist services run alongside thosewith general practice networks, and ensuring that the overall mix of contracts added up to theintegrated care pathway agreed for people with diabetes in Tower Hamlets. At the time ofwriting, only the general practice networks have risk-based contracts, which may act as anincentive for practices to exert pressure on community diabetologists, community nursingand allied health professional staff to play their part in enabling overall achievement ofpopulation health outcome targets” HAM, C., SMITH, J. & EASTMURE, E. 2011.Commissioning integrated care in a liberated NHS. London: The Nuffield Trust..‘Each network consists of three to five practices from the same locality, with commissioningoccurring across networks rather than through individual practices. The networks werecommissioned to deliver an enhanced care package for diabetes. Care planning, training,patient education and an annual review with results sent out beforehand are all intrinsic partsof the commissioned diabetes care package’.http://www.diabetes.org.uk/upload/Professionals/Year%20of%20Care/YOC_casestudies_web.pdfImmunisation and vaccination‘Following the roll-out of the diabetes programme, networks were encouraged to roll-out apackage of care for immunisations and vaccinations. The focus of the programme has beento implement a call/recall system across the network. As there are issues with literacy levelsin Tower Hamlets, people are also contacted by telephone or in person. An IT system wasdeveloped to support roll-out of the programme. The system was developed with clinicalassessment groups (who are responsible for data entry). The PCT has found that thereporting of results motivates the networks and provides an opportunity for recognitionamong peers. The information is trusted and considered to be useful because it is:69

• frequently updated – not live, but everyone can see the impact of activity on the indicatorswithin a week• clinically led (the indicators were developed and agreed by clinicians)• obtained by an honest broker ’ (HAM, C., SMITH, J. & EASTMURE, E. 2011.Commissioning integrated care in a liberated NHS. London: The Nuffield Trust.)ivNHS Networks: The document (NHS NETWORKS. n.d. A suggested framework for the selfassurance of service delivery networks.) explores formal groupings of networks from theclinical fields which operate within hierarchical and individualistic models (or a blend of both)and which span a number of HC organisations, (e.g across primary and secondary care,seeking to provide clear patient pathways & quality assured care).vNetwork-Centric AdvocacyThis is seen as a hybrid of the: ‘individual determination and participation typical of direct andgrassroots models with the efficiencies and strengths of the organizational model. The hybridis only possible because of the increased density of communications connections amongpotential participants and the ability to scale those connections to meet demand. Thenetwork-centric advocacy focuses on supporting individual engagement by connected gridresources (that may reside with individuals or organizations). The network-centric approachrelies on dense communication ties to provide the synchronizing effects, prioritization anddeployment roles of the organization. The potential for network-centric advocacy increaseswith each advancement in connectivity technology (web meetings, phone wi-fi,teleconference, voice mail, cell phones, voice over IP, etc.) and drop in transportation cost(flights, low cost shipping, etc.)’ Seehttp://activist.blogs.com/networkcentricadvocacypaper.pdfviWhat needs to be done if these networks are to achieve better integrated care?(GOODWIN, N., PECK, E. & FREEMAN, T. 2006. Managing networks in 21st centuryorganisations, Palgrave Macmillan.)1. Achieve a position of centrality and leverage2. Have clarity of purpose and goals3. Be inclusive in their design and development4. Avoid very large networks and inertia5. Develop cohesion – the role of the ‘boundary spanner’ and IT6. Avoid over-regulation and mandating7. Engage professional leadership8. Avoid capture by an elite (managerial or professional)9. Stay relevant and worthwhile10. Provide the mandate for managers70

viiStrengths of Advocacy ApproachThe strengths of advocacy approach include the involvement of external evaluators, whichcan facilitate participation and ensure checks, balances, and the objectivity of the process.Even in the formal, summative evaluations, the greater the involvement of the advocacynetwork’s staff, members, allies and donors, and the more the evaluators serve as‘facilitators in a joint inquiry rather than experts wielding “objective” measuring sticks’, thegreater will be the quality and validity of the evaluation. Perhaps most importantly, throughtheir participation the stakeholders, and especially the advocacy network’s member, willdevelop the understanding and the commitment to implement the conclusions andrecommendations (Harris, 2005: n.p).viiiPublic Sector Networks: The PSN Programme team, led by the Cabinet Office, is workingclosely with industry and other public sector groups, in six distinct workstreams, to define anddeliver PSN standards, practices and governance. This work is in its early stages.71