OUR HEALTH IN OUR HANDS: BUILDING ...

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OUR HEALTH IN OUR HANDS: BUILDING EFFECTIVE COMMUNITY PARTNERSHIPS FOR RURAL HEALTH SERVICE PROVISION Susan Johns, Sue Kilpatrick & Jessica Whelan Abstract ] This paper reports findings from a study in two small Tasmanian rural communities that examined the process of developing and sustaining partnerships between health services and their communities. It identifies a generic framework for partnership development that appears to be common to partnerships, regardless of their purpose or of partners involved. The framework comprises ten predictors or indicators of effectiveness, and a sequential nine-stage partnership development process. Integral to the framework are social capital, and the leadership practices of health service and community leaders. The influence of context on the partnership development process is also examined, with reference to historical precedent, age or maturity of the partnership, and community readiness. Keywords ] Partnership, Rural health, Social capital, Community leadership. Received 13 March 2006 Accepted 22 July 2006

Introduction

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losure, relocation or downgrading of health services, along with other services such as schools and banks, is a scenario that has been played out in many country towns across Australia and in other western countries over recent years. Yet issues of rural health and wellbeing continue to be of concern, with rural communities tending to have poorer health outcomes than their metropolitan counterparts (Australian Institute of Health and Welfare, 2005). There is growing evidence of the effectiveness of partnerships involving the community, in increasing the capacity of communities to respond to their own health needs (Ley, Matthews & Singe, 2001), and in improving health outcomes (Roussos & Fawcett 2000; 50

SUSAN JOHNS is a Junior Research Fellow and PhD candidate with the University Department of Rural Health at the University of Tasmania. She is currently researching health, education and community partnerships in rural communities, with a focus on early childhood interventions.

A S S O C I ATE P RO F E S S O R S UE KILPATRICK is Director of the Uni-

versity Department of Rural Health, University of Tasmania. She has a special research interest in rural issues, including health, social capital, agriculture, small business and vocational education and training in regional Australia. JESS WHELAN is an Associate Lecturer with the University Department of Rural Health at the University of Tasmania, and is currently completing her PhD on drinking water and public health in Tasmania. She has published articles on her research in a range of journals.

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Our health in our hands: Building effective community partnerships for rural health service provision Shortell et al., 2002). As rural communities have fewer and a more limited range of resources available for delivering primary health care and wellbeing outcomes, they also have heightened incentives for working in partnership both within the community and with outside services (Asthana & Halliday, 2004). The purpose of the study reported in this article was to replicate in the rural health context, one component of research conducted into rural school–community partnerships (Kilpatrick, Johns, Mulford, Falk & Prescott, 2002). The focus of the study was on the process of developing and sustaining partnerships, as well as factors that influence partnership development. This article focuses specifically on rural health services and communities working in partnership. It does not consider other forms of community participation in health service decision making, nor does it cover partnerships that facilitate integration between health services. For the purposes of this paper partnerships are defined in the following way: Collaborations characterised by the shared and long-term commitment of a diverse group of members to achieving a common goal.

Partnership development: literature review Coverage of the sometimes invisible and time-consuming processes of developing and sustaining partnerships is less prevalent in the health literature. Billett, Clemans and Seddon (2005) note that in general, agencies responsible for funding partnerships do not adequately recognise or resource these processes which build trust and capacity within the partnership. The material reviewed in this section is therefore restricted to articles which focus on the ‘how’ of partnership development and sustainability. The categories of predictors, processes and people are used

to allow a more structured and comprehensive breakdown of the partnership development literature.

Predictors of partnership effectiveness According to Roussos and Fawcett (2000), there is no ‘best way’ to implement a community partnership. Other partnership literature supports this view, although research clearly identifies social capital as central to effective capacity building efforts (see, for example, Balloch & Taylor, 2001; OECD, 2001; Putnam, 2000; Woolcock & Narayan, 2000). Defined as ‘networks together with shared norms, values and understandings that facilitate cooperation within or among groups’ (OECD, 2001, p. 41), social capital is a community resource that is both drawn on and built through interactions between individuals and organisations. Higher levels of social capital have been linked to increased collaboration between groups or organisations (OECD, 2001; Putnam, 2000). Research indicates that collaborative capacity is enhanced by the quality and diversity of linkages both within (horizontal linkages) and external (vertical linkages) to the community (Falk & Kilpatrick, 2000; Stone & Hughes, 2001). The fundamental importance of community participation, engagement and accountability in influencing the effectiveness of health partnerships is well documented (see Crisp, Swerissen & Duckett 2000; Palsbo, Kroll & McNeill 2004; Sutherland, Harris, Foulk & Gessner, 1998). Poole and Van Hook (1997, p. 2) argue that ‘involving community members in the design and delivery of services’ and ‘emphasising community ownership for health problems and solutions’ are two of the most important characteristics of partnership development and collaboration.

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Susan Johns, Sue Kilpatrick & Jessica Whelan Along similar lines to the predictors identified by Roussos and Fawcett (2000), but writing about vocational education and training (VET) partnerships, Billett et al. (2005) identified five principles and related dimensions of partnership work. They noted that when these principles were absent, partnerships were less likely to be effective in their practices and outcomes. These principles are listed below, with their related dimensions in brackets following each: • Building shared purposes and goals (cultural scoping work) • Building relations with partners (connection building work) • Building capacities for partnership work (capacity building work) • Building partnership governance and leadership (collective work) • Building trust and trustworthiness (trust building work) The importance of capacity building to the development and effectiveness of health partnerships is prominent within the literature, and includes developing community structures (social and physical) and developing community members’ skills (King & Wise, 2000). Crisp et al. (2000, p. 103) maintain: ‘if capacity building is successful it produces fundamental and lasting changes in how organisations and communities address health issues’ without the need for ongoing funding and assistance from which most partnerships often develop. Capacity building and partnership sustainability are therefore closely linked. Trust, has been identified as both a source and an outcome of social capital (Falk & Kilpatrick, 2000; OECD, 2001), and as central to the partnership process (Billett et al., 2005; Edwards, Goodwin, Pemberton & Woods, 2000; Kilpatrick et al., 2002; Roussos & Fawcett, 2000; Schorr, 1997). Billett et al. (2005, p. 24) reflect the findings of other researchers 52

when they state that ‘partnership work … contributes to the consolidation of relationships of trust but is never completed. Participants must continue to work at relationship-building if trust is to be maintained between the partners’. Kilpatrick et al. (2002) produced a set of 12 indicators of effective school–community partnerships, which incorporate the key issues identified by Roussos and Fawcett (2000), and Billett et al. (2005). However, the indicators go beyond broad statements of belief regarding effective partnerships, to present a series of criteria against which partnership effectiveness (or the likelihood of partnership effectiveness) can be assessed. Although these criteria relate to school–community partnerships, it is suggested they are sufficiently generic to be transferable to other contexts. They include the need for commitment by organisational leaders (school principals) to fostering increased interaction and to empowering others within the community to undertake leadership roles, as well as a range of organisation/school and community attributes such as access to extensive internal and external networks, openness to new ideas, and a shared and clearly articulated vision for the future.

Processes for developing and sustaining partnerships Amongst the extensive health service literature accessed, only three writers (Poole & Van Hook, 1997; Sutherland et al., 1998; Veazie, Teufel Shone, Silverman & Connolly,. 2001) specifically outline a staged or chronological process for developing partnerships. Both Veazie et al. (2001) and Sutherland et al. (1998) identified six stages in the development of local partnerships, beginning with broad forms of community consultation, and followed by more formalised processes including sub committees.

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Our health in our hands: Building effective community partnerships for rural health service provision Veazie et al. (2001) also identified regular monitoring and evaluation as key features of the process. Conceptions of health service–community partnerships in terms of a progression or lifecycle, moving from informal to formal processes, accords with findings from the broader partnership literature (Falk & Smith, 2003; Henton, Melville & Walesh, 1997; Kilpatrick et al., 2002; Warner & Sullivan, 2004). Recent models have refined the cyclical nature of this process by conceiving of the partnership model as an outward spiral, to reflect the way that subsequent partnership cycles build on, but do not replicate, earlier cycles (see, for example, Falk & Smith, 2003; Johns, 2004). Kilpatrick et al. (2002) synthesise and build upon the research in their five stage model of partnership development: trigger, initiation, development, maintenance and sustainability. A key stage of the process is sustainability, during which partnership vision, goals and processes are evaluated. More recent research (Johns, 2004; Kilpatrick, Fulton, Johns & Weatherley, 2006) suggests that evaluation is the least well understood stage, with some partnerships focusing only on evaluating the initiatives that the partnership has implemented, rather than reflecting on the processes and direction of the partnership itself.

People: who is involved and how are they organised? Building effective partnerships is essentially about developing individual and institutional capacity, and about processes and structures to facilitate participation and collaboration. Leadership is central to any discussion of capacity building, because successful community renewal depends on ‘the way the community leads the development of its stores of social capital’ (Falk & Mulford, 2001, p. 221). Effective community leadership

comprises multiple actors, is multi-directional and not coercive (Rost, 1991), and is context dependent in the sense that it is ‘situated in a particular location, with particular needs and planned outcomes in the form of enabling others’ (Falk & Mulford, 2001, p. 227). Conceptions of community leadership reflect a paradigm shift from earlier research that centred on the attributes and actions of the leader, to more recent research that views leadership as a social process (Barker, 1997). Kirk and Shutte (2004) link this process focus to an increase in interagency and interprofessional partnership arrangements, which demand leadership that is distributed or dispersed, rather than centralised or hierarchical. In rural areas, sources of community leadership come from within and outside communities (Kilpatrick & Loechel, 2004). Shortell et al. (2002) found that the ability to attract and rely on multiple components of leadership was a defining feature of the ‘most successful’ partnerships. The most effective and progressive partnerships were those with three components: committed core leadership, a consistent ‘organisational driver’, and the practice of subsidiary or shared leadership amongst partners. Committed core leaders included key health service personnel. These findings accord with those of Kilpatrick et al. (2002) regarding school–community partnerships, where the role of school principals as committed core leaders was found to be critical to partnership effectiveness. Shared or subsidiary leadership (Shortell et al., 2002) is facilitated when the core leaders are committed to leadership as a collective process, and actively enable and support others to participate. This is a similar concept to that identified by Falk and Smith (2003), who concluded that a leadership approach that enables others to participate is most effective in achieving meaningful and lasting change.

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Susan Johns, Sue Kilpatrick & Jessica Whelan The work by Shortell et al. (2002) is complemented by Billett et al. (2005), who noted the importance of leadership at the local level, particularly in the initial development stages of the partnership. A local leader is described as ‘an agent at the local level who can motivate, organise and direct the effort of the social partnership, and at times give confidence’ (Billett et al., 2005, p. 22). Coupled with this is the role of community organisers (Sutherland et al., 1998), or boundary crossers (Kilpatrick et al., 2002), who are well known and respected community members who speak the language and have the trust of all partnership stakeholders. Roussos and Fawcett (2000, p. 385) draw attention to the ‘core competencies’ of effective leaders within partnerships. They report that effective leaders share generic leadership skills including meeting facilitation; negotiation and networking; framing and communicating the vision and mission of the partnership to a broad range of stakeholders; communicating, and helping or enabling other leaders through different community sectors and groups (businesses, schools, cultural groups).

Influences on partnership development The literature highlights a range of factors that influence the development of partnerships. At a macro level, the role of policy is identified in a number of research projects. Specifically, sustainability of partnerships is in part linked to the impacts of policy (including availability and continuity of funding) on capacity building activities, and on continuity of partnership personnel (see, for example, Edwards et al., 2000; Kilpatrick et al., 2002; James & St Leger, 2003; Schorr, 1997). Continuity of partnership personnel has been identified as a key determinant of partnership sustainability (Kilpatrick et al., 2002). 54

Although there is little research on health service–community partnerships that specifically examines how contextual factors influence partnership development, other partnership research has shown that context does influence the development and sustainability of partnerships. On a broad level, Edwards et al. (2000) found that communities to which people have moved for lifestyle reasons tend to generate more partnership activity than communities to which people have moved for a quiet life. At a more specific level, Kilpatrick et al. (2002) found a key influence to be the readiness of communities to work in partnership and the resulting level of partnership maturity. Less mature partnerships require more direct leadership from institutional drivers such as school principals or health service managers, while more mature partnerships are driven by the community. Community readiness may be linked to existing levels of community social capital, which Roussos and Fawcett (2000) identify as both a facilitator and an outcome of health service– community partnerships. Billett et al. (2005) list a range of other contextual factors that need to be taken into account when developing partnerships: localised need and engagement; diversity of local interests and values; origins and process of partnership development; initiating and leading activities, and history and culture of partnership practices. The need to understand and build on the history and culture of partnership practices is also identified by Roussos and Fawcett (2000) as contributing to effective health service–community partnerships, while Falk and Kilpatrick (2000) identify the need to take account of the history of the partners and the context, which they term historicity, as one of a number of elements necessary for facilitating social networks and building social capital.

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Our health in our hands: Building effective community partnerships for rural health service provision

Methodology

The communities

This study employed multi-method, multi-site techniques to investigate effective health service–community partnerships in rural Australia. The methodology comprised case studies of good practice in two small Tasmanian rural communities, and input from stakeholders through a project reference group. The role of the reference group was to assist in site selection, validate project findings, provide input into the preparation of this article, and assist with dissemination of project findings. With input from the project reference group, two case study sites were selected from the nine nominated. Nominations were invited from staff and associates of the Tasmanian Department of Health and Human Services, a private sector community health care organisation operating in rural Tasmania, and the University Department of Rural Health, Tasmania. As much as possible, the two sites were selected to represent differences in ter ms of community characteristics (composition of the community, history of partnerships). The linking factors were a common focus on the provision of facilities and services for the aged within each community, and the fact that both communities had previously been featured in the broader community development literature as examples of good practice (see Kenyon & Black, 2001). Data were collected from three sources: individual and group interviews with relevant health ser vice staff and community representatives, written documentation, and observation. Interviews were audio-taped and later transcribed. Transcripts were analysed manually for themes and two in-depth case studies were prepared. Full copies of the two case studies are available from the authors on request.

Oatlands Oatlands is located between Tasmania’s two major cities, Launceston and Hobart, and is home to around 580 residents and a service hub for some 5521 people scattered around the greater Southern Midlands municipality (Australian Bureau of Statistics 2002a). A snapshot of the region shows that 10.5% of the population is aged 65 and over (Australian Bureau of Statistics, 2002a). Integral to meeting the health and community service needs of Oatlands and adjoining districts is the Midlands Multi-Purpose Health Centre, which was established by a local Council-driven steering committee in response to increasing aged care needs within the municipality. The Midlands Multi-Purpose Health Centre was opened in December 1991 and is also a nucleus for a number of unique and effective community and health service partnerships including two selected for analysis in this paper, the Oatlands District Homes Association, and the Community Advisory Committee. The Oatlands District Homes Association is an incorporated, non-profit partnership, that raises funds for and manages accommodation and support to allow elderly people to stay within Oatlands. It was initiated some 40 years ago by a small group of community members concerned at the lack of aged care facilities within the district. The local Council and community called a public meeting with the idea of setting up a nursing home. However, the availability of government funding for residential housing, as opposed to nursing home accommodation, prompted a change of focus by the Association. After successfully raising funds from within the community, as well as accessing a grant from the State government, the first two elderly persons’ units were built in Oatlands. The Association now

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Susan Johns, Sue Kilpatrick & Jessica Whelan owns and manages 16 units adjacent to the Midlands Multi-Purpose Health Centre. The Community Advisory Committee is a group that supports and assists in the planning, delivery and evaluation of the Midlands MultiPurpose Health Centre services in order to promote and improve health within the Southern Midlands community. The shift in management of the Midlands Multi-Purpose Health Centre from the local Council to the State government in 2001 meant a shift in governance, with the previous board of management replaced by a governmentmandated Community Advisory Committee. The Committee has five members from the broader community, as well as a representative from the local Council, a local GP, and the manager and an elected staff member from the Midlands Multi-Purpose Health Centre. Community members were appointed through a formalised nomination and selection process. The Committee meets regularly, and maintains strong formal and informal linkages with the local Council. Successes to date include increased awareness within the community of the Health Centre and services offered, and initiation of a regional women’s art project. They have been successful in lobbying the government for services and facilities including a new laundry for the Midlands Multi-Purpose Health Centre which employs local workers.

Deloraine Located in northern Tasmania, Deloraine is a country town with a population of 5524 (Australian Bureau of Statistics 2002b). It serves as a centre for a number of smaller outlying communities. Deloraine has a district hospital which recently underwent a major redevelopment, as well as the Meander Valley Centre for Health and Wellbeing, located on the hospital site. A snapshot of the region shows that 12.34% of the population is aged 56

65 and over (Australian Bureau of Statistics, 2002b). In 1990, the local Council appointed a community development officer to help address a range of issues impacting on community morale, including gaps in service provision, social divisions between the recentlyarrived conservationists and traditional land users, and rural recession. The success of this initiative is reflected in the community’s strong ‘can do’ ethos. The partnership between health service and community reported in this paper had its beginnings in 1997, when a local GP initiated the idea of forming a community committee to improve health service delivery in the community and to stop the drain of services away from the area. A community meeting was called and a partnership of community members, health providers and the Director of Nursing from the local hospital was formed. The committee commissioned a survey of community health needs in the Deloraine area which identified amongst other things, the need for respite for frail aged residents. The Committee accessed funding to build a day centre, negotiated its location with the Department of Health and Human Services, and opened the Meander Valley Centre for Health and Wellbeing in December 2000. It was built on the hospital site and incorporated a day centre. The Deloraine Day Care Steering Committee originally managed the centre and employed staff, but management has subsequently been handed over to the Director of Nursing at the hospital. The committee still works with the Director of Nursing in an advisory capacity, not only in relation to the centre, but also in raising health-related issues for the director of nursing to further, if possible. Once its original purpose had been achieved, the Committee reviewed its options and made several key decisions regarding new priorities including mental health and youth

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Our health in our hands: Building effective community partnerships for rural health service provision health. They changed their name to the Meander Valley Centre for Health and Wellbeing committee, and developed a new mission statement. The Committee is currently working on three projects—a community shed, a community garden, and a biennial community health expo.

Findings and discussion The case studies are not, and are not intended to be, representative of all rural towns. This is particularly so of Deloraine, where the rural lifestyle and relative proximity to Launceston for work purposes, has attracted a number of professional people. They have brought to the community skills in community activism, lobbying and submission writing, and are actively involved in a range of community committees and groups. Supporting findings by Edwards et al. (2000), it is not surprising that this community generates a high level of partnership activity. The purpose of the following discussion is to highlight and illustrate with examples from the case studies, a range of issues and contextual factors relating to the development and sustainability of effective partnerships within two rural communities. Methodological research literature suggests that the presentation of rich, thick narrative description enhances the transferability of findings to other contexts (Stake, 2000). Because people and leadership underpin partnership development and sustainability, these topics are incorporated into the following sections on partnership predictors and processes, rather than being discussed separately as in the literature review.

Predictors (indicators) of effective partnerships The findings indicated a strong commitment by health service managers in both sites to working in partnership with the community,

as well as knowledge and experience in applying community development approaches in order to foster community ownership of health issues and solutions. The Director of Nursing (DON) at the Deloraine hospital described how he liked ‘to work with a lot of organisations to assist them in meeting their goals’, then step back when they were ‘up and running’. There is a strong sense that health service managers in both sites act as boundary crossers (Kilpatrick et al., 2002) or community organisers (Sutherland et al., 1998), comfortable and skilled in working with both the community and the health bureaucracy, and with the ability to engender trusting relationships within and across multiple contexts. The unique position of health service managers facilitated their ability to build community social capital, which has been identified as central to effective capacity building (Balloch & Taylor, 2001; OECD, 2001; Putnam, 2000; Woolcock & Narayan, 2000). Within each site, key community members, along with health service managers, are committed to preserving and improving community health and wellbeing, supporting Poole and Van Hook’s (1997) findings that community participation and ownership of health issues are important characteristics of partnership development. Health service managers, together with committed community champions, played a key role in initiating the Oatlands District Homes Association, and Meander Valley Centre for Health and Wellbeing partnerships. Local leaders included a former local Council employee in Oatlands, a local GP as well as a school counsellor in Deloraine, and health service staff acting in a community capacity in Oatlands and Deloraine. Their actions led to the development of a shared vision for community health and wellbeing, centred on

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Susan Johns, Sue Kilpatrick & Jessica Whelan improving local health services and preventing the drain of services away from their area. High levels of trust are an integral part of the partnership process (Billett et al., 2005; Edwards et al., 2000; Kilpatrick et al., 2002; Roussos & Fawcett, 2000; Schorr, 1997). Health service managers in both sites, as well as other community leaders, described how they drew on and built trust within the community, and between community and external organisations. Early meetings of the Meander Valley Centre for Health and Wellbeing committee were characterised by ‘a lot of forming, storming and norming’, a necessary process given the mixture of personalities and differing agendas of some members. The chairperson noted that this process was fundamental to establishing relationships and building trust between partners, a necessary forerunner to collaborative action. In Oatlands, the Community Advisory Committee’s high levels of trust and commitment to the partnership were illustrated by the fact that a recent call for nominations for new Council members resulted in ‘more people applying than we have places’. Within both sites there is a deliberate focus on capacity building within the partnership, and on the role of health service managers in building capacity through their facilitative leadership style. In Deloraine, the DON of the hospital, who is also deputy chairperson of the Meander Valley Centre for Health and Wellbeing committee, provided information and coordinated workshops to develop muchneeded submission writing skills within the partnership. This was part of an ongoing process of capacity building and continuous improvement: ‘so we’ve worked really hard on how to make us better and how to get the ones interested in the group to get skilled up’. He also facilitated formal linkages between 58

committee members and external partners, such as the Department of Health and Human Services, which resulted in co-location of the Meander Valley Centre for Health and Wellbeing on the Deloraine hospital site. The enabling and capacity building focus of this health service manager supports findings by Shortell et al. (2002) and Falk and Smith (2003) that shared leadership is facilitated when core leaders are committed to leadership as a collective process, and actively enable and support others to participate. It also acknowledges the importance of both internal and external sources of leadership in rural communities (Kilpatrick & Loechel, 2004). Capacity building is a feature of each of the health service–community partnerships in the sites, a role not restricted to health service managers. In Deloraine, the chairperson of the Meander Valley Centre for Health and Wellbeing committee described her guiding principle as ‘mak[ing] people feel valued … try[ing] to maximise the contributions that are made and get[ting] a good team going’. In Oatlands, the Department of Health and Human Services provided a workshop on governance structures and responsibilities to members of the Community Advisory Committee. The deliberate focus on capacity building in both sites supports findings from Crisp et al. (2000) and Roussos and Fawcett (2000), regarding the link between capacity building and partnership effectiveness and sustainability, and also supports Falk and Mulford’s (2001) concept of enabling leadership. By building the capacity of partners, leadership is gradually shared amongst members according to their different skills and interests. This is in line with findings from Rost (1991) regarding community leadership, and supports Shortell et al. (2002) who found that the most effective and progressive partnerships were based on the practice of subsidiary or shared leadership amongst partners.

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Our health in our hands: Building effective community partnerships for rural health service provision Within both sites there is clear evidence of the willingness and ability of partners to seek new ideas, explore new roles and take calculated risks where necessary in order to achieve their goals. These risks were taken within a broadly supportive policy environment. The willingness to risk take and to mould opportunities to match their vision was also found to be a key attribute of effective school–community partnerships (Kilpatrick et al., 2002). Risks included accessing, acquitting and accountability for substantial amounts of funding from public and private sources, and forging strategic relationships with government and other internal and external stakeholders, sometimes needing to step beyond established protocols in order to achieve their goals. For example, the Community Advisory Committee in Oatlands had no decision making powers, unlike the previous board of management of the Midlands Multi-Purpose Health Centre. This encouraged them to explore new roles and alternative sources of power, including lobbying government. At a meeting with the Minister for Health they described themselves as ‘an advisory committee prepared to lobby…I’m not sure he liked that much!’. In another example, community members, including members of the Oatlands District Homes Association, went through a long process to establish the Midlands MultiPurpose Health Centre in the early 1990s. An external agent from the federal health department assisted them to expand the vision beyond aged care, to a broader health focus shared by the community and all three tiers of government. The Association was receptive to this person’s suggestion as to ‘how the community could act and what they could achieve’. Although the literature notes that formal monitoring and review of partnership

processes is important for accountability purposes (Billett et al., 2005; Veazie et al., 2001), there is little in the health–community partnership literature that specifically identifies how formalisation of partnership processes and practices contributes to effective partnership development and sustainability. Yet issues of transparency, accountability and professional conduct were highlighted by partnerships in both sites. In Oatlands, ongoing commitment to the Oatlands District Homes Association is ensured because ‘meetings run like clockwork … these people are experts at running meetings’. In Deloraine, founding members of the Meander Valley Centre for Health and Wellbeing committee recalled that formal meeting procedures were and still are an important part of the committee’s effectiveness. To maintain the focus of the partnership, the chairperson initiates a regular review and re-endorsement of partnership rules and meeting procedures because ‘I can’t do it as chairperson unless [they] actually give me authority …’. There is a clear sense from both sites, that the local health service is very much a community hub, over which the community has a strong sense of ownership. The development of the Meander Valley Centre for Health and Wellbeing and its co-location on hospital grounds was in direct response to a community health needs survey, which found that people wanted ‘a one-stop shop, they wanted an MPS type of facility, they wanted it co-located so they could go to the health centre or the hospital … and access the services …’. In Oatlands, the relatively new site manager of the Midlands Multi-Purpose Health Centre was struck by the ‘wonderful support from the community … a lot of it is people that have been here for a long time and have been involved with things like the auxiliary’. Health

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Susan Johns, Sue Kilpatrick & Jessica Whelan service managers played a key role in facilitating this sense of community ownership, through multiple linkages and networks within the community, including making themselves accessible to community groups as guest speakers. Drawing on findings from both sites, a set of ten predictors of effective rural health service–community partnerships has been identified: 1. Local health service managers are committed to fostering increased integration between health services and the community and have a strong focus on preventative care, health promotion and community development 2. Health service and community are committed to a vision for the future centred on preserving and improving community health and wellbeing 3. Local health service managers empower others by their facilitative leadership style 4. There is a high level of trust amongst partners 5. Health service and community groups value the skills of all and focus on building the capacity of all 6. Health service and community have access to and utilise extensive internal and external networks to achieve their vision 7. Health service and community are open to new ideas, willing to take risks and willing to mould opportunities to match their vision 8. Health service and community place importance on transparency, accountability and professionalism of partnership processes and practices 9. Health service and community together play an active, meaningful and purposeful role in identifying and meeting community health and wellbeing needs 60

10.There is a strong sense of community ownership of the health service as a community hub, bringing together physical, human and social capital resources. The predictors are largely sequential, in that later predictors build upon earlier ones. A number of these bear similarity to the indicators of effective rural school–community partnerships identified by Kilpatrick et al. (2002).

Processes of partnership development Within both sites there was evidence that partnerships were the result of a carefully planned, and largely sequential development process, driven by local champions and supported by a core of committed leaders from the community and the health service. These findings are consistent with the literature on partnership development (Falk & Smith, 2003; Kilpatrick et al., 2002; Roussos & Fawcett, 2000; Sutherland et al., 1998; Veazie et al., 2001; Warner & Sullivan, 2004). The formation of each partnership was in direct response to a problem or opportunity. In Deloraine, the Meander Valley Centre for Health and Wellbeing committee was formed to address community concerns about dwindling health services. In Oatlands, the community identified problems in relation to aged care, and under the formal banner of the Oatlands District Homes Association, set about raising funds to build an aged care facility. This process echoes the findings of Shortell et al. (2002) and Billett et al. (2005) regarding the importance of leadership at the local level, particularly in the initial development stages of the partnership. Notably, in both of these partnerships, several of the original community champions or drivers are still involved today in leadership roles. This suggests the importance of continuity of leaders and other partnership

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Our health in our hands: Building effective community partnerships for rural health service provision personnel, all of which have been identified as key influences of on partnership effectiveness (Edwards et al., 2000; James & St Leger, 2003; Kilpatrick et al., 2002; Schorr, 1997). The Community Advisory Committee in Oatlands had slightly different beginnings, given that it was a government-mandated body, but was nevertheless embraced and supported by community leaders as an opportunity to lobby for improved local health service provision. The Oatlands District Homes Association and the Meander Valley Centre for Health and Wellbeing committee clearly illustrate a development process that moved from infor mal, broad based discussion and brainstorming, to more formalised and focused planning and decision making, guided by the development and articulation of a shared vision and mission. The chairperson of the Meander Valley Centre for Health and Wellbeing committee played a key role in guiding the partnership to refine its focus and develop a shared purpose and mission statement. The mission statement was subsequently used to guide planning and decision making. She described how development of a clear mission signalled a major turning point in the development of that partnership, in the sense that a greater sense of shared purpose mobilised partners and increased their commitment to translating the mission into an achievable and tangible project to benefit the community. The chairperson displayed a range of skills associated with effective leadership, such as meeting facilitation; negotiation and networking, and communication (Roussos & Fawcett, 2000), and the ability to develop trust amongst partners (Billett et al., 2005; Edwards et al., 2000; Kilpatrick et al., 2002; Roussos & Fawcett, 2000; Schorr, 1997), as well as a high level of awareness of the importance of these

skills. In Oatlands, the chairperson of the Community Advisory Committee and the president of the Oatlands District Homes Association undertook broadly similar roles, although the processes were not described with the same level of awareness or in the same depth. While effective partnerships focus on the internal aspects of partnership development, in terms of developing relationships, building trust and developing a vision, they also demonstrate an awareness of the importance of seeking input from others with relevant knowledge, skills and influence, to assist them in realising their vision. This includes lobbying government ministers, in the case of the Community Advisory Committee in Oatlands, as well as targeted negotiations with external stakeholders, as in the case of the Meander Valley Centre for Health and Wellbeing committee, who met with government officials to determine where the Centre would be located and to negotiate how it might complement existing government health services in the community. This attention to building social capital with external partners reflects each community’s awareness of the importance of developing both horizontal and vertical networks (Falk & Kilpatrick, 2000; Stone & Hughes, 2001) in order to achieve their goals. Whilst the Deloraine and Oatlands partnerships followed a similar pattern in terms of initiation and development, what differentiated them was their focus on the later evaluation stage of the partnership process. In most models reported in the literature (Kilpatrick et al., 2002; Veazie et al., 2001; Warner & Sullivan, 2004), evaluation is the final stage in the cyclical process, which may lead to a reaffirmation or refocusing of partnership goals, and to the refinement or development of a new initiative. This was the case in Deloraine, where the Meander Valley Centre

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Susan Johns, Sue Kilpatrick & Jessica Whelan for Health and Wellbeing committee undertook a major evaluation once it had achieved its original purpose. This action is consistent with processes for sustaining effective partnerships identified by Kilpatrick et al. (2002). It may be that the strong focus on evaluation reflects the composition of this particular partnership, comprised of largely professional people, many of whom brought with them knowledge and experience of the evaluation process. In Oatlands, for both the Oatlands District Homes Association and the Community Advisory Committee, partnership evaluation centres mainly on succession planning and the need to replace ageing community volunteers with ‘new blood’. The Community Advisory Committee acknowledges partnership evaluation as an area requiring further attention, if they are to continue to meet the health and wellbeing needs of the whole community. This suggests the need for capacity building and further partnership development work, and supports findings by Johns (2004) and Kilpatrick et al. (2006) that evaluation is the least well understood (and often the least well developed) stage in the partnership process. Drawing on findings from both sites, a ninestage process for developing effective rural health service–community partnerships has been identified: 1. Community or health service identify problem or opportunity 2. Local champion(s) come forward 3. Community consultations/meetings gauge interest and build support 4. Core group of interested members form to drive the partnership 5. Partnership process is formalised and partnership goals and strategies articulated 6. Building of trust amongst partners and development of individual and group capacity is on an ongoing basis 62

7. Support is sought from others with relevant knowledge, skills and/or influence 8. Implementation and management of partnership initiatives is supported by formal and informal processes and networks 9. Evaluation of partnership purpose, roles, performance and sustainability occurs The process is largely sequential, in that later stages build upon earlier ones, with the exception of stage 6, trust building, which researchers have identified as ongoing throughout the life of the partnership (Billett et al., 2005). This staged process is closely linked to the predictors identified in the previous section and expands upon the five-stage process identified by Kilpatrick et al. (2002) in relation to school–community partnerships. Although the process appears to be generic, it may be implemented differently depending on different partnership contexts.

The influence of context on partnership development Three factors relating to context are particularly relevant to this discussion: (1) historical precedent, (2) partnership maturity, and (3) community readiness; the second and third factors are closely related. In Oatlands, which has a long history of community activism and strong links between the local Council and the community, there are established procedures and practices for developing partnerships which are ‘known’ to those within the community. The development of new partnerships is facilitated by building on those precedents, supporting findings by Billett et al. (2005) and by Falk and Kilpatrick (2000) regarding historicity as a necessary element in the development of social capital. One Oatlands interviewee cited an example of the difficulties faced by a new community member who was attempting to build a health service–community partnership,

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Our health in our hands: Building effective community partnerships for rural health service provision without sufficient reference to the history and culture of partnership practices. As a result, the partnership had limited support and was developing much more slowly than it might have done. In terms of partnership age or maturity, the findings suggest that newer partnerships (the Oatlands Community Advisory Committee) require more direct leadership input from the health service manager and not surprisingly, focus their attention more on the ‘front end’ of partnership development, including implementation of partnership initiatives and celebrating successes. More mature partnerships (Oatlands District Homes Association, and Meander Valley Centre for Health and Wellbeing committee) require less direct leadership input from the health service manager, and, in the case of the Meander Valley Centre for Health and Wellbeing committee, deliberately and regularly undertake evaluation of partnership processes and future directions. These differences support findings by Kilpatrick et al. (2002) relating to partnership maturity and community readiness. Community readiness is reflected by the skills and capacity of community representation in the partnership. The case studies suggest that capacity can come from community members’ experiences in other contexts, as for the professionals in the Deloraine partnership, and can also be developed through the experience of working in community partnerships.

Conclusions The partnerships described in this paper reflect a community development approach that delivers a range of tangible (improved health and aged care services) and less tangible (increased community capacity) outcomes. Empowering rural communities by building their capacity to respond to their own health and wellbeing needs is a complex process

dependent on a range of factors. However, the process itself appears to be generic and largely sequential, guided by a generic set of predictors. A key outcome of this study is the development of a framework for developing and sustaining health service–community partnerships. Central to the framework is the need for a continued focus on developing the largely invisible ‘soft’ skills of trust- and capacitybuilding, and the need for greater attention to the all important evaluation stage of partnership development. Evaluation is critical to continuous learning and growth, ensuring responsiveness to changes in the health and wellbeing needs of communities. Partnerships need to be provided with the knowledge, tools and resources to evaluate not just the outcomes of their initiatives, but also their own performance and direction. In order to further develop the framework proposed in this study, it is recommended that further exploration and refinement of the predictors and processes be conducted across a range of different health service and community partnerships. This includes further research into how skills in trust- and capacity-building, as well as evaluation and reflective learning, can best be developed, supported and resourced, with an emphasis on fostering and strengthening community development approaches by rural health services.

Acknowledgements The authors would like to acknowledge the input of the project reference group into site selection and their comments on the findings and the paper.

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