Tim Rhodes, Janet Holland and Richard Hartnoll
The new paradigm informing drugs work has produced initiatives that do not sit easily with existing British systems of healthcare provision An evaluation of one London Outreach project provides an insight into some of the problems that can arise
There has been increasing interest in community-oriented and community-based approaches to health education and service provision (McGuire, 1989). This has involved challenging conventional models of health and illness and disease prevention which emphasise biomedical understandings of illness and tend to restrict the possibilities of change to the individual (Crawford, 1977,1980; Brown and Margo, 1978; Doyle, 1979;). As an alternative to mainstream models of health education such as 'information giving' (Tones, 1981; French and Adams, 1986; Beattie, 1991), the recent commitment to community development for health and to community-based intervention has advocated empowerment, and community and social change (Homans and Aggleton, 1988; Beattie, 1991). In recognising the [ wider social and cultural constraints on health behaviour, these approaches emphasise the facilitation
of 'self-organisation' and 'mutual assistance' (Beattie, 1991) above the more commonplace health education notions of health beliefs and self-efficacy in individual behaviour change (Becker and Joseph, 1988; Ross and Rosscr, 1989?. Fundamental to this approach is a commitment to developing 'client responsive' services in the context of social inequalities about health and service provision.
Throughout its history, community development for health - like the concept of community development as a whole - can be seen to have embodied contradictory elements (Webster, 1991). Essentially, these have been characterised on the one hand by the commitment to facilitating change within communities from the 'outside' by local and central state, voluntary and philanthropic organisations, and on the other by the commitment to encouraging change 'internally', from within affected communities themselves. This has brought to light the conflicts which exist between truly 'bottomup' approaches to health - those that start with the health priorities of communities and involve them as active participants in the process of change - and 'topdown' approaches - those that reflect the issues and ) goals defined as important by health educators and policy makers (Beattie,1986) .
Recent interest in community-based intervention has further encouraged a narrowing of divisions between 'external' and 'internal' approaches to community intervention, and tensions arising between bottom-up and top-down strategies have become further embedded. In practice, this has led to change. It has meant, for example, the increasing dependency of community health and self help initiatives on statutory rather than charity funding, and a shifting of the community work ethic away from opposition towards structural change (Webster, 1991). Fundamental principles of community intervention, such as community participation and the redressing of health inequalities, are now being viewed in similar terms to wider agendas, for example, those of the World Health Organization National Community Health Resource (1989). The establishment of the (now disbanded) Health Education Authority's (HEA's) Professional and Community Development Division and recent NHS interest in consumer health needs (e.g. Community Care Act 1990) were both moves in this direction (Beattie, 1991; Smithies and Webster, 1991; Webster,1991)
The advent of HIV infection and AIDS has heightened the potential for intersectoral collaboration and commitment to developing community-based intervention. Reaching the 'hard-to-reach' has besome an urgent concern for many service sector's, and the development and implementation of 'innovative' and 'user-friendly' HIV prevention programmes outside formal health service settings has been fast and furious. Although initially concentrated within existing agencies with the aim of developing 'lower threshold' approaches, these initiatives have since moved towards the creation of new entities such as the syringe exchange (Stimson et al., 1998), and recently have moved out of the agency altogether: HIV outreach health education has become a fast expanding field (Rhodes and Hartnoll,1991).
Outreach intervention thus aims to identify gaps in existing service provision and to provide effective health education and services to populations within the community which are without adequate or equal access to available and appropriate services. This means:
'a community based activity with the overall aim of facilitating improvement in health and reduction in the risk of HIV transmission for individuals and groups from particular populations who are not effectively reached by existing services or through traditional health education channels.' Rhodes et al., l 991c
The historical evolution of outreach health education has closer associations with bottom-up and community-based approaches than with top-down responses to health intervention (Rhodes and Hartnoll, 1991) . This is because it remains an axiomatic principle of outreach to identify, reach and provide services in response to inequalities in existing service provision and in response to clients' expressed health needs. This approach necessarily accepts the need for context-specific health education and active participation on the part of the client in the process and implementation of change. There is then an encouraging departure from 'information-giving' models of health education and the concomitant recognition that the presentation of accurate information alone and simple exhortations to change individual lifestyle and health behaviour often do little to encourage behaviour change (Gatherer et al.,1979).
But like the historical development of community development itself, approaches to outreach intervention - especially HIV-related outreach - are increasingly emerging from a combination of bottom-up and toll down service perspectives. In the USA, for example outreach interventions operating from a combination of service perspectives including community work, self help, ethnography, philanthropy, epidemiological research and public health intervention may actually be the norm (Des Jarlais, 1989; Rhodes et al., 1991a). In the United Kingdom, although most HIV outreach projects remain situated in the voluntary sector (66% in a recent national survey, Hartnoll et al., 1990), projects are increasingly being established within statutory sectors, employing a mix of 'community' and 'professional' work styles.
In this paper, we describe an evaluation of one such model of outreach intervention Central London Action on Street Health (CLASH *1). The model was considered 'innovative' because its explicit aim was to integrate service provision and service management through both voluntary and statutory health sectors.
|was an attempt to provide access to a comprehensive network of service provision for central London's large populations of young people involved in drug taking, prostitution and homelessness, who had been identified by several voluntary agencies as in need of primary health care and HlV-specific services. In effect, this meant going some way towards acknowledging the t potential for conflict between 'community' and 'professional' approaches: statutory services alone would have little hope of attracting previously neglected populations without drawing on the experience and guidance of community-based organisations with a long commitment and influence in this area, and simply providing a 'community front' for existing statutory services may fall short of the fundamental aims of outreach to provide tangible services according to clients' expressed needs.
In the light of these broad collaborative aims, the project was set up in 1986 with the dual objectives of providing both detached in situ street health education among hard-to-reach sex workers, drug injectors and homeless young people, as well as opportunities for referral access into existing voluntary and statutory treatment, and helping services.
The evaluation (*2) of CLASH began In January 1988 and ended in March 1991. A combination of qualitative and quantitative methods were employed to produce an ethnographic and statistical account of the project's origins, development, practice and performance. The evaluation was process rather than outcome oriented, although a number of process performance indicators and intermediate outcome measures were employed. Here we outline the methods used to investigate the feasibility and effectiveness of the management functioning of the project; we have described both the evaluation of service provision and the methodology in full elsewhere (Rhodes et al., 1991b; Rhodes and Holland,
Data on the way management functioned were qualitative in nature and were drawn from a variety of sources. Historical documentation of the origins, setting up and development of management structures was achieved through collation and analysis of documentary evidence of correspondence, minutes of developmental meetings, project proposals, and progress and policy reports.
Field notes of observations undertaken at the project, at the project's weekly progress and review meetings, and at other regular management meetings, provided data on intra-team management and the management process. These centred on the process by which project members organised and managed their work, how decisions were made, and on the problems encountered in the styles and structures of management adopted.
Data relating to the functioning of the CLASH project within its managerial setting were provided primarily through interviews with voluntary and statutory managers, CLASH workers and other key people involved in the setting up and running of the project. These semi-structured interviews generally lasted between 11/2 and 2 hours. A total of 18 interviews were conducted: 7 with statutory participants, 4 with voluntary participants, and 7 with past and present outreach workers of the CLASH team.
The management structure adopted aimed to reflect the project's broad voluntary-statutory collaborative aims (Figure 1).
The overall strategy for the CLASH team's policy and practice was to be overseen by a steering group (on which the CLASH team were 'observers') consisting of Bloomsbury Health Authority (BHA*4) representatives involved in HIV health promotion, HIV service co-ordination, Health Service Management and representatives from voluntary groups involved in detached, youth and advice work with young people involved in homelessness, drug use and prostitution.This steering group was balanced, on the one hand, by a Management Group and, on the other hand, by a Voluntary Sub-Group. The Management Group, in turn, accountable to the District Unit General Manager (who was also a member), consisted of three BHA representatives and the CLASH team, and aimed to provide administrative direction to project workers on day-to-day business. The Voluntary Sub-Group consisted of voluntary representatives and the CLASH team, and aimed to provide supervision on issues directly-associated with the development of outreach services.
In practice, the Management Group met irregularly and rarely provided the professional supervision intended. The Voluntary Sub-Group, which had emerged in response to tensions developing between outreach workers and statutory managers, survived for an initial year: 'That group is not meeting now, it was not very powerful, it was basically struck down with a case of apathy.' Similarly, participation on the Steering Group was irregular, particularly from voluntary managers.
Findings on the functioning of project management will be discussed as they relate to three distinctive levels of the management process: intra-team management; worker-manager relations; and voluntary-statutory manager relations. Each of these are examined below.
These three elements can be viewed in the context of an initial polarisation of interest, particularly between outreach workers and statutory managers, where two groups inhabiting entirely alien cultures relentlessly confronted each other in mutual incomprehension. As one statutory agency manager commented
'CLASH are more aligned to non-statutory sector services, yet being managed within the statutory service. The very nature of the people that one wants to recruit into jobs like that makes them less amenable to the bureaucracy that the Health Service chucks out.'
The CLASH project was established without specified internal management structures. The original ClASH team simply consisted of three outreach workers each with identical job descriptions. In the vacuum of non direction, the workers themselves decided to work as a collective. This meant each had equal involvement in the internal organisation, management and decision making processes within the project. The commitment to work as a collective generated a clear identity as a collective, which coloured both the approach to work issues within the team, as well as having direct effects on the team's relations with Steering and Management Groups. In principle this was a problem of the viability of a collective operating within a host organisation firmly rooted in hierarchical management structures. It was exacerbated by the style and nature of outreach work and the orientation of the outreach workers themselves, which were closer to voluntary and community work styles operating on egalitarian or democratic principles.
There was general consensus among both voluntary and statutory managers that the team's decision to work as a collective was the first problem in management design:
'That was kind of accidental. That was maybe a fault, the fact that it wasn't really addressed.'
'It was their decision. I think originally we appointed three people on the same grade and that was probably an error.'
'Perhaps the workers are victims of inadequate management in the first place. There weren't any options, no one was in charge. There wasn't a hierarchical structure to start with, so they didn't have any choice. they were a collective.'
As a collective, the team 'presented a corporate image', required a group decision on almost every issue, and often 'came round as a threesome' when approaching project managers. This was seen as inhibiting the management process and flow of decision-making:
'It got to the point where it became a bit of a joke where you couldn't talk about seeing a member of the CLASH team. You had to see the whole CLASH team.'
The collective approach meant that the CLASH team were able to protect themselves by acting as a solidarity unit against the Health Authority, but over time it became clear that the apparent consensus of 'collective' working often masked a reality of divided opinion and conflict within the team. These tensions became apparent in interviews with individual team members 'the tyranny of collective working'; 'an unequal collective'; 'the hidden hierarchy of the collective'.
The unequal power relations in intra-team management were largely a result of a high turnover of staff within the project, where longer standing team members assumed greater power and control within the team:
'They found it hard to let go of that power. It's not really fair for the other team members that
come along, because it means that they never get the chance to be equal, because there's this hidden hierarchy.'
Distinctive personality clashes, perhaps inevitable m a team of this size and nature, also led to further disruptions in the functioning of intra-team management
'I basically felt like there was a real power struggle going on. A power struggle that I didn't really want to be part of. But I couldn't help being involved in it because if I didn't, then what was happening was rather than keeping my position, I would just go under because I would have things pushed on me. And so l felt that I had to fight.'
The team's lengthy collective decision-making process at weekly meetings often became a battleground for these tensions, and itself functioned precariously. As one of the workers remarked: 'we managed ourselves very badly. I think it's improving, but I think it's appalling'. As the team were concerned to protect the 'idea' of collective working, agenda items or decisions were often deferred until all team members were present - a rare event, and a process which meant decisions were sometimes deferred for weeks. When it came to acting on decisions, workers were neither accountable to each other nor reliable in undertaking their responsibilities:
'He wasn't actually accountable to anyone. He was accountable to all of us, but in that he was also accountable to none of us.'
Managers acknowledged this problem in so far as liaison between the team, Steering and Management Groups were concerned:
'Here was a group of people who said "we're all equal, none of us is the leader, and we don't report to anybody".'
'It's not clear to people always to whom they're responsible.'
A desire for direction and accountability gradually emerged within the team, although this was rarely vocalised between workers as fervently as were the team's collective ideals:
'We didn't feel contained in any sort of structure, and that's why we sort of desperately built up a whole lot of structures around us. Like all these sub-groups, like an attempt to hook our selves into something, and actually to be accountable.'
Ultimately the need in practice for systematic direction and accountability to improve intra-team functioning led to a concomitant desire for explicit hierarchy. This was as much a concern about the unwieldy and time-consuming processes involved in actually arriving at mutually agreeable team decisions as it was a concem of the more experienced outreach workers to have overt recognition of their position and power within the team:
'I certainly didn't want to be anything other than a team member before. But I feel differently now.'
At this stage, most statutory and voluntary managers had felt the need for re-structuring the team on a hierarchical basis for some time, and indeed that it was an error that the team had been allowed to build as a collective. At a time when most were aware that problems of intra-team management existed - though they had never been overtly negotiated between workers and managers - and at the request of the Steering Group, a management consultant was appointed to collaborate with the team in clarifying a hierarchical structure. By mid-1990, the team and Steering Group had accepted the consultant's proposal that an external appointment should be made to a co-ordinating managerial post within the CLASH team. This person would act as a line manager and professional supervisor to outreach workers, be responsible for liaising with the Health Authority, co-ordinate the direction of CLASH's outreach work, and be accountable to the Health Authority's HIV Prevention Co-ordinator.
Tensions between outreach workers and statutory managers were perhaps inevitable in a collaboration of this type. Although part of its 'innovative' charm, this stemmed from a relatively natural collusion between outreach workers and voluntary representatives on the basis of shared experience, conceptualisations of health and service provision and ideological positioning. Inadequacies in statutory sector performance were expected, even if at times not always evident. The battle which ensued was about identity and ownership over what the workers saw to be 'community' work:
'The job that the voluntary organisations do is very similar to what we do, except we're statutory. It's the statutory that we're fighting, and that's why it's so difficult.'
'I think we were all fairly suspicious of them [CLASH]. They looked different, they behaved differently, they were rather arrogant in our eyes.'
Worker-statutory manager relations became polarised, and participants would attend Steering Group meetings expecting the latest in a series of confrontations:
'The Steering Group became confrontational. The Steering Group was bizarre. It was confrontational, it was always "what does management feel".'
'[People would say] "I really do not know what the point of these meetings are: they're hostile, they're aggressive, we don't make decisions, the Health Authority side is suspicious and grossly cautious of everything".'
In this context, the CLASH team sought alliance with voluntary managers. This led to a voluntary statutory split and the creation of the Voluntary SubGroup where voluntary managers advised the CLASH team on service and management issues:
'If we've got certain things we want to say, and we'd like something to happen, we'll tell the voluntary staff so they can argue it for us at the Steering Group. Otherwise, it would be just CLASH with the management.'
For outreach workers, the voluntary participants became a go-between, close allies who would help them to get what they wanted from 'management' - perceived as exclusively statutory in orientation, even if not in membership. For some statutory managers, this was viewed as confrontational - they were being set up:
'I have a very clear view that members of the voluntary sector and the CLASH team actually got together before the Steering committee to say "Okay, what do we need to get out of this today?".'
The principal problem of management functioning, relevant to both intra-team functioning and worker-manager relations, and rooted in the structure itself, was summed up by one worker:
'There's an essential problem in that the reason that we haven't been managed terribly well is because there is no interface between us as a team and the management that do exist.'
This lack of 'interface' resulted from no direct line management between the CLASH team and their Steering Group:
'We get no managerial supervision at all. Not that I particularly would want managerial supervision, but it's not even offered. We get no clinical supervision provided by the Health Authority either.'
Indeed, the professional and clinical supervision promised by the Management Group rarely materialised:
With a group like CLASH it is very unclear what their professional management should be, because there is no obvious animal. For a group like this there is no obvious line management to fit in.'
Paradoxically, with no pre-existing model of management practice to follow, the CLASH team received a singular and disproportionate amount of high level Health Service management time:
'CLASH was actually taking a disproportionately large chunk of management time. This amazing kind of support system for three workers. CLASH was unusual. We all went along ~ with it because it didn't fit in anywhere else.'
'They felt unsupported, despite the immense amount of support going on.'
The lack of 'interface' between outreach workers and managers to channel such support or to encourage a system of line management was aggravated by three related factors: the CLASH team's own difficulties in managing themselves effectively; the team's alliance with voluntary managers and their aim to mobilise voluntary participants into confrontation with statutory managers; and the Steering Group's difficulties in managing itself in the context of an ongoing confrontation between voluntary and statutory sector managers (see below).
It was this structural vacuum between the outreach team and its Steering Group of managers which allowed the CLASH team a disproportionate amount of autonomy and independence to manage themselves, at least on an everyday level, more or less as they wanted. It is ironic for the CLASH team to feel on the one hand 'undermanaged' whilst on the other wishing to manage themselves, and for the Health Authority to feel the workers 'unsupported' despite the 'immense amount of support' they clearly wished to give them. For this was essentially the problem. Without the skills to know how to work effectively within a Health Authority and to gain the management support they required, the CLASH team were unable to translate their expertise and knowledge about their clients and their service needs into constructive service development and delivery. The team had ideas about the direction of service changes on ground level but they experienced great difficulty in actually understanding, and certainly manipulating, the management process:
'We're managed by the statutory but we don't really get much management, we don't get much encouragement, nobody's coming to us helping us - we're having to go up to them and tell them what we want, and then fight with them to get what we want, and then wait a longtime-to see if anything occurs.'
The problem in providing the CLASH team with the 'interface' they required to 'work' the management process was, however, exacerbated by the lack of control the Health Authority had over the project and the refusal of the workers to actually be managed. The question of how much the Health Authority actually wished to assist CLASH in becoming effective manipulators of management remains:
'As one of the principal objectives of the CLASH team is to access people into the Health Service, one would have thought you would specifically employ people who would have the skills in order to do that. What we did was to specifically employ people who had the skills to do outreach work - and that's what they've done successfully. We didn't employ people with the skills to manipulate and persuade the Health Service to change and that's simply what they haven't done.'
Similarly, the question remains as to how much CLASH were actually willing to learn, preferring instead to remain distanced from management, taking as they did (at least in appearance) an democratic egalitarian stance. As long as CLASH lacked these essential management skills, however, the extent to which they were effective in facilitating improvements and changes in outreach services remained limited (see below). In this respect, there was little chance of the management structure responding effectively to the needs of clients.
We have suggested that the tensions operating between statutory and voluntary managers, and between statutory managers and outreach workers, stemmed from differences in the style and ideology of work. The voluntary sector, working closer to the principles of community intervention, valued negotiation and participation with clients as one of the most basic principles of outreach work. There was a tendency for voluntary participants to view the Health Authority in top-down terms: as 'desk-sitters', as a bureaucratic, inflexible and controlling organisation which favoured prescription to participation. These expectations of the Health Service as unable to understand the nature of outreach work directly affected the response of voluntary managers to their statutory counterparts: 'when CLASH started we realised what a horrible monster the Health Service is, and what an incredible bureaucracy it is.'
Aware of this, one statutory manager explains:
'Tension was established from very early on and has existing throughout the project. On the one hand there is the criticism of the Health Authority for not taking on the issues but in fact when the Health Authority does take on the issues it is often seen as highly bureaucratic and very controlling, a tension around statutory organisations as agents of social control - not on the agenda quite as explicitly as that but that, but around.'
There was thus a fundamental 'managerial cultural difference' between voluntary and statutory participants. These differences were aggravated by what appeared to be a structural imbalance between voluntary and statutory representation in the collaborative organisation of the project. Voluntary managers frequently felt that the balance of power was firmly weighted in favour of the Health Service:
'It was set up to have an imbalance in favour of the Health Service.'
'Ultimately the power is always going to lay where the money is because we can suggest whatever we like and the voluntary groups can support us to the hilt but they're not paying.'
This tendency for decisions to be 'top-down' was recognised by one statutory manager:
'The fact that they would often come up with the initiatives for decisions and we would end up in the role of sanctioning or vetoing was one of the real tensions. They would say "you're paying, but all initiatives, all suggestions, all the actual direction of the project is actually not coming from the Health Authority side", which was fair comment .'
Although the Unit General manager viewed the voluntary-statutory relationship in more co-operative terms, the implications for power and control in practice were essentially the same:
'The Health Authority did not just grab the high ground. We were paying for the team but we were also trying to learn from the voluntary sector about how this kind of activity would work. I think there was an acceptance from the voluntary sector, from day one almost, that we would be the senior partner by virtue of holding the budget and contracts of employment.'
Eventually, voluntary participation in the project began to decline. Voluntary interest was influenced by two main factors. On the one hand, some voluntary participants felt they had already achieved their objectives once the project was established:
'I think CLASH is established both internally and externally to the Health Authority. It therefore experiences less difficulties in terms of the Health Authority internal management structure. Externally it's seen as being established and there is no immediate threat of it being cut or disbanded, so in some ways the external voluntary groups have been able to relax. With it up and running, we can back off a little bit.'
On the other hand, with the balance of power in favour of the Health Authority, others felt they were unable to achieve their objectives:
'It felt increasingly that we had very little actual power to do anything except to withdraw.'
'We have no influence except our ability to argue and stamp our feet or withdraw our support.'
In the light of management changes, the project has taken on new hierarchical structures within the Health Authority. The CLASH team, now accountable within a hierarchical system of line management, is directed on aspects of strategy and policy by an Advisory Group rather than a Steering Group. This Advisory Group consists of some voluntary representation, although the responsibility for decision making now rests exclusively with statutory participants. The commitment to collaborate with representatives from voluntary and community-based projects in the organisation and management of service delivery therefore proved inoperable.
In the light of its broad collaborative aims, the CLASH intervention aimed to provide an integrated service by combining the dual objectives of providing in situ street health education services and referral access for 'hardto-reach' populations into existing statutory and voluntary sector health services. In practice, it was precisely these collaborative objectives which became the source of managerial conflict between voluntary and statutory managers and outreach workers (see also Rhodes andHolland, 1992).
Statutory managers were aware of theif inexperience in the field of outreach and community-based intervention. As one voluntary manager remarked: 'they didn't understand at all the nature of detached work.' The collaboration with voluntary and community-based managers was intended to facilitate a learning process for Health Service personnel in the management of outreach services. In the light of the management conflicts described above, however, and - in particular - in the context of there being no 'interface' or line management between workers and managers, the outreach project was unable to function as an appropriate instrument of change:
'The Health Service by and large is highly unimaginative, when it comes to service delivery. They are not interested in service delivery, they are interested in balancing the books.
They are not really interested in "quality of care", and don't understand the environment; neither do 1. I think they [CLASH] have had immense hostility and suspicion from quite senior levels, and lack the ability to understand in what world they're operating'.
As the CLASH team did not possess the appropriate management skills to 'understand the world in which they were operating' and statutory managers acted with extreme caution in response to recommendations made by voluntary managers and outreach workers, the impetus for service development was largely curtailed. In this respect, the outreach workers found themselves unable to translate clients' needs for services into appropriate changes in service delivery:
'The managers should be using CLASH as an essential tool. But in some ways what happens is the opposite, is that managers [statutory] see what it's throwing out and it becomes more and more a thorn in their side.'
'There is still a tension now around how much influence CLASH can exert to actually get real change happening in the Health Authority.'
tThis-tension for change was centred on the balance of ~jectives in outreach work; between providing in situ street health education services and referring clients into existing health services. For outreach workers, providing health education services in situ was viewed as an objective in its own right, and as a part of a process where referral was the ultimate aim: 'The idea of offering services is like a carrot to then introduce people to other services.' This was seen to be in accord with statutory managers' expectations: 'what management want us to do and what we'd like to do is to get people into services which do exist.'
In practice, however, referral was experienced as being 'important but traumatic'. Despite imaginative efforts, not only was the proportion of clients referred low (approximately 12% of clients), but the proportion of these reaching their referral destinations were even smaller *5. There was almost unanimous agreement that referral objectives had not been achieved: 'I don't think our referrals into other services are very good at all, we just don't do it.'
Finding referral into statutory services almost impossible, the outreach team recommended move towards a more comprehensive and independent in sit service provision:
'The initial objectives were to contact people and pass them on to statutory organisations. I think that is one main objective that has really changed. We don't really do that anymore. We kind of get stuff for them, keep the client. . .'
'I would like to see the project have a lot more workers and be doing a lot more work. We should have someone with medical professional skills within our team.'
For outreach workers, moves in this direction were 'ground level' response, a 'natural' development emerging from within the capabilities of the outreach work itself, an attempt to respond to perceived clients' need (see Rhodes and Holland, 1992). The CLASH team put forward recommendations to Steering Group for a mobile outreach bus and a community based drop-in and health centre for women prostitutes to be situate near Kings Cross. The aim was to work 'CLASH round the clients rather than the clients round us'.
The response from statutory managers was at best
lukewarm:
'Is it one of the aims and objectives to provide drop-in services or is it to access them into other services? And I actually think that CLASH are thinking differently to everybody else in that. I'm still holding onto this original thing which was the idea to access into other services.'
'They are asking for things now like drop-in centres, like a mobile bus. . . They can't do everything: an outreach team is not a drop-in centre.'
From the Health Service perspective, the 'principal aim' of outreach services, once contacts had been developed, was to 'find access into the Health Service' for their clients. This was seen as 'justification' for the outreach service:
'I really don't think we would be putting all the money that we have done into the CLASH team if it was purely to do street outreach work and to provide free condoms and free works to these people. There is a further aim which is to get them to have services, which makes it all worth doing.'
As one voluntary manager commented, this tension went 'to the heart of the difference to where voluntary sector involvement is seeing streetwork as opposed to where the Health Authority is seeing it', whereas outreach workers and managers were keen to work 'CLASH round the clients', as one statutory manager remarked: 'You don't develop a service that people can access simply because you want to do something with these people.'
These differences in the expectation of the objectives of outreach work to some extent reflect wider tensions in the conceptualisation of health between bottom-up negotiated approaches and top-down prescriptive approaches (Beattie, 1991). As one statutory manager involved in health promotion indicated, the real problem was not so much about achieving specific objectives, but were 'ideological': moves towards a more comprehensive independent outreach service meant 'changing the nature of what we mean by services'. As long as tensions remained in the management process, there was little chance of CLASH being effective in encouraging such change, particularly when these changes meant challenging established systems of service delivery.
The CLASH project was considered innovative because of its explicit attempt to integrate voluntary and statutory services in reaching out to 'hard-to-reach' populations. Like similar collaborative ventures in the past (Beattie, 1991; Webster, 1991), however, our findings show the management of the CLASH project to be characterised at once by innovation and constraint.
The collaborative management of the CLASH intervention seemed to suffer less because the managers involved would not collaborate but that they felt they could not. The union of 'differences' in styles of management and service delivery, rather than becon1ing the source for mutual learning, became further entrenched as difference. The combination of problems in the functioning of management structure and circumstance (largely the unmanageability of the outreach team) rendered the practice of collaboration problematic, where l the 'differences' between participants became the terms: by which the problems of management were articulated, and contributed to the essence of the conflict itself. The increasing inflexibility of the Health Authority, for example, can be seen as similar to the tactics employed by the outreach team to mobilise in 'collectives' and 'alliances'. Although rooted in wider differences in t approaches to health service provision, the inability of CLASH to effect changes in outreach services in response to clients' perceived needs was constrained by the incapacity of the management structure to facilitate collaboration.
These management problems can be summarised in two ways. At the level of management structure, there was a lack of definition and direction for internal team organisation and management; a lack of interface between the outreach team and managers; and little accountability between outreach workers, between workers and managers, and between managers themselves. These problems were exacerbated by competing ideologies of management, by the principles of collective and NHS hierarchical work styles, and by the 'community' and 'professional' work styles, of workers, voluntary managers and statutory managers. The 'differences' were further aggravated at the level of service delivery and development by competing ideologies about the nature and objectives of outreach service provision.
Whilst management structures can be viewed as 'tools which can be created, selected and used by groups to attempt to achieve co-ordination and control in relation to their objectives', it is also clear that these indeed will incur 'costs as well as benefits' (Dawson, 1986). This point is significant because it makes a problem out of the idea that collaborations will necessarily 'work'. Although, an element of 'difference' was inevitable in the collaboration we have described, questions remain as to the efficacy of future similar collaborations if 'innovation' is to be encouraged in practice. Recent NHS reforms enable District Health Authorities to subcontract services to the voluntary sector. In the increasingly competitive marketplace of health, where limited resources may encourage competition between the two sectors, there remains a potential for tension to exist in future voluntary-statutory partnerships and 'provider coalitions'. Within a Health Service of finite resources, the possibilities for instrumenting 'innovative' service changes may become ever more uncertain. In conclusion, there is little point in encouraging intersectoral collaboration in outreach intervention unless all parties remain committed to the principles and objectives of this work.
The findings above demonstrate the conflicts played out in management arenas over the enthusiasm or reluctance to develop appropriate services related to the nature of the management conflict itself as well as to competing viewpoints on health and service provision.
In attempting to gain managerial control over the outreach project, statutory managers began to exert increasing control over styles of service delivery and the potential for service change. This meant restricting the influence of voluntary managers and outreach workers in the decision making and management process to the point of re-instating the CLASH project in line with explicit NHS hierarchy. Without a management commitment to collaboration with those working most directly with 'hard-to-reach' clients, this may have a profound impact upon the capacity of the project to respond effectively to clients' needs as they are identified with outreach workers in the community. If there is no commitment to service change which involves a departure from normative and established modes of service delivery, there may be little scope in the long term for making clients any 'easier to reach'. Innovative methods of contacting clients may require innovative changes to services on offer.
The problems experienced in effectively translating clients needs for services into appropriate service changes raises the question of outreach as an instrument for change. From the Health Service perspective, evidence of client need is required so as to plan, purchase and provide appropriate services. This requires a system of monitoring and feedback of demand for and satisfaction with. existing services. The CLASH team did not provide such evidence, relying on more informally gathered information from their client sources to support their recommendations for service change. These recommendations and any negotiation about client needs were in addition articulated in the light of the management conflicts we have described. Outreach workers and (at times) voluntary managers lacked the appropriate skills to 'work' the management process in order to manipulate the Health Service to change, whereas statutory managers remained unwilling to consider the possibility of change on the basis of recommendations and 'evidence' of client need put forward. If monitoring and needs assessment are to be considered an integral component of project objectives, then acting on these findings must also be considered a managerial imperative. This at times may require the commitment of managers to 'change the nature of what we mean by services' if this is what clients both need and demand.
This evaluation was undertaken as part of a wider programme of Department of Health funded research. We thank Anne Johnson (Middlesex Hospital) for her
comments and input throughout the research project
as a whole, the outreach workers at Central London Action on
Street
Health, and the statutory and voluntary managers for their time
and comments in inter views.
Tim Rhodes, Research Fellow, Department of Politics and Sociology, Birkbeck College, University of London, UK
Janet Holland, Senior Research Officer, Social
Science
Research Unit, Department of Policy Studies, Institute of
Education,
University of London, UK
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*1
For more information on the work of CLASH, please contact the project direct at Central London Action on Street Health, Soho Hospital, Margaret Pyke Health Centre, Soho Square, London WIV.
*2
This evaluation was undertaken was funded by the Department of Health as part of a wider study investigating HIV outreach health education as a means of preventing HIV infection among hard-to-reach populations of drug injectors, sex workers, homeless and transient young people and their sexual partners.
*3
Findings reported here are extracted and revised from Rhodes er al. ( 199 lb) . Permission has been granted from Central London Action on Street Health and Bloomsbury and Islington Health Authority to publish the findings presented here and elsewhere.
*4
Bloomsbury Health Authority has since merged with Islington health Authority to become Bloomsbury and Islington Health Authority. CLASH was also part funded by the charity The Monument Trust.
*5
Referrals proved unworkable for three main reasons:
inflexibility and inaccessibility of statutory health services;
structural relations of CLASH to the Health Authority; and lack
of expressed client need for such services. These and their
implications
for the direction of outreach service development are discussed
in greater depth elsewhere (Rhodes and Holland, 1992).