This essay is adapted from the original service manual ‘Team Around the Child: Multi-agency service Co-ordination for children with complex needs and their families’ by Peter Limbrick, Interconnections UK, 2001
The manual from which this paper is adapted is intended for managers and practitioners in statutory services, workers in parent organisations and the voluntary sector, and individual parents and other family members who want to respond to the call for co-ordinated or joined-up services for children with disabilities and special needs and who are looking for practical ways to do it. The call for joined-up services in the UK and other countries is as urgent now as it was over two decades ago.
Team Around the Child (TAC) is an approach to multi-agency service co-ordination at the level of the actual service to the child and family. In this model the handful of practitioners who already work closely and regularly with the child and family offering practical input in education, treatment and therapy, agree to meet together regularly to share observations, to agree a joined-up service plan and to review progress. The essence of TAC is that practitioners from the different agencies and the child’s parent(s) come together on equal terms at regular family-friendly meetings to discuss the child and family’s needs in detail and to agree a co-ordinated approach. The shared focus is on both the child and the family. Each individual TAC has a team leader or TAC facilitator who can be or become the child and family’s keyworker, lead practitioner or primary interventionist.
There is very great need for reform of services to children with complex needs (who can also be defined as children who require a complex service) so that they are co-ordinated for the family and not by the family. The general picture in the UK is that when there is some degree of service co-ordination for a child it is because the family have used their own time, energy, and money to achieve it themselves.
TAC is offered as a first approach for service providers (from statutory, voluntary and private sectors) who wish to remedy this situation and assume the responsibility for joining services together for these children and their families. It is a low-cost model but does require commitment from senior managers, effective planning at all levels in the various agencies and some resources. Disjointed and fragmented services are wasteful of valuable time and energy for individual practitioners and the agencies in which they work. In this sense service co-ordination includes an element of service rationalisation and will bring with it the reassurance that wastage and duplication is being minimised.
Why some children and families need TAC
Some children and families require regular and frequent services over many years from a large number of practitioners coming from two or more agencies. There is not a tradition of practitioners or their agencies working together to provide all of these separate services as a co-ordinated package. The task of co-ordinating and rationalising services falls to parents, making yet one more demand on people whose resources are probably already severely stretched.
There is a growing acknowledgement that fragmentation of services can cause families great additional stress. In the author’s experience, the harmful effects on families of fragmented services can include the following:
- parents are not given comprehensive information about all local services
- parents have to encounter each practitioner and each agency separately
- parents are not given the reassurance of seeing practitioners communicate with each other about their child
- the pattern of appointments, clinics, therapy sessions, home visits, etc. might be chaotic and wasteful of energy and time
- the child’s daily and weekly routine of appointments might not be in the best interest of the child –
- and might not represent a workable balance between the needs of the child and the needs of other family members
- the service to the child and the family might have gaps of unmet need and some duplications
- the child and parents will have to undergo repeated interviews, assessments and reviews
- there might be unresolved contradictions in diagnosis, treatment and advice
- parents and child might be overloaded with activities and programmes to carry out at home
- parents will have to pass essential information from one practitioner to another
- parents will not have one practitioner with whom they can discuss all aspects of their child’s daily life, condition, development and learning –
- and no one to help them arrive at a whole and integrated picture of their child’s abilities and needs
- the child and the parents might lose valuable support when one particular practitioner is ill or changes post –
- or when services and practitioners change at a transition
- parents will have no opportunity to comment or influence the situation when they feel they are being helped by too few or too many practitioners
The harmful effects of fragmentation of services on practitioners and their agencies can include:
- each practitioner might be unaware of who else is involved with the child and the family or of what their involvement is
- therapists, teachers and other workers might have no opportunities to arrange joint sessions –
- and no opportunity to rationalise and integrate home programmes, helpful advice and suggestions
- practitioners will have no opportunities to share information, observations and ideas
- practitioners might have to rely on the parent remembering what other practitioners have said or done
- a particular practitioner might feel isolated and unsupported in her work with a particular child or family and must face some very difficult situations alone
- practitioners will have no opportunities to integrate their approaches with joint visits, shared goals and holistic programmes
- a wastage of effort, time and money as some services are duplicated or even triplicated
The Team Around the Child model is designed to help remedy the above ill effects of fragmented and disjointed services. In essence, the model consists of the small number of people who are most involved with the child and family agreeing to meet regularly at meetings which are smaller, more frequent, more detailed and more family-friendly than formal reviews and case conferences.
Parents have a full place on the TAC (this is a defining feature) and the child might be present at meetings. The venue, frequency and timing are decided by general agreement. The venue can be nursery, school, centre, clinic, home, or elsewhere. The frequency is determined by needs at the time with greater or lesser frequency depending on how quickly needs are changing. The choice of daytime or evening, weekday or weekend is likely to be a compromise between family routines, the needs of working partners and the flexibility of the practitioners.
The tone of meetings is honest, positive, respectful, encouraging, and supportive to all present. The meetings are not rushed and might require one to two hours depending on what needs to be discussed. One person, probably one of the practitioners, will be acting as team leader (but not a manager) to guide the meeting and keep notes.
Team Around the Child is a needs-led approach. It is important to check at each meeting that services in general and programmes in particular are matching needs as far as possible. There is a twofold advantage in this:
- By identifying any needs which are not being met and any former needs which no longer exist, the over-all service can be rationalised.
- Parents and children will probably have greater motivation to collaborate on any agreed approaches that are designed specifically to meet real needs the family has identified.
As the child’s needs and the family’s circumstances change the membership of the Team Around the Child will change. This is a gradual process so that the child and the family continue to receive support from the Team as a whole even during a major transition. As needs change, particular practitioners in the peripheral group (i.e. the practitioners in the wider circles around the child) can become members of the Team Around the Child and particular members of the Team Around the Child can move to the peripheral group. It might be appropriate for an entirely new practitioner who is not in the peripheral group to be invited in. After a major transition (not before or during) it might be appropriate for a new practitioner to take on the role of team leader. It is important that the Team Around the Child remains small and manageable. It would lose much of its value if it had more than a handful of people.
The Team Around the Child should operate as far as possible as a team rather than as a group of individuals. This will vary depending on how long the Team Around the Child has been running and how frequently its membership has changed. The skills of the team leader will be an important factor in this. The ideal to work towards is a team:
- which is encouraging and supportive to all members
- in which all members have an equal voice
- which can arrive at collective agreements
- which can acknowledge differences of view and negotiate workable solutions
The Team Around the Child, once a level of trust and shared concern for the child and family has been established, can provide an effective and supportive forum for negotiation of difficult issues. This might be when the practitioner view differs from the parent view or when there are differences of view between practitioners. It can be reassuring both to parents and practitioners that important issues have been discussed by the group and have resulted in a collective agreement about how to proceed. It is important that the Team recognises when a very difficult issue requires outside help or mediation.
Benefits of the Team Around the Child model
An effective service for children with complex disabilities and their families must meet particular criteria regardless of which agencies are involved or which disabilities are present. These criteria determine both the effectiveness of the service and its sustainability against the common threats. In the author’s experience, an effective service for children with complex needs and their families requires that:
- practitioners work in partnership with parents
- services are co-ordinated
- programmes are integrated
- support is continuous
- the service is stable
- the service is flexible
- provision is uniform across the locality
Partnership with parents: Parents are likely to be closely involved in their child’s health, wellbeing, development and learning during the pre-school years, while the child is at school and perhaps for many years after he or she leaves school. Their involvement should be acknowledged as the major resource and any multidisciplinary team supporting the child and the family should be considered incomplete if it does not offer a place to the parents. The Team Around the Child includes the parent but recognises that the parent’s preparedness to participate may vary from time to time. For instance, in the traumatic days and weeks after first disclosure the dominant need of some parents will be for understanding and support. Later on, most parents will want to be involved in planning the service to their child and some can take a lead role.
Service co-ordination: The effective co-ordination of services is the prime motive for offering children and families a Team Around the Child. This model ensures that services are co-ordinated where it most matters – at the ‘grass roots’ with the child and family. The Team Around the Child model:
- enables practitioners to know who else is involved and what their involvement is
- establishes whether there is any unmet need or duplication of input
- allows appointments, clinics, home visits, etc. to be rationalised as far as possible
- ensures that the daily and weekly routines of education and therapy are in the best interests of the child and the family
- enables services to provide collectively for the whole child and family
By co-ordinating services in this way the Team Around the Child model reduces the time, energy and money that parents have to waste pursuing disjointed services and lessens the stresses and strains that many experience as a consequence. The demanding and time-consuming role of service co-ordination is taken from the shoulders of those parents who are very happy to be relieved of it.
Integration: Child development and early learning does not happen in the separate disciplines of movement, posture, hand function, language, social skills, independence skills, etc. and neither children nor parents naturally divide their activity into these compartments. The distinction between therapy and education is also often artificial. For young children with complex needs it is preferable to work towards the ideal of integrated activity for the whole child. Such activity should be both motivating for the child and appear relevant to the parents. The Team Around the Child offers a spectrum of integration opportunities that can match the particular child’s abilities and needs and the preferred working style of the practitioners.
Continuity: Support to the child and family should be seamless, continuing without interruption from the time around disclosure for as long as required. Some parents will need support from the time they first have cause for anxiety about their child, whether or not disability is yet confirmed or labelled. For some children it will be appropriate to provide the first intervention programmes based on a functional diagnosis while waiting for any medical diagnosis.
Stability: Services to complex children are always vulnerable to such inevitable events as a practitioner leaving their post or taking sick leave and the upheaval of periodic reorganisations of statutory services. The child’s illnesses and periods in hospital will often cause a break in services that lasts much longer than the actual episode. It can happen that any one of these events will bring to an end a complicated pattern of interventions which the parent and others have spent much time and energy organising and which will now have to be organised again. In the Team Around the Child model the team persists as a whole, as it does over transitions, and over-all support can continue during these events. When there is advanced warning of such an event the team members can plan for it.
Flexibility: No two families are the same and children with complex needs are each unique in their abilities and needs. For a service to be effective it must be tailored to the individual child and family. An effective service must also be able to adapt as the child’s needs and the family’s situation change, whether the changes are expected (e.g. the child getting older) or unexpected. Because the Team Around the Child offers a needs-led approach and works in a close relationship with the child and family it can adapt quickly when necessary and plan ahead for expected changes.
Uniformity: Good practice should be uniformly available to all families in the locality. In the present situation, even across one locality, the service can be patchy, depending on the family’s address, which practitioners they happen to have encountered and whether or not the parents have learned to shout. The Team Around the Child model should be available to all local families who have a child with complex needs in a system which is fair and seen to be fair. This will help remove the common perception that the only families who get a good service are those who make a fuss. (If this is true, it is not parents who have created the situation.) It will also help reduce the requirement on otherwise gentle and reasonable people to become fighters.
Establishing a Team Around the Child system
Individual statutory services operate complex systems in obscure hierarchies from elected members and chief executives at the top down to practitioners who work directly with children and families. Any major change to a new type of system requires very careful planning and negotiation. The task is greater and even more complicated when the proposed change encompasses two or more agencies. But it is never impossible and the needs of families dictate that local agencies should collaborate to find ways to move towards such multi-agency initiatives as the Team Around the Child.
As conditions differ in each locality the following general points are offered only as the briefest of guides. Once the process is begun the sequence will largely be imposed by events but there is some advantage in starting with a combined bottom-up and top-down approach as follows:
- Make contact with all the practitioners at all levels in all services who are enthusiastic about service co-ordination and the Team Around the Child model.
- Locate parent organisations and individual parents who are enthusiastic about service co-ordination and the TAC
- Identify a small group of these people who will help in the first planning stages.
- Locate all examples of good practice in practitioner collaboration in your locality and try to build on these.
- Locate people in other localities who have established the TAC model and learn from their work.
- Work out where to place this initiative for change within existing planning structures. Ideally this will be a multi-agency committee or a senior manager with some responsibility for multi-agency collaboration.
- Start writing a proposal for the new system with help from the people you have identified above.
- Think about establishing a small localised project involving enthusiastic practitioners and parents.
In recent years the author has worked to develop the Team Around the Child model in consultation with many health, education and social services, parent groups and voluntary agencies in the UK and other countries who are working towards multi-agency service co-ordination for this client group.
Peter Limbrick, 2023
Related books by Peter Limbrick: