Planning interagency teamwork around disabled babies and children: Tasks for managers. An essay by Peter Limbrick
Summary: Effective interagency collaboration for babies and young children who require on-going support from plural agencies, services and practitioners is very often an aspiration rather than a reality. In the author's experience, a major limiting factor in achieving joint working can be the reluctance of professionals to work outside the confines and security of their employing agency – valid reluctance if they fear entering a no-man's land with no standards or accountability in which they could become exposed and vulnerable if something goes wrong.
In an attempt to address this impasse, this essay draws a distinction between traditional vertically organised agencies, (e.g. health, education, social care) and the horizontal landscape that professionals enter when they work with others outside their particular agency. This horizontal landscape becomes a new workplace that must be carefully designed and managed to train, support, oversee and protect local professionals and the children and families they are helping. The horizontal landscape has, inevitably, a flattened power structure rather than hierarchical management and so becomes a space in which the parent and older child's voice is more clearly heard.
Planning interagency teamwork around disabled babies and children: Tasks for managers
This essay is an attempt to take a fresh look at the current international challenge in service provision for babies and young children who, for whatever reason, require simultaneous or closely consecutive interventions from two or more services or agencies. Families, professionals and researchers have reported over many years the damage caused when services around a particular child and family choose to operate independently of each other. Put briefly, the effects on children can be that they are treated in bits with no consideration of the wholeness of each child and that parents can become confused, disempowered and anxious in the absence of any coherent and shared perception of the child's abilities and needs. Parents and children can become overloaded by too many people each with a different agenda. In these ways and others fragmented support often creates new problems for the child and family.[1]
This attempt at a new approach starts with asking why interagency collaboration remains such an intractable challenge and offers, as a very large part of the answer, the suggestion that many staff members in the various support services are apprehensive about working outside the boundaries of their employing agency – and so choose not to. There can be valid anxieties about confused accountability, lowered professional standards, lack of training, support and supervision – and about being exposed and vulnerable if something goes wrong. While practitioners and managers understand very well the need for joint working across agencies for some of the children and families they are supporting, the suggestion that they participate in interagency initiatives can appear as an invitation into a dangerous no-man's land – an invitation to be declined if possible.
In ideal terms, effective interagency collaboration has as its outcome a seamless, co-ordinated, coherent support system for each child and family that appears to the family, more or less, as a single service. A large part of the means to this end is horizontal teamwork[2] between practitioners from each service or agency involved with the child and, following TAC (Team Around the Child)[3] principles, also involving the parent. 'Horizontal' refers to the absence of hierarchical management in a team comprised of people of equal status.[4] I explain later how, to achieve this grass-roots horizontality, there must also be horizontal teamwork at operational management and senior management levels across agency boundaries.
We can see from this vertical-horizontal analysis that staff members in any of the support agencies can have two places of work; their employing agency with its vertically organised management and the spaces between these vertical agencies where they meet others for horizontal teamwork. The contribution offered in this essay to meeting the challenge of interagency collaboration is that this space between vertical agencies – the horizontal landscape – represents a whole new workplace that must be carefully designed and managed as such. When the horizontal landscape no longer appears as an unstructured and hazardous no man's land, staff members will be more willing to enter it.
Pursuing this theme of verticality and horizontality, we can contrast traditional public services with the horizontal structures of interagency collaboration; while traditional public services have been with us for a long time and have adopted the same top-down management style typical of the military, industry, hospitals and schools, horizontal structures, for example a child's TAC, are novel, un-researched and have a flattened power structure. Vertical organisations hold their own budgets, employ their own staff and offer to their users, by and large, a single-agency support system. Horizontal structures usually do not hold a budget for employing staff and are effective only to the extent that they offer an interagency support system.
Empowerment is a strong theme within horizontality. The flattened power structure in the horizontal landscape allows parents and older children to be fully informed, involved and empowered[5] and can at the same time empower grass-roots practitioners and operational managers in their attempts to influence the design and management of horizontal structures.
In my experience, the horizontal landscape does not just fall into place. In pursuit of effective interagency collaboration, local public service managers have the task of working with each other across agencies to design and then oversee horizontal structures to meet the needs of children who require on-going interagency support.
A horizontal structure for local babies and young children who have a multifaceted condition will be an Integrated Pathway[6] at the start of which is an intake panel to accept referrals and to plan what needs to be done to create the initial unified action plan. Key practitioners will be put in place (if not already supporting the child and family) to learn more about strengths and needs of child and family and to provide relevant integrated TAC support. At successive TAC meetings – which include the parent – progress is reviewed and the action plan is updated.
While this part of the design of the local horizontal landscape is directly and exclusively focused on the needs of children and families and is informed by research, surveys, official guidance and legislation and with formal input from local families, there must now be consideration of the workforce in this new workplace. The Integrated Pathway requires practitioners and operational managers to work in new ways for which they must be properly prepared and supported.
This task will have already begun by including grass-roots practitioners and their managers in the design of the Integrated Pathway and continues now with training programmes in which staff members get to know each other across the agency divides and are prepared for the new and different demands of horizontal teamwork.
An essential part of this workplace design is setting standards of performance and systems for evaluating staff members against them. This is the antidote to the unregulated no man's land that could compromise children, families and workers. Within this, local agency managers must agree systems for support and supervision of workers at all levels in the horizontal landscape.
A common apprehension when it is suggested practitioners or teams could embark on or extend interagency collaboration is that it would add more demands to an already over-stretched schedule. Taking this valid fear, it is essential that horizontal teamwork is designed to require different ways of working rather than yet more additional tasks. In fact, the process of designing the horizontal landscape is an opportunity to radically rethink how agencies cater for children who have an on-going multifaceted condition.
For instance, in the collective design of each stage of the Integrated Pathway questions can be asked about why there is a persistent waiting list at a particular stage, about which meetings now become superfluous, about which written reports are really needed (and in what degree of detail) and about which administrative and professional processes are duplicated across agencies and could now be unified.
In the same effort to cater more effectively for children and families and to consider the workload of grass-roots practitioners, there can be consideration of the number of practitioners and programmes each individual child and family really need and can benefit from. While in the UK many children have to wait a long time for or manage without particular specialist practitioners, it is also my experience that some babies and young children are asked to relate to and tolerate hands-on interventions from more workers than they are comfortable with. Babies, young children with serious sensory loss and young children with learning, emotional and communication needs will be unnecessarily challenged by the demand that they relate to a large group of non-family people.
Similarly, parents can be overwhelmed by too many interventions, too many appointments and too many home visits – all detracting from their efforts to re-build their version of normal life and all also impacting negatively on siblings.
The simplistic additive approach in which a new worker is automatically added each time a new need is suspected or identified in a baby or child should be consigned to history. Many children will benefit from more imaginative systems with a consultant approach between practitioners and for some, a primary interventionist for a period of time.[7] These elements alone within a radical re-think of service delivery will enable busy practitioners to make much better use of their time.
An example of this radical shift in thinking when a new condition, situation or impairment is identified in a child with a multifaceted condition is to avoid the automatic response, 'We need to bring in such and such a practitioner or service to cater for this new need.' A more child- and family-centred response is to first consider which people among those already around the child are equipped to assess the child's strengths and needs in this new area and offer some relevant intervention. The second question, if it is decided at this point or later that a new practitioner is needed, is to ask if the new person can work in a consultant capacity with the present team. This approach can avoid overloading child and family, can make better use of local practitioners' time and efforts, and ensures that the new intervention will be integrated as far as possible into the child's existing activity – acknowledging the interconnectedness of all elements of the child's learning.
The horizontal teamwork of interagency collaboration brings new professional and administrative challenges in the effort to improve support to children and their families. In my experience it also brings clear benefits to staff members at all levels in local support services.
We must consider benefits to children and families first in this discussion because improved support for them is the whole point of the interagency exercise. I used the term multifaceted condition above in preference to the more common multiple disabilities because it is my contention that an infant's neurological development does not keep such impairments as cerebral palsy, sensory impairment, learning difficulties, autism, etc. separate from each other. As the child responds to the environment and acquires new understanding and skills these elements fuse together into a condition that is more than the sum of the parts – a single, unique multifaceted condition.
This thinking can help us move away from thinking about multiples (multiple practitioners, multiple programmes, multiple goals) towards providing a single, unified, coherent multifaceted intervention system for each unique child. At its best, interagency collaboration can deliver this while separate and multiple interventions cannot.
Grass-roots practitioners, whether from education, therapy, nursing, psychology or family support services, etc. benefit significantly by having increased opportunities to learn from each other, to enhance their ability to see each child as a whole child, to understand how impairments and new skills impact on each other and to understand how interventions can link naturally together into a whole approach. Managers at all levels, by working closely with their counterparts in the other local agencies, gain an understanding of each other's concerns and priorities and are enabled to see the bigger picture of support for particular categories of local children and their families. Practitioners, operational and senior managers have the reassurance that the support they are providing has been developed and agreed at the highest level as a local collective exercise.
Though the local horizontal landscape must be designed with extensive consideration of the needs of the workforce, its raison d'être is effective support for children who have a multifaceted condition and their families and must be evaluated in terms of their experiences. Keeping intervention systems understandable, transparent and uncomplicated is a crucial part of the TAC approach and the same should apply to the evaluation of local interagency collaborations.
The crux of the local collective effort is that each child receives an integrated support system that is agreed and described in a single, interagency action plan that is child- and family-centred. The local evaluation exercise can start by finding out how many children with a multifaceted condition actually received such a plan in the period being evaluated. The following questions can be about whether the family feel the plan was properly followed and if the goals were achieved. These questions provide a broad view of the success of the new work. When some children were not given a unified plan, when the plan was not followed or when the goals were not achieved, further investigation is required to explore the reasons.
The integrated action plan, as the crux of interagency collaboration, also offers a good place to start in moving to an Integrated Pathway in the local horizontal landscape. Once relevant local agencies have come together in a collective effort to improve support for these children and families, there can be a commitment to provide a particular cohort of babies or children a unified action plan by an agreed date a few months ahead. Once this commitment is made there will follow discussions about how to collectively assess strengths and needs of each child and family and how to construct the plan. There then follow discussions about how everyone will work together to deliver the support described in the plan and then review progress. In this way, the Integrated Pathway for this category of children is designed and agreed at the practical rather than theoretical level, responds to local conditions and incorporates all local good practice.
Moving away from babies and young children with disabilities, I want to suggest that this horizontal-vertical perspective is equally relevant in the design of services for older children, adults and elderly people who need support from more than one agency or service simultaneously or consecutively. Examples are addicted teenagers leaving a care home, school leavers on the autistic spectrum with learning difficulties, new parents who themselves have a sensory, physical or learning disability and frail elderly people who are shuffled back and to between geriatric ward and residential care home.
It is interesting to speculate how many users of any of the public services (health, education, social care, housing, probation, etc.) in any country are receiving support at the same time from other local agencies. It is my understanding that the numbers are significant but unknown and that disorganisation and fragmentation for these people represent the norm rather than the exception. For any agency wondering how seriously to take horizontal teamwork and how much time and energy to invest in the horizontal landscape, it would be a simple matter to ask their users if they are also getting support from other services, which ones they are using and what problems are caused by any lack of integration.
When problems in support for disabled babies and young children from multiple providers are uncovered in this way, it is my experience that merely asking grass-roots practitioners to work together across agency boundaries is not a recipe for success. A serious commitment to interagency collaboration will provide a new workplace for horizontal teamwork that offers staff members at all levels new opportunities for professional development, training for new styles of work, measurable standards to work to and full support to meet all contingencies.
In this essay traditional vertical agencies have been contrasted with novel structures in the horizontal landscape that are specifically designed to bring agencies together around those children who need multifaceted help and support. The horizontal landscape has been characterised as a new workplace for practitioners and their managers that must be designed and managed as carefully as any other more traditional place of work – or even more carefully because there is not a single employer. This analysis is offered as a major part of a remedy to professional nervousness and apprehension about horizontal teamwork.
References
Dunst, C. J., Trivette, C. M. & Deal A. G. (eds) Supporting & Strengthening Families. Volume 1: Methods, Strategies and Practices. Cambridge, Mass. Brookline Books
Limbrick, P. (2003) An Integrated Pathway for Assessment and Support for children with complex needs and their families. UK: Interconnections
Limbrick, P. (2009) TAC for the 21st Century: Nine essays on Team Around the Child. UK: Interconnections. This is also available on Kindle.
Limbrick, P. (2012) Horizontal Teamwork in a Vertical World: Exploring interagency collaboration and people empowerment. UK: Interconnections
Limbrick, P. (2012b) An Introduction to Keyworking and TAC in the Horizontal Landscape: Joint working in support of children and adults in need. Kindle: Interconnections
Sitrin, M. (ed) (2006) Horizontalism: Voices of popular power in Argentina. Oakland, USA: AK Press
[1] See Limbrick, P. 2009 pp 12-13 and p 39
[2] See Limbrick, P. 2012
[3] For an account of TAC see Limbrick, P. 2012b and Limbrick, P. 2009
[4] For an account of horizontality see Sitrin, M (Ed) 2006
[5] For an account of family empowerment see Dunst, C. J. et al 1994 pp 2-28
[6] See Limbrick, P. 2003
[7] Limbrick, P. 2009 pp 43-46 and pp 71-72
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