By Peter Limbrick in 2012
My direct working experience in recent years has been mostly with young children who have a multifaceted condition and in this essay I am going to focus on two connected models of successful joint working for them and their families. At the same time, I am going to suggest that these approaches are also appropriate for older children, young people and adults who need support from two or more agencies or services at the same time – or in close sequence.
The persistent problem, in the UK and other countries, to which the essay suggests solutions is the, often chaotic, disorganisation and damaging fragmentation that has come to seem almost inevitable when a child or older service user is receiving simultaneous interventions from a number of people that come from separate organisations. The problems arise for the service users and also the practitioners working with them when there are no organisational systems to bring everyone together to share observations, agree needs, create a coherent joined-up action plan and then provide co-ordinated seamless support. In the absence of any joint strategies (which can be termed ‘interagency collaboration’, ‘multiagency co-ordination’ or ‘multidisciplinary teamwork’) each practitioner will provide her intervention for the service user regardless and perhaps in ignorance of what interventions the service user is receiving from other people.
Infants with, what has traditionally been termed ‘multiple disabilities’ or ‘complex disabilities’, have been my focus over recent years and will serve here as an illustration of the inappropriateness of unco-ordinated plural interventions for any service user who needs a whole approach. Some babies are born with, or quickly acquire, neurological impairment that results in some combination of cerebral palsy, sensory loss, learning disability and social/communication difficulties – and then perhaps epilepsy, respiratory and feeding problems and uncertain life expectancy. The traditional response in the UK and other countries by health, education and social care agencies (that have evolved separately and still seem to want to function without much regard for each other as if by instinct) is ‘additive’ in that a new practitioner comes along as each of the child’s problems comes to light.
The dual problem with this, in my view, misguided additive approach is that the child and family are soon overwhelmed with interventions, and that the interventions themselves might not fit together subjecting both child and family to mismatches and contradictions. Thinking, for example, of an infant with limited vision or blindness and cerebral palsy, if the practitioner who is trying to help the child cope with visual impairment and the therapist helping with movement and posture do not talk to each other, then any consistency in how they communicate with the infant, how they handle him and the positions they offer him for play and work will be by chance. The stronger likelihood is that the child will receive inconsistent or even contradictory approaches that will impede his development and learning and even detract from his quality of life.
I prefer to describe such a child as having a single multifaceted condition rather than multiple disabilities in the hope that we will come to think in terms of providing him with a single coherent multifaceted intervention system rather than multiple practitioners with multiple separate programmes. I would briefly justify this new phrase in neurological terms by observing that each of the developing child’s conditions (cerebral palsy, sensory loss, etc) must stand in interaction with each other as he lays down new neural connections and pathways. Each new learned activity, for instance rolling to find a toy on the floor, communicating to a parent his desire for a biscuit, will represent an amalgam of adaptations, successes and struggles to overcome each of the impairments. Just as we cannot find separate flour and fat in pastry once it is cooked, so we cannot separate out the cerebral palsy from the visual impairment when the child has learned to reach for a bauble. Continuing to think of separate and multiple disabilities in the development and learning achievements of these babies and young children makes no sense.
This introductory essay is about creating multifaceted intervention systems for people who need plural interventions and goes much further than requiring a service user’s practitioners to talk to each other. Though this is good practice, any joint working at grass-roots, to be effective and available to all in need, must be embedded within local interagency collaborations at senior level to create shared referral systems, joint assessments and collaborative teamwork – as well as a collective effort for training, supporting, monitoring and resourcing practitioners.
The first of the two approaches offered here is multiagency keyworking model and the second is the TAC System (originally an acronym of Team Around the Child) which evolved around the turn of the century from a keyworking project called One Hundred Hours. Both respond to different situations and needs to achieve joint working at the grass-roots with service users and both adjust themselves to three increasing levels of joint working (Limbrick, 2009, pp. 40-47):
- Liaison and networking.
- Co-ordination of appointments, meetings, assessments, reviews, etc.
- Collaborative teamwork for appropriate integration of intervention programmes.
This effort to liaise, co-ordinate and collaborate across and between services and agencies (for instance, health, education, social care, police, prisons, housing and support services for addiction, poverty and unemployment) does not come naturally. I have described traditional agencies and services (public, voluntary and private) as ‘vertical’ organisations in contrast to keyworking and TAC that can only prosper in the ‘horizontal’ landscape – a landscape that must be created with great ingenuity and effort by the vertical agencies in the spaces between them (Limbrick, 2012). When services are disorganised and fragmented, at worst, children and other service users die, families fall apart, lives are wasted and opportunities to really make a difference for people in need are lost. It is my contention that each vertical agency is likely to share a significant proportion of its service users with one or more other local agencies and that these users should be counted and catered for. Interagency collaboration and horizontal teamwork should become a large part of the business of all agencies and services that support people in need.
In the horizontal landscape of interagency collaboration people empowerment becomes a key factor when we remind ourselves that we all have rights and responsibilities in how we are helped. We are no longer content to be ‘done to’; we want to be part of the process with a voice to be listened to and choices to be considered. Any helping process that takes away a user’s autonomy might be doing more harm than good. In the One Hundred Hours model the keyworker works in partnership with the child’s parent or parents. By the same principle, a TAC is not a TAC if the young child’s parent or the older service user is not a full member of the team.
This essay is offered as an introduction to the keyworking model and the TAC System and to their place in the horizontal landscape for service users who require support from two or more agencies or services in the same time period. Readers are invited to relate its content to the needs and situations of the service users in the care of their agency or service (or to themselves, their family member or the person they care for). This will enable the reader to consider whether there is harmful fragmentation and, if so, whether the suggestions here for joint working to remedy these ills are valid.
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