Integration Made Possible: A practical manual for joint working – multiagency, multidisciplinary, transdisciplinary. For people of all ages. INTRODUCTION
The whole Manual is offered in 7 parts – Introduction first and then 6 Sections
'Integration Made Possible: A practical manual for joint working – multiagency, multidisciplinary, transdisciplinary.'
By Peter Limbrick. Published by Interconnections in 2020. ISBN 978-0-9576601-7-5
Contents
Introduction
References and additional resources relevant to all 6 sections
SECTION 1: All about integration
Types of integration
Problems caused by fragmentation
When integration is needed
Integration that occurs spontaneously
SECTION 2: Benefits of integration
Benefits to service users
Benefits to family, carers and friends
Benefits to service providers
SECTION 3: Common approaches to integration
Co-location and one-stop shops
Keyworking
Individualised multidisciplinary teams
Primary interventionists
Integrated pathways
Directories and communication systems
SECTION 4: Considerations in promoting integration
Partnership with service users
Surveys
Horizontal teamwork
Attitudes to integration
SECTION 5: Wider integration
Integration with the private sector
Integration as a cultural phenomenon
Academic responsibilities in integration
SECTION 6: First moves to promote integration
Tasks for leaders
Introduction
The word ‘integration’ can be defined as unifying diverse elements into a whole. Integration is described in this Manual as a process of joining things together with the purpose of achieving something better than was there when the things were separate. When various elements of support are integrated around a baby, child, teenager, adult or elderly person, a support system is created that is more whole. Support for people in need that is unified in this way is always better than a collection of fragments that do not fit well with each other, so we can think of integration as the antidote to harmful fragmentation. This Manual takes the widest possible interpretation of integration from joint working between the major local agencies to co-operation and collaboration at community level in such facilities as swimming pools and food banks.
Integration in the context of this Manual is a process in which people in local health, education and social care agencies and in other services and facilities work together in some way to create effective support around people with special needs. Special needs can be the result of disability, illness or some other condition or situation. People who share the same condition, for example dementia or muscular dystrophy, might have very different situations: one might be wealthy while another lives in poverty; one might be in a refugee camp while another enjoys all the trappings of celebrity.
Integration is a process rather than a one-off event requiring people to work together in some practical way. In this, people in need are not passive recipients of support. They are involved as fully as possible in all decisions about joint working. This is respectful and empowering and works towards the unified whole. Integration must include person-centred care and co-production and must have an evidence base.
Person-centred care
Though integrated working might involve managers at the highest levels in local health, education, social care and other agencies, the principles of person-centred care must be strictly adhered to. Babies, children, teenagers, adults and elderly people who have special needs must be the focus of all planning decisions about joint working. The Social Care Institute for Excellence (SCIE) defines person-centred care:
Person-centred care moves away from professionals deciding what is best for a patient or service user, and places the person at the centre, as an expert of their own experience. The person, and their family where appropriate, becomes an equal partner in the planning of their care and support, ensuring it [meets] their needs, goals, and outcomes.
With an emphasis on doing with rather than doing to, person-centred care runs through both individual and group settings, allowing users of services to be active not only in their own care but also in the design and delivery of services. This approach can improve both the experience and quality of care.1
Co-production
In the aspiration for people who use public services to be powerful in how those services operate, the concepts of co-production and integration overlap each other. Boyle and Harris in the discussion paper, The Challenge of Co-production2, define co-production as follows:
Co-production means delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and their neighbours. Where activities are co-produced in this way, both services and neighbourhoods become far more effective agents of change.
While co-production argues for meaningful partnership between the people who work in public services and the people who use them, integration in the context of this Manual has a wider ambition that embraces co-production but also advocates co-operation and collaboration between people in the various organisations that provide services or support. Included in both integration and co-production are, as appropriate, family members, carers, friends and neighbours.
Evidence-based planning
This Manual advocates an evidence-based approach that investigates and documents problems caused by fragmentation to the group of people being focused on both locally and, using published reports and research, in other regions and countries. Similarly, local good practice that counters fragmentation is collected as well as relevant good practice from further afield. In this, a persistent focus is kept on the local situation to avoid integration becoming an academic exercise. All planning takes account of relevant local and national government guidance and legislation
The ideal to aspire to in integration is for each child or adult to experience a total pattern of support that is sensibly organised, harmonious, effective, empowering and apparently seamless without them having to be always conscious of the various agencies, practitioners and other people that have come together to create it. It is possible to achieve the ideal, but in most cases, the level of integration will be the best that can be achieved at the time in the particular situation. Once a degree of integration is achieved and shown to be successful it will surely expand its scope and attract more people into the culture of joint working.
Returning to the definition I started with, we can characterise the process of integration as always working towards wholeness. Firstly, there is respectful recognition of the person in need as a whole adult or child. Then there is the wholeness of their condition and situation made up of many interconnected elements. Next, there is the aspiration to wholeness of their intervention system in which practitioners and other people around them connect with each other to create a whole approach.
There is much variety in the sort of joint working that is necessary for particular adults and children. Some, because of major obstacles to their health and development, will need on-going multidisciplinary teamwork bringing together people from health, education and social care services. Others will need only an occasional collaboration, for instance between one of their health practitioners and the people running a local sport and leisure facility with the aim of improving access.
The starting point for this Manual was a 2019 paper from England’s Council for Disabled Children (CDC) entitled It takes leaders to break down siloes: Integrating services for disabled children3. During the autumn of that year Interconnections published further articles of informal observations4 on the paper.
The CDC paper asserted that:
Leadership is the most important factor in enabling (or hindering) integration...
Other enabling factors were listed as family involvement, co-location, multi-disciplinary teams and key workers. In my informal observations I suggested disability prejudice as a major hindering factor that has always kept agencies short of the funds that full integration would require. Two other major hindering factors I suggested were firstly, the failure of universities to prepare health, education and social care students for joint working and secondly, the anxieties and apprehensions that many practitioners have about collaborating with people across agency or professional boundaries.
This Manual goes beyond the scope of that paper, children with disabilities, and addresses integration for people of any age who have some sort of special needs and require support from a number of sources simultaneously or consecutively.
Disability prejudice
This is not addressed in depth in this Manual. There is widespread disability prejudice in my country and perhaps in yours that condemns many children to a second-class education, severely reduces employment opportunities, keeps people in poverty and limits access to good housing, travel and meaningful sexual relationships. In my view, this prejudice deprives public services and communities of the resources, finance, creativity and commitment that could make full integration possible. While this Manual cannot eradicate the evils of disability prejudice, it can offer ways for people to work together to ensure adults and children who have disabilities and special needs can play a full part in all aspects of life. This is discussed in Topic 19 ‘Integration as a cultural phenomenon’. (Because integration has a dual meaning, it is important to be clear that integration in this Manual is about joint working and not about racial integration.)
Pooled budgets
This Manual offers no expertise in pooling agency budgets. Though integration would become so much easier if there were pooled budgets, finance managers say this is fraught with problems. In fact some children wait for months for an item of essential equipment while managers argue about which agency should foot the bill. Perhaps it would help to have a small local pooled budget that could be used without delay. Managers could then decide later which organisation has responsibility for a particular expense and then adjust contributions to the pooled budget retrospectively.
About the Manual
The Manual is intended as a contribution to:
- understanding the issues around integration
- planning projects to promote integration for service users
- writing undergraduate courses on integration
- designing research projects about integration
- writing funding applications for local projects and research
Readers who are embarking on a project to promote integration in their locality, region or country, will probably have a particular group of people in mind. They might be a member of the group themselves, one of the people who support them in a professional capacity or a family member, carer or friend. It is unlikely anyone will address simultaneously all the aspects of integration I describe so the Manual can be used to focus on particular topics in some order of relevance or first achievability.
There are six main sections interspersed with topics for discussion which are intended to aid planning discussions about establishing or enhancing various aspects of local integration. The sections and discussion topics are designed to be relevant whichever group of people this effort is directed towards. This might be a group of people who have the same condition or who use a particular service, centre or unit. It might be all the people having simultaneous support from two or more agencies. It is important for the people involved in the integration effort to be as clear as possible about who they want enhanced joint working for.
A note of caution is appropriate at the end of this preamble: We are in an age of rapidly developing technology and communication systems. While this technology can be used to support integrated systems, it must not be allowed to replace human interactions between people working together. Joint working around people who need on-going support is a very human activity requiring people to get to know each other and work together with respect and trust. This cannot be a technological function.
1 This is an extract from the SCIE website under the page heading ‘Prevention and Wellbeing’ https://www.scie.org.uk/
2 Boyle, D. & Harris, M. (2009) The Challenge of Co-production
3 Allard, A. et al. (2019) It takes leaders to break down siloes
4 Limbrick, P. (2019) TAC Bulletin comment, Issue 249 onwards
Siggested Discussion Topics following the Introduction
- Does integration as discussed so far fit with your idea of it and with what you are trying to achieve? In what ways does it not fit?
- Who is already joined with you now in wanting integration or enhanced integration? Who would you next approach to join you?
- Which people would you like to read this Manual at the same time as you?
- Can you define the group of service users you are focused on? (Is it a group of people sharing a condition; the people using a particular service, centre or unit; the group of people using two or more agencies simultaneously; other?)
- Are you focused on adults or children or both?
- Can you outline some major ill-effects caused by fragmentation?
- Can you define the locality you are focused on?
- Are there any local people for whom integration is part of their remit?
- Is there local good practice in integration, perhaps for another group of service users?
- In this project, do you need to cater for people whose first language is not English?
- In this project, do you need to consider a variety of readability and access needs?
- Are there any people in your locality or region working on co-production?
- Are you up to date with person-centred care?
- How will you collate evidence about fragmentation and good practice?
- What resources do you need? (To embark on an integration project; to apply for funds for it; to design an academic course or research project.)
- Other topics to add?
References for the whole Manual
Note: All web links were checked during November 2024
Allard, A., Fellowes, A., Gardiner, A. & Hart, S. (2019) It takes leaders to break down siloes: Integrating services for disabled children. England: Council for Disabled Children
Web: https://councilfordisabledchildren.org.uk/
Ashdown, R. (2015) Penny Lacey – a celebration in PMLD Link Vol 27, No 2, Issue 81
Web: http://www.pmldlink.org.uk/issue/penny-lacey/
Boyle, D. & Harris, M. (2009) The Challenge of Co-production: How Equal Partnerships Between Professionals and the Public are Crucial to Improving Public Services. England: NESTA
Web: https://www.nesta.org.uk/report/the-challenge-of-co-production/
Capra, F. & Luisi, P. L. (2014) The systems view of life: A unifying vision. Cambridge: Cambridge University Press
Changing Places. Web: http://www.changing-places.org/
Davis, H. (2009) The Helping Relationship: Understanding Partnerships. In Interconnections Quarterly Journal. Vol 2, No 6.
Web: http://www.tacinterconnections.com/index.php/allnews/developmentsintreatment/3134-the-helping-relationship-understanding-partnerships-essay-by-professor-hilton-davis
Davis, H. & Day, C. (2010) Working in partnership: The Family Partnership Model. London: Pearson
Gem Centre, Wolverhampton. Web: https://www.nhs.uk/services/clinic/the-gem-centre/RL4CA
King, G., Strachan, D., Tucker, M., Duwyn, B., Desserud, S. & Shillington, M. (2009) The application of a transdisciplinary model for early intervention services. In Infants & Young Children Vol 22, No 3, pp 211-223
Levitt, S. (1994) Basic Abilities: A whole approach. UK: Souvenir Press
Limbrick, P. (2001) The Team Around the Child: Multi-agency service co-ordination for children with complex needs and their families. UK: Interconnections
Limbrick, P. (2003) An integrated pathway for assessment and support for children with complex needs and their families. Worcester: Interconnections
Limbrick, P. (2009) TAC for the 21st Century: Nine essays on Team Around the Child. Clifford: Interconnections
Limbrick, P. (2012) Horizontal Teamwork in a Vertical World: Exploring interagency collaboration and
people empowerment. Clifford: Interconnections
Limbrick, P. (2016) Caring Activism: A 21st century concept of care. Clifford: Interconnections
Limbrick, P. (2017) Early Childhood Intervention without Tears: Improved support for infants with disabilities and their families. Clifford: Interconnections
Limbrick, P. (2019) TAC Bulletin comment: ‘It takes leaders to break down silos’ – report by Council for Disabled Children offers more of the same. Disappointing. In TAC Bulletin Issue 249. Clifford: Interconnections. (Comments continued in Issues 250, 251, 253 and 255.)
Limbrick, P., Boulter. L., Wassall, Liz. & Rimmer, S. (2011) What do the terms ‘therapy’ and ‘therapist’ really mean in early childhood intervention for children who need on-going multiple interventions? In PMLD Link Vol 23, No 3, Issue 70
Limbrick-Spencer, G. (2001) The Keyworker: a practical guide. Birmingham: Wordworks with Handsel Trust
New Economics Foundation on Co-production.
Web: https://neweconomics.org/2009/12/challenge-co-production
Orelove, F. P. & Sobsey, D. (1996) Educating Children with Multiple Disabilities: A Transdisciplinary Approach. Baltimore: Brookes
Pfund, R. (2010) Pathways in palliative care. In Perspectives on palliative care for children and young people: A global discourse, eds Pfund, R. & Fowler-Kerry, S. Oxford: Radcliffe. p 189
Townsley, R., Abbott, D. & Watson, D. (2004) Making a difference? Exploring the impact of multi-agency working on disabled children with complex healthcare needs, their families and the professionals who support them. Bristol: Policy Press
Some additional resources
Anning, A. (2010) Developing Multiprofessional Teamwork For Integrated Children's Services. UK: OUP
Frost, N. & Robinson, M. (2016) Developing multiprofessional teamwork for integrated children’s services: Research, policy, practice. UK: OUP
Housley, W. (2017) Interaction in Multidisciplinary Teams. UK: Routledge
Hennan, D. & Birrell, D. (2018) The Integration of Health and Social Care in the UK: Policy and Practice. England: Macmillan
IFIC (International Foundation for Integrated Care)
Web: https://integratedcarefoundation.org/
Lloyd, H. M. et al. (2017) Collaborative action for person-centred co-ordinated care (P3C): an approach to support the development of a comprehensive system-wide solution to fragmented care. In Health Research Policy Systems. 2017; 15: 98.
Lawrence, J. & Thorne, E. (2016) A Systems Approach to Integrating Health in Education. USA: Cairn Guidance.
Littlechild, B. & Smith, R. (eds) (2013) A Handbook for Interprofessional Practice in the Human Services: Learning to Work Together. UK: Routledge
Lotrecchiano, G. R. & Misra, S. (Eds) (2019) Communications in Transdisciplinary Teams. California: Informing Science Press
Mallinson, I. (1995) Keyworking: Examination of a Method of Individualizing Care for Older People in Residential Establishments. UK: Avebury
Miller, R. (2019) Social Work and Integrated Care. UK: Routledge
Mitchell, R. (1993) Crisis Intervention in Practice: The Multidisciplinary Team and the Mental Health Social Worker (Studies of Care in the Community). UK: Avebury
Ovretveit, J. (1993) Co-ordinating Community Care: Multidisciplinary Teams and Care Management. UK: OUP
Payne, M. & Campling, J. (2000) Teamwork in Multiprofessional Care. London: Palgrave
Tebbett, K. et al. (2006) Management of Cerebral Palsy: A Transdisciplinary Approach. USA: Sage
Timmins, N. (2019) Leading for integrated care ‘If you think competition is hard, you should try collaboration’. London: King’s Fund
Sanderson, H. & Lepkowsky, M. B. (2014) Person-Centred Teams: A Practical Guide to Delivering Personalisation Through Effective Team-Work. London: Jessica Kingsley
Speck, P. (2006) Teamwork in Palliative Care: Fulfilling or Frustrating? UK: OUP
Stacey, M. (2009) Teamwork and Collaboration in Early Years Settings. UK: Learning Matters
