Integration Made Possible: A practical manual for joint working – multiagency, multidisciplinary, transdisciplinary. For people of all ages. SECTION 1
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
SECTION 1: All about integration
There is not just one effort or outcome that we can label as integration. It is always a dynamic and flexible process that goes as far as possible to bring an effective multi-faceted response to a person’s multifaceted condition and situation. The motivation is always to remove harmful fragmentation and bring people into a shared and coherent effort. This section has four topics:
- Types of integration
- Problems caused by fragmentation
- When integration is needed
- Integration that occurs spontaneously
Topic 1: Types of integration
There is not a single technique for achieving integration, nor any universal outcome to work towards except for the broad ambition to achieve an effective whole approach. It is always a matter of two or more people or organisations working together in an attempt to remove some problematic fragmentation, lack of co-ordination or dis-jointedness. Integration is not necessary if support is not fragmented. The following list gives some examples to show the wide range of types of integration. They overlap each other and are not mutually exclusive.
Integration across place
When an adult or child is being supported in two or more places, it might be necessary for people in those places to work together so that support is seamless. For a young child who attends a nursery and a therapy clinic, it might mean parents and staff members in both places agreeing a shared approach to communication. For an elderly person who moves periodically back and to between a care home and a hospital ward, it might mean creating a shared view of the person’s habits, tastes and preferences – involving family members, friends and neighbours when possible.
Integration across time
The aim here is to anticipate and achieve, as far as possible, seamless transitions. People in a nursery or school need to work with those in pre-school services so that successful approaches can be continued for a particular child. Psychologists and social workers in children’s services around an addicted teenager might need to work with colleagues in adult services so there is no gap in provision when the child becomes adult.
Integration to rationalise on-going interventions
When two or more organisations are supporting a child or adult there might be a need for people to work together to achieve a well-co-ordinated pattern of interventions.
This avoids such difficulties as multiple appointments in different locations on the same day and duplicated journeys to the same place when appointments could have been combined. In moving from fragmented services to integrated support in this way, there are advantages to service users in terms of quality of life and saving energy and money. This basic co-ordination brings similar advantages to the people providing support.
Integration to harmonise on-going interventions
When a service user has two or more intervention programmes being offered at the same time, there might be a need to harmonise them so they fit together well and do not work against each other. This might be appropriate for a child being helped by a teacher of the deaf and an autism specialist. Similarly for an infant and parent being helped by a physiotherapist, a pre-school teacher and a psychologist. The process of harmonising can raise the question whether one multifaceted programme would be better than separate ones.
Integration to establish a keyworker
When a number of practitioners and other people are directly involved with a child or adult and are aware of each other, there can be an agreement for one of them to become the person with the closest involvement and the main link between the person in need and the others.
Integration to form an individualised multidisciplinary team
When a number of people are directly involved with a child or adult and are aware of each other, they can agree to meet together to work as an individualised multi-disciplinary team with unified approaches and goals. The characteristics that define a team, rather than a group, include relationship, trust and mutual support.
Integration to create a pathway
When two or more agencies or services are involved with a group of people who share a condition, for example, cerebral palsy, addiction or dementia, managers and prac-titioners can work together to create a local care pathway for that group of people with a single point of entry, shared assessment processes, joined-up support and joint review.
Integration to establish a primary interventionist
For some children and adults for a period of time best practice might be to provide multidisciplinary support through just one worker. This worker is then supported by others in the multidisciplinary team who remain in the background. This way of working approaches the model of transdisciplinary teamwork.
Integration of information and communication systems
A local directory of all support systems is both an essential product of the integration effort and an invaluable asset in promoting integration around adults and children. Hassle-free communication between people in the local network around each person is essential. It is a matter of achieving what is possible within the limitations imposed by different communication policies and systems in local agencies.
These are all examples of how people can work together to achieve better outcomes than are possible in fragmented approaches. The people involved in this integration, in addition to the person in need, can include their family members, carers and friends and practitioners, managers and directors of local services. In all cases, the people receiving support are involved as far as possible in shared agreements about joint working.
Elements of integration can be used in combination: A multidisciplinary team can agree that one of its members becomes a keyworker; in a multiagency pathway, there can be agreement to establish a primary interventionist. These modes of integration are all antidotes to the problems caused for children and adults when everyone works separately from each other. Each is a creative and imaginative response once people become aware of the additional problems being caused by fragmentation.
For Discussion
- For the group of people you are focusing on, is it already clear what type or types of integration would be appropriate?
- Is it clear how these would be effective antidotes to the ill-effects of fragmentation you have identified?
- Do you have a type of integration in mind that is not in listed in this Manual?
- Are one or more types of integration already in place for this group?
- What are the successful elements of this integration?
- What are the failing elements of this integration?
- In your locality, are there some successful types and outcomes of integration for other service users that would also fit the people you are focusing on?
- Where you have found successful types of local integration, can you liaise with the people running them?
- What examples of good practice in this do you have for your evidence base?
- Other points?
Topic 2: Problems caused by fragmentation
Integration becomes an imperative when the damage fragmentation can cause is considered. This damage includes erosion of quality of life, mental ill-health following long-term stress, some interventions being made ineffective when used in conjunction with others and a person’s illness or disability being made worse than it was before. The harmful effects of fragmentation include these interconnected elements:
- Chaos and confusion
- Stress and strain
- A piecemeal approach
- Repeating the story
Chaos and confusion
When two or more practitioners are working with the same child or adult and do not share their work with each other, they are, in a real sense, working blind. Then ‘the right hand does not know what the left hand is doing’. There is no guarantee that the separate approaches fit well together without harmful contradictions. To counter this, a concerned practitioner might ask the service user to relate what the others are doing. Even if the service user has the capacity to do this, imposing this additional responsibility on someone who already has enough to deal with cannot be thought good practice.
In my experience, many new parents of disabled children experience the totality of their local services as a mystifying jungle. They start with no knowledge of what support is available and when they find a service they might need, they find it difficult to access. They have to struggle at a very difficult time in their life to make headway without any sort of comprehensive guide.
Stress and strain
Having a long-term condition, being a carer of someone who has a long-term condition or being the parent of a child with a long-term condition is already stressful enough with its own mix of emotional ups and downs. When support is fragmented, stress and strain are increased by a disorganised pattern of appointments and interventions that waste time and energy. Any effort the service user makes or others make on their behalf to appeal to practitioners to properly co-ordinate their work around the child or adult can bring a whole new set of frustrations for everyone.
A piecemeal approach
It might or might not be appropriate to treat each aspect of a person’s whole condition separately. A physiotherapist sorting out a person’s back pain will most likely not need to liaise with the person’s dentist treating a gum infection. But there are clear instances when a joint approach is necessary. One example is an infant who has cerebral palsy and impaired vision. In this case it is good practice for the physiotherapist, vision specialist and parent to work together to teach the child how to move around the house or manage at mealtimes. Another example is a teenager who has an addiction leaving their care home. An integrated approach to support them will bring together the teenager, key people from the care home and any education establishment they attend, a concerned relative and any concerned social worker and psychologist.
In a piecemeal approach, each practitioner will apply the work for which they are trained and contracted without considering properly how this fits with the work others are doing – or might not even be aware of the other interventions. Human beings do not come as an assembly of separate parts and their conditions and situations have interconnected elements. For the infant above, movement and vision are inter-dependent and progress in one will help the other. For the teenager, addiction, education and domestic arrangements are interrelated parts of the whole life situation and must be addressed together.
A piecemeal approach will dilute the impact of each intervention and might make the person’s situation worse if people are working towards different goals that do not fit together. As an example, support for the teenager above will be problematic if a relative and social worker have different aims for the teenager’s living arrangement.
Repeating the story
An argument that is often put forward for integration around young children with disabilities is that it will prevent the parents having to tell their story to each new practitioner they meet. This is a valid argument but perhaps not quite as simple as it sounds. It depends on the parents and on what information each new practitioner is asking for. It is tedious for a parent to keep repeating the sequence of birth events, problems, tests and diagnoses with personnel, places and dates. But each story also has emotional content including anxiety and aspirations and a parent of a disabled child or any other person in need might find it therapeutic to go over issues again to a new practitioner they feel they can trust. Having the story typed up for handing out might not always be all that some people need.
But such a typed account will work very well in some situations. If there has been a shared multiagency effort to produce a single document describing a person’s condition, situation and pattern of present support, then that person can send it to a practitioner they are due to meet for the first time and ask them to read it before the appointment. As ever, it is matter of being person-centred within agreed integrated systems.
Countering fragmentation to fully remove these problems and ill-effects is a massive task. Taking health, education and social care agencies as an example, a large part of disjointedness comes from how they were set up the first place. These agencies and services were established and have evolved as separate institutions. This works well for many people who have a single health, education or care need but it breaks down when needs cross the institution boundaries.
In this separate evolution, each institution has developed its own culture, language and methods of working. Universities prepare practitioners to work in these institutions with separate courses and qualifications. Practitioners are then employed in separate organisations each with management hierarchies, contracts and job descriptions that are peculiar to their institution. This perspective on the background to fragmentation shows the great challenge that integration presents.
For Discussion
- What are the major harmful effects of fragmentation for the people you are focusing on?
- Are there other ‘lesser’ effects?
- Are these harmful effects known from recent surveys?
- Can the information be collated into an evidence-based report:
- with a short version on a single A4 page?
- with a more detailed account?
- with some account on film?
- Are further surveys needed at this time?
- Can co-production be part of gathering further information?
- What are the harmful effects for the people around service users as family members, carers, and friends?
- What are the harmful effects for their practitioners?
- What are the harmful effects for the local support services?
- Do you have evidence from published research about the problems fragmentation causes to the group of people you are focused on?
- Other points?
Topic 3: When integration is needed
We can now attempt to define people who need an integrated service, either as individuals or as groups sharing a condition or situation. These are people whose disability, illness or condition is multifaceted rather than singular with parts that interconnect with and impact on each other. Babies and infants who have neurological impairment from birth might have difficulties with movement, communication, vision, hearing, cognition and dexterity. A child with a complex genetic syndrome might have difficulties with organ function, digestion, hearing, vision, growth and development. A person with autism might have difficulties with communication, cognition, relationship, mood and sleep. A frail elderly person might have difficulties with self-care, nutrition, general health, memory, staying safe and might suffer long-term loneliness. An integrated support system will attempt to address all aspects of a person’s condition and situation.
Family members and carers are part of the whole picture. People close to the person in need might have their own practical, social and emotional needs. Services supporting a child with disabilities and/or short life expectancy, if they are truly family-centred, will support parents, siblings and perhaps grandparents as far as they can. A whole and integrated pattern of care for a person with dementia might embrace family members, carers, friends and neighbours – both for their own sake and to help them in their caring role.
Some people who have disabilities and special needs will need integrated support as they transfer from one service or practitioner to another. A situation to be avoided is when a child or adult’s support service comes to an abrupt halt leaving the person to wait for the next service to begin. The gap without support is itself a problem. Difficulties are increased when relevant information does not pass from one service to the next and when an effective approach is dropped to be replaced with another that is unfamiliar and seemingly less effective. This can happen when school age is reached, when children’s services give way to adult services, when an elderly person moves from home to hospital (or vice versa) and when one practitioner is replaced by another – perhaps because of change of employment or extended leave.
This is not meant to be an exhaustive list. It just makes the point that for some people needs are interconnected and that an effective professional response is to integrate interventions into a unified whole as far as possible.
For Discussion
Note: You might not need to use this list if you have already clearly decided the group you are focusing on. Or you can use it to confirm and clarify your focus.
- Are you focused on a group of people who share a condition?
- Are you focused on a group of people who use a particular service, centre or unit?
- Are you focused on a group of people who need support from two or more agencies?
- Are you focused on a group of people defined in some other way?
- Are they adults, children or both?
- Do you have evidence of ill-effects from fragmentation when elements of support are provided simultaneously?
- Do you have evidence of ill-effects from fragmentation when elements of support are provided consecutively and at transitions?
- Is co-production helping identify the ill-effects of these fragmentations?
- Is there information about how many agencies or services the people are using?
- Is there a need to collect further evidence?
Topic 4: Integration that occurs spontaneously
There have always been some instances of integration in which people come together in joint work with little or no conscious planning. This can be in response to a sudden crisis or when it is eventually realised that a person’s long-term condition or situation has not been helped by practitioners each doing their separate work. Concerned practitioners might then come together on the basis that ‘two (or three) heads are better than one’.
Joint working can also arise more or less informally between practitioners who get on well with each other. Capra and Luisi5 describe ‘communities of practice’:
...informal social networks exist within every organization. They arise from various alliances and friendships, informal channels of communication, and other tangled webs of relationships that continually grow, change, and adapt to new situations.’
These social networks are probably very common and can cross agency boundaries with or without co-location. Being informal and impermanent, they cannot be relied on to bring the necessary people together for each child or adult that needs integrated support. But they can be a good start.
Capra and Luisi, authors of The Systems View of Life, and other writers on Systems Theory have a lot to offer on the subject of integration. The central observation of Systems Theory is that the whole is more than the sum of the parts or, to put it another way, when parts are properly connected, new characteristics emerge that the parts did not have. So a multidisciplinary team can achieve more than any of the single people in it. In the next section, I discuss the benefits that can emerge when people work together in integrated systems.
5 Capra, F. & Luisi, P. L. (2014) The systems view of life, p 316
For Discussion
- What local examples are there of practitioners coming together spontaneously to successfully address a crisis situation or a so-far intractable problem for a service user or group of service users? Is this integration multidisciplinary? Is this integration multiagency?
- What local examples are there of practitioners and other people (family members, carers, friends, neighbours) coming together spontaneously to successfully address a crisis situation or a so-far intractable problem for a service user or group of service users?
- Can you identify the elements of good practice in this integration?
- What examples of ‘communities of practice’ do you know of?
- are you involved in one?
- what factors helped get them established?
- what factors help keep them going?
- if they have not lasted, what factors brought them to an end?
- Where you have examples of ‘communities of practice’, can you identify the types of joint working they generate?
- Where you have examples of ‘communities of practice’, can you use them as a starting point for extended integration?
- What changes to work environments and communication systems could be made to foster and consolidate ‘communities of practice’?
- Are you up-to-date with basic Systems Theory?
- Any other points?
