Integration Made Possible: A practical manual for joint working – multiagency, multidisciplinary, transdisciplinary. For people of all ages. SECTION 3

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 3: Common Approaches to Integration

Integration is not a new invention for this 21^st century. Nor is the awareness that effective support for some adults and children who have multifaceted conditions and situations means there should be some sort of shared effort. This section discusses some common approaches to joint working in the following topics:

Co-location and one-stop shops
Keyworking
Individualised multidisciplinary teams
Primary interventionists
Integrated pathways
Directories and communication systems

Topic 8: Co-location and one-stop shops

I am going to argue here against co-location in buildings being a primary answer to the challenge of integrating local agencies. Co-location means bringing workers from more than one agency or service into a shared work space. It can be just a shared office space or a space for practitioners to be with the people they are supporting, for example an elderly person’s day centre or a children’s centre. A shared office space might be cheaper to establish and run than separate offices and ought to make communication easier, but it is not a guarantee of effective integration of support around local children and adults. While it should bring bureaucratic advantages and economies, if it is going to go beyond the spontaneous and ad hoc communities of practice, some training and support will be needed to generate integrated systems for real joint working based in familiarity, trust and respect between everyone in the shared space.

When service users are invited into a shared space it can be a one-stop shop for them, one advantage of which is bringing workers together across agency boundaries and avoiding service users having multiple appointments and journeys on a regular basis. One-stop shops facilitate integration to only a limited extent but they have other significant benefits and should not be discounted.

Child development centres (CDCs) are an example. The ones I have known in the UK have been health units with a central core of paediatricians, nurses, therapists and receptionists. After that, the model varies greatly. Additional CDC team members can include social workers, teachers, psychologists and clerical workers. A child might be seen individually by each team member or team members can come together around a child. Children can be organised into small groups for some activities. Parents might stay with their child or have their own parent groups for sharing and mutual support.

The one-stop shop aspiration breaks down in the CDC model when child or parent needs the services of a geneticist, neurologist, sensory specialist, counsellor, benefits adviser, housing officer or any other service that is not based at the CDC.

Obviously, no CDC could ever be big enough and broad enough to include all the people a child and family might need access to during the childhood years.

Even within a CDC or children’s centre, the patterns of integration around children and families will vary. For instance, it will probably not be necessary for every practitioner to be involved with each child at the same time: A physiotherapist might not be necessary because of the nature of the child’s condition; involvement of a social worker might not be relevant; a paediatrician might be needed at one stage of the child’s life but not at others; people who can support parents in learning to play with their child might be the predominant need while others move to the side-lines for the time being.

CDCs, children’s centres and one-stop shops for adults and elderly people, rather than being considered as whole solutions to fragmented services, are more usefully seen as places where joint working is easily organised as necessary within their walls and as control centres for organising joint working in the local support networks beyond the building.

Co-location and one-stop shops have very great benefits for both service users and practitioners. However, when the primary objective is to fully integrate health, education, social care and other support services around local children and adults, investment in a new building should not be the first option. There would not be sufficient gains in joint working to justify the expense.⁷

⁷Wolverhampton’s Gem Centre in the UK is an example of a multiagency centre for children

For Discussion

In your locality, what administrative buildings are there that co-locate people of different support organisations?
What are their successes in establishing joint working?
What are their failures in establishing joint working?
Can you identify good practice that could transfer to other facilities?
In your locality, what buildings are there that operate as one-stop shops for service users?
What are their successes in establishing joint working?
What are their failures in establishing joint working?
Can you identify good practice that could transfer to other facilities?
Are there surveys of service users’ views on local one-stop shops?
Are there surveys of practitioners and managers’ views on local co-located offices?
Are there surveys of practitioners and managers’ views on local one-stop shops?
Can co-production support development of these facilities?
Other points?

Topic 9: Keyworking

In my view, every child or adult who has a multifaceted and long-term condition should have the option of a keyworker. (Use of the two terms ‘keyworker’ and ‘key worker’ is a matter of choice.) This keyworker would be one person they get on well with and trust and who is easily available for regular and direct support. Keyworkers are an important asset in integrating support, helping bring fragmented parts into a whole when the locality has no other elements of integrated working.

A keyworker’s wider functions can include: providing emotional support; helping with confidence and empowerment; helping get relevant information; helping with access to relevant services; helping rationalise all appointments; helping to harmonise separate programmes; helping create an individualised multidisciplinary team; being an advocate.

These various functions are potentials that come into play when necessary. We can think of a keyworker sitting with the person at the centre of their support network and helping with communication across the network to and from the person being supported. It is a demanding professional role in which activities must be limited by each keyworker’s competence and available time.

When the usual pattern of support from local services is fragmented and chaotic, this will impact on keyworkers in their role of helping achieve a well-organised and coherent system of support. Keyworkers will then be in danger of getting lost in the same mystifying maze that frustrates service users. Keyworking works best when there are local multiagency pathways with easily accessible information about all support that is available and effective multiagency communication systems.

The registered charity One Hundred Hours explored and validated the role of the keyworker. This approach was described in The Keyworker: a practical guide⁸.

In this guide, the keyworker is described on page 7 as:

A source of information for families of children with disabilities and a conduit by which other services are accessed and used effectively...

To do this effectively, it is argued, the keyworker needs to be able to offer the family specific services – such as emotional support, information, advocacy and co-ordination of services – and needs to operate under specific principles such as being parent-led, being ‘dedicated’ (focusing solely on keyworking), independent and operating in partnership with the parents.

Clearly, this is a demanding role. After the publication of The Keyworker, there was general agreement in the UK that keyworkers could be a major asset for families of disabled babies and young children. It was recognised that many families wanted a keyworker to help co-ordinate the various elements of support. The dual aims in this were: to rationalise all appointments to save the child and parents’ time, money and energy; to build a whole approach to the child with a coherent picture of their child’s strengths and needs and harmonised interventions. There were two ways of doing this: the keyworker could meet each of the child’s practitioners separately or the prac-titioners could be invited to the family home to meet each other and begin the process of collaborating. The second of these, the individualised multidisciplinary team approach, was the ideal for most families and was later written up as Team Around the Child (TAC)⁹.

Keyworking and individualised multidisciplinary teams both have a range of valuable characteristics and overlap in the task of integrating support: the multidisciplinary team can have one person in a leadership role sharing many of the characteristics of a keyworker; a keyworker can help generate an individualised multidisciplinary team when this is felt to be the best antidote to fragmentation. In some situations, one practitioner can combine the roles of keyworker and primary interventionist. This is explained further in the Discussion Topic 11, Primary Interventionists.

Keyworkers have an important part to play in integration. They are person-centred and bring many direct benefits to people. But the model still presents great challenges to service providers and only a minority of adults and children in the UK who could benefit from having a keyworker do so. Factors in this include practitioners’ time pressures and their apprehension about expanded and uncertain responsibility and accountability.

⁸Limbrick-Spencer, G. (2001) The Keyworker: a practical guide

⁹Limbrick, P. (2001) The Team Around the Child and Limbrick, P. (2009) TAC for the 21^st Century

For Discussion:

Which local services (public, voluntary or private) give children or adults a keyworker?
What are their successes in establishing joint working?
What are their failures in establishing joint working?
Can you identify the main elements of good practice?
To what extent are these keyworker services limited in terms of the numbers of people (who meet the criteria) they can help? Do they have waiting lists?
How many service users would benefit from having a keyworker?
In keyworker services you know of, how are keyworkers trained, supported, supervised and monitored?
Do you have surveys of the views of service users on keyworking?
Do you have the views of practitioners, managers and keyworkers on keyworking?
Can co-production help you develop local keyworking?
What published research do you have about keyworking with the group of people you are focused on?
Other points?

Topic 10: Individualised multidisciplinary teams

An individualised multidisciplinary team can be defined for the purposes of this Manual as a small number of practitioners and other people committed to working together to support an individual child or adult. The person being supported is as full a member of the team as possible and parents are members of the teams around their children. An individualised multidisciplinary team will often also be multiagency. For instance, when a teenager, nurse, psychologist and teacher get together to address self-harming or smartphone addiction or when a parent, nursery worker, therapist and sensory-impairment teacher meet to support an infant who has neurological impairment.

A multidisciplinary team has to be much more than a mere group of interested people. Effective teamwork requires the members to work together in relationships of familiarity, honesty, respect and trust. Observations and approaches are shared so that the interventions fit well with each other and work towards an agreed shared goal. This is a whole approach to a whole person or, to put it another way, a coherent multifaceted approach to address a person’s multifaceted condition and situation. Team members support each other so that no one is alone in meeting the challenges the person brings. While, with effective leadership, a group can evolve into a team, in most cases something valuable would be lost if a team dissolves into a group.

An individualised multidisciplinary team around an infant with a multifaceted condition (i.e. two or more disabilities or impairments) can be termed a Team Around the Child, or TAC. The TAC approach has well-established philosophy, principles and practice. It brings key people together to support the child and the family with a co-ordinated pattern of appointments and interventions, it knits together therapy and education programmes into a whole-child programme and it facilitates joined-up support over the transition from pre-school to nursery or school.

The TAC approach is easily adapted to other service users. For example, an individualised multidisciplinary team around a frail elderly person would bring together key people from the settings the person uses simultaneously or consecutively. This can include practitioners from community health and social care services and staff members from the care home and/or local hospital. This integrated teamwork creates a unified plan of support that persists as the elderly person moves from one place to another and is the antidote to them being passed around like a parcel.

Some multidisciplinary teams are generic rather than individualised, overseeing support for a specified group of people rather than for an individual person. These multidisciplinary teams, which might also be multiagency, prevent fragmentation by bringing people together into a shared effort. Such a team could function in an integ-rated pathway to accept people into the process and then identify particular practitioners as potential key players in each person’s future support. For example, in services around children with disabilities this sort of generic or wider-scope multi-disciplinary team can establish TACs around individual children.

Caring activism

Commonly, multidisciplinary teams have strong elements of public service involvement. Caring activism offers another sort of teamwork around vulnerable people who might have little or no support from public, voluntary or private organisations. This approach is described in Caring Activism: A 21^st century concept of care¹⁰ :

Caring activism is proposed as a secular concept of care for vulnerable people of any age who are struggling with ineffective support or with no support at all...Team members would be ordinary citizens. They might be connected to a vulnerable person as a family member, friend or neighbour or as a worker in a local project or agency. Or they might have no previous connection before becoming a local caring activist... (pp 14-15)

Very many people receive very little support from their local public and voluntary services and many get no support at all. Examples with increasing incidence include people who are struggling without benefit payments, people who are homeless, people seeking asylum and people in refugee camps. Caring Activism brings concerned citizens together into a shared effort around a vulnerable person so they are not abandoned to their fate. This unofficial support could help a frail elderly person who is lonely at home and getting little or no help with basic needs. It could provide additional community support to the family of a child who has short life expectancy to enable them to maintain study, social, sport and leisure activities. It could support a young person who has left special school and is stuck at home with no training or occupation.

In summary, there are very great advantages when the key people around a child or adult integrate their support with each other in user-friendly individualised multi-disciplinary teams. Membership is ideally restricted to the small number of people who have the most regular, practical and direct involvement in providing support. Part of the role of the team is then to stay in two-way communication with other people in the support network but who are further from the centre or out on the periphery. When people who need support are fully involved in their multidisciplinary team, they are empowered to shape the support as they want it to be and are helped to gain confidence and strength to help them through future challenges.

We can widen the potential make-up of multidisciplinary teams further to include people who work in private agencies, for instance therapists and psychologists. When they are not included and have no opportunities to share their approaches and goals the outcome might be that the various elements of support for a person with disabilities and special needs do not fit well together or even work against each other. I address this further in Topic 18, Integration with the private sector.

¹⁰Limbrick, P. (2016) Caring Activism

For Discussion

Do you have individualised multidisciplinary teams established around some service users (adults or children)? Are any of these also multiagency?
What successes do they bring?
Do they work to:

- construct a whole picture of the person they are supporting

- co-ordinate all interventions in terms of dates and venues

- harmonise their interventions

- establish a keyworker

- establish a primary interventionist when appropriate?

What good practice do these teams bring?
Do you have any generic multidisciplinary teams? Are they sometimes multiagency?
What elements of integration do they give rise to?
What are their failings?
Do these generic teams help generate individualised teams around service users?
Are there multidisciplinary teams of managers at any level? Are some of these multiagency?
What elements of integration do they generate around the people you are focused on?
Do you have surveys of views on individualised multidisciplinary teams from service users, from practitioners, from managers?
What are the criteria for a child or adult being present in their team meeting – age, capacity, etc?
Other points?

Topic 11: Primary interventionists

A primary interventionist¹¹ can be agreed for a service user by their multidisciplinary team. In this model, one team member has the most regular and direct contact with the person in need for a period of time. Other team members stay in the background to prepare and support the primary interventionist in their role. A multidisciplinary team that functions in this way is moving a long way towards a transdisciplinary model¹².

The primary interventionist model brings advantages to the person being supported and to the people providing support. Having only one interventionist might be the best for people whose social, emotional and psychological state at the time renders them unable to form plural relationships. Examples are people with social and communication difficulties and those suffering trauma. Having a primary interventionist should mean fewer appointments and brings the reassurance that the person supporting them has the whole picture of their condition, situation, needs and aspirations.

In transdisciplinary teamwork each team member hands over relevant knowledge and skills to the primary interventionist. This creates flexibility in how each practitioner spends their time. Those who are not the primary interventions are freed up for work with other service users. Practitioners extend their range of knowledge and skills by learning from their colleagues in practical situations. By eliminating unnecessary multiple practitioners and programmes, each agency or service makes better use of its resources.

A keyworker can take on the primary interventionist role if they have the time and necessary competence. In the One Hundred Hours model (see p 61), when keyworkers had a background in education and child development, this combined role evolved naturally in response to the wishes of parents. When this happened, working with the child and supporting the family merged into a seamless whole approach.¹³

¹¹See Limbrick, P. (2018) Primary Interventionists

¹²King, G. et al. (2009) The application of a transdisciplinary model for early intervention services

¹³Levitt, S. (1994) describes a whole approach around children who have disabilities in Basic Abilities: A whole approach

For Discussion:

What local examples do you have of practitioners acting as primary interventionist either formally or informally?
Are these primary interventionists established by an individualised multidisciplinary and multiagency team around the person?
Are these primary interventionists effectively supported by other practitioners with relevant skills?
What successes do these primary interventionists bring?
What are their failings?
Do you have surveys of views on the primary interventionist model from service users, from practitioners, from managers, from primary interventionists?
What good practice do you have for your evidence base about the primary interventionist way of working?
What published research do you have about primary interventionists for the group of people you are focused on?
What published research do you have about primary interventionists for other groups of people?
Other points?

Topic 12: Integrated pathways

When two or more agency directors or managers work together to develop a seamless support system for some local children or adults, the outcome will be a multiagency integrated pathway¹⁴. An integrated pathway has to be designed for a particular group of people who need support, it cannot be for everyone. For instance, managers from departments within social services can join managers from one or more departments within the health service to build a pathway for people with addictions. Managers from within education and health services can build a pathway that brings pre-school teachers and therapists together around babies and young children who have neurological impairment. A pathway for frail elderly people can be constructed by managers from social care, health and voluntary services.

An integrated pathway has five essential interconnected phases: the meeting phase; the learning phase; the planning phase; the support phase; the review phase.

The Meeting Phase

This begins when the person needing support encounters someone in one of the agencies who have created the pathway. There is no need for the person to approach other local agencies or services. There is a collective process now using available information to agree that the person does in fact need this integrated support and that the person wants to enter the pathway once it has been explained.

The Learning Phase

While some immediate support can be offered, more in-depth work might need to be preceded by a detailed assessment of the person’s condition and situation. This can have two elements: a general assessment process, perhaps with a whole-person focus; any assessment schedules individual practitioners wish to use in their work. Learning and support go hand in hand in integrated pathways as interdependent processes.

The Planning Phase

This is when a unified plan of action is agreed between the practitioners involved and between them and the person needing support. It is a single plan rather that a collection of separate plans. It will specify who is going to be offering interventions, what they will be working on, any joint working they will do and the date for the review.

The Support Phase

In this fourth phase, support is offered in line with the agreed plan. There is flexibility to address any new conditions or situations that arise.

The Review Phase

A team meeting, involving the person being supported, shares observations about progress and, if necessary, agrees a new or refreshed plan of action.

Rita Pfund¹⁵ describes integrated care pathways (ICPs) in children’s palliative care borrowing from a UK government document. In this we learn that they are a tool and a concept that embed guidelines, protocols and locally agreed, evidence-based, patient-centred best practice into everyday use for the individual patient. She adds that an ICP aims to have the right people doing: the right things; in the right order; at the right time; in the right place; with the right outcome – all with attention to the patient experience.

In summary, an integrated pathway is a full expression of multiagency and multi-disciplinary integration. It allows the service user to see the whole journey in the support process ̶ where they are now and what is coming next. Practitioners too can see their work as part of the whole. People who feel lost and confused in the local maze of services will welcome an integrated care pathway as a map and a guide that shows what the journey is, who is contributing to it and how they all fit together.

¹⁴See Limbrick, P. (2003) An integrated pathway for assessment and support

15 Pfund, R. (2010) Pathways in palliative care in Perspectives on palliative care for children and young people: A global resource

For Discussion

Are there local integrated pathways for the people you are concerned with?
Are they fully multidisciplinary and multiagency to the extent required?
What are their successes in integration?
What are their failings in integration?
Are there some integrated pathways already operating for other local service users?
Are there surveys of integrated pathways by service users, by practitioners, by managers?
What good practice do you have for your evidence base?
What published research do you have for your evidence base?
In a new or enhanced integrated pathway:

- which local agencies would have to be involved?

- which departments of these agencies would have to be involved?

Can co-production facilitate development of integrated pathways?
Other points?

Topic 13: Directories and communication systems

It is very important for a locality to have an up-to-date directory of the agencies and services that can support people in need. A comprehensive directory is both an outcome of joint working and an essential tool for joint working. It is of equal value to service users and service providers and is an antidote to anyone becoming lost and despondent in the local service maze. Keeping a directory up to date will usually mean publishing it online with persistent attention to local languages, accessibility and readability. The system must offer guidance in using the directory and allow for questions about services and how to access them.

A major obstacle to integration can be a mismatch between local agencies in their communication policies and systems. If different policies are not the issue, then incompatible computer software might be. Perhaps the day will come when there are sensible multiagency decisions about communication systems. In the meantime, we have to accept it as a hindrance but not an insurmountable obstacle. People with an urge and a commitment to share information in the interests of joint working around users will use their ingenuity, creativity and persistence to achieve as much as they can within the local limitations and confidentiality rules. I can imagine co-production bringing some common sense into this.

In a local culture of integrated working, all practitioners must feel they share in the responsibility to find answers to users’ questions. It is then not appropriate to tell a user, ‘That is not part of my brief’ or ‘That is outside my area of knowledge’. Each question asked or problem shared must be passed to people who can respond to it ̶. within the agreement made with service users about confidentiality.

For Discussion:

Is there a local general directory of service providers?
Does this cater for the people you are focused on?
Is it effective and up to date with due consideration to local languages, accessibility and readability?
Is guidance and help offered in using the directory?
Is a new directory required? Or a new section in an existing directory?
Who could take responsibility for this?
Can a local directory include those private services and practitioners who have signed up for joint working? Refer to Topic 18.
Can a local directory include those community services and facilities that have signed up for joint working? Refer to Topic 19.
Are there surveys of views on local directories by service users, by practitioners, by managers?
Are there surveys of views on communication systems by service users, by practitioners, by managers?
What are the major challenges to be addressed in information and communication for the people being focused on?
What are the examples of good practice in writing directories and designing communication systems for your evidence base?
Can co-production facilitate development of local directories and communication systems?
Other points?