Integration Made Possible: A practical manual for joint working – multiagency, multidisciplinary, transdisciplinary. For people of all ages. SECTION 4

SECTION 4: Considerations in Promoting Integration

This section discusses various topics that are connected in some way with integration of health, education, social care and other agencies and services supporting adults and children who have special needs for some reason. The section is intended to help readers identify local hindering and enabling factors. The four topics are:

• Partnership with service users
• Surveys
• Horizontal teamwork
• Personal attitudes to integration

 

TOPIC 14: Partnership with service users

Public agencies might differ from voluntary agencies in how well they work with users in service development. It is fair to predict that a voluntary agency that is recently established by people in need and the people around them will be proactive in maintaining the working relationship with service users. This is not necessarily true of health, education and social care agencies in which, traditionally, users are not powerful. A large part of the message of this Manual is that service users have a prime part to play in developing improved integrated support systems. Partnership work in service development has been termed co-production. There are necessary conditions in any organisation that promote the voice of service users. These operate at two levels:

• The culture of the organisation and its written policies must advocate service users having influence and control with a proactive effort at all levels to empower and work in partnership with service users. There must be an established forum for hearing the collective voice of service users.
• Individual managers and practitioners must have necessary skills for working in partnership with each service user they encounter, including skills in negotiating and active listening. There must be mechanisms for individual service users and the people around them to give feedback about to what extent they feel informed, involved and empowered in how support is, or was, provided to them.

           

If public agencies are going to become as responsive to service users as many new voluntary agencies are, then a new attitude is needed at all levels from directors down to people at the grassroots. Just as it would be nonsense to hold a meeting about race discrimination without involving black and ethnic minority people or a meeting about gender discrimination without involving women, so must it be seen as nonsensical     and offensive to discuss service improvement in a public agency without involving representative service users.

We are told in the executive summary of The Challenge of Co-Production that:

[Co-production] is important and exciting for those of us who have been trying to shape a new conversation along these lines, arguing that the key to reforming public services is to encourage users to design and deliver services in equal partnership with professionals. The time seems to have arrived for the idea that the users of public services are an immense hidden resource which can be used to transform services – and to strengthen their neighbourhoods at the same time.¹⁶

When people who are dependent on some level of integrated support from health, education, social care and other agencies are brought more fully into discussions about service development, they can help at successive stages. Initially, they can help nudge their service managers into an integrated mindset. The late Dr Penny Lacey¹⁷ of the University of Birmingham’s School of Education once observed to me that in her experience some agencies can delay fully implementing new official policy and guidance for ten years or more. In these cases, a strong message from service users, individually or in groups, might help get things moving more quickly.

            If managers are going to be drivers for change, then some will first need to be persuaded why change is necessary. Service users can have a strong part to play in this. Very many of the health, education and social care agencies I have worked with have seemed to operate under a ‘take it or leave it’ institutional attitude. This is in spite of the commitment and professionalism of individual people working in them. Agencies that have transcended this out-dated attitude spend time learning in depth what adults and children feel about the support they are receiving and then respond to what they hear. This learning process will involve family members, carers and other concerned people around service users. 

            When an agency makes no serious attempt to find out what service users feel, service users are held powerless in the running of that agency. They are then also powerless to influence how the local agencies work together to provide an integrated service. While many adults and children are receiving unsatisfactory fragmented support, there is no mechanism for them to collectively report in depth to service managers, and then service managers have no incentive to strive for integration. So it goes on. Concerned managers and directors remain unaware of the problem while those happy to leave integration on the back burner can continue doing so.

            Logically, service users should have a prime position in service development working in partnership with practitioners and managers. This is because they are the focus of each agency’s work and, by paying taxes, are footing the bill. The initiative does not have to come from management. A strong service-user forum, council or campaign group could take up the integration challenge focussing on local issues that it knows are relevant at the time. Service users and their family, carers and friends can then take every opportunity to talk about this push for joint working with service managers and directors. This will be very powerful.

            If fragmentation has been highlighted in a survey as a problem for local people in need, there is nothing to prevent them and their representatives setting up a meeting about integration and inviting service managers to it. In this way, service users can be a strong driver for change. It is not a matter of setting service users against managers or vice versa. When users and managers can work together in the spirit of partnership, they will become very strong in shaping local provision.

            In this, there is a danger to be avoided of exploiting willing service users beyond what is fair and reasonable. Agencies who want to benefit from service user expertise in on-going processes of service development must arrange their budgets so they can pay for it. This will include fees, travel expenses and any necessary child care. It is not reasonable or fair to expect service users to be the only people around the table who are unpaid and even ending up out of pocket. An agency’s budgets can be drawn up in anticipation of these expenses during each coming year. The potential benefit for the agency is very great. 

¹⁶ See link in References to New Economics Foundation website

¹⁷ Ashdown, R. (2015) Penny Lacey – a celebration

 

For discussion

• What examples are there locally of service users being involved in the development of an agency or service?
• Are these service users in forums that the agency has helped establish?
• Are these service users in forums or campaign groups operating independently of local agencies?
• What are the successes here in partnership working?
• What are the failings here in partnership working?
• What models of good practice do you have for your evidence base?
• What examples are there locally of people around service users being involved in the development of an agency or service?
• Is there a need to establish or enhance a service-user forum?
• Is there a need to establish or enhance a campaigning organisation?
• Are you up to date with co-production?
• Who needs to be contacted to allocate service user fees and expenses for partnership working into future budgets?
• Other points?

 

TOPIC 15: Surveys

Integration plans must be firmly based in the experience and views of local service users and of the carers, friends, practitioners and managers around them. In this Topic I am focusing on service users but in many Topics the Manual emphasises the need to survey the views of professionals and of family members, friends and others around service users.

            User surveys are an essential part of any process of involving service users in service development. While this manual is about integrating services to counter fragmentation, I would not suggest that local surveys should focus their questions in these terms. It is later, in the analysis of responses, that some dissatisfactions and unmet needs are identified as being caused by fragmentation and some elements of user satisfaction are found to be the result of people working together. The second of these two are the good practice that service development programmes can build on.

            Which agency carries out the survey will depend on the local situation. It can be a health, education, social care or voluntary agency (or one of their departments) operating on its own. If two organisations are already working together, they can do a joint survey. If there are already some effective integrated pathways then each will have built into it a system for regular service user surveys. Even a survey carried out by a single agency can show problems caused to adults and children by fragmentation.

            Questionnaires are not the appropriate medium for an in-depth survey. These are unlikely to do justice to the complexities of a person’s condition and situation or to the practical, relationship and emotional components. Interviews and group discussions will go deeper and accommodate a necessary broad scope. This is true whether the survey is for individuals or groups of people who share a condition or situation.

            The topics to be surveyed in detail will depend on which service is doing the survey. It will be essential though to include some broad questions to make sure the person’s whole situation is properly covered. For instance, discussions can consider quality of life, sleep, children’s attachment and such negatives as fatigue, frustration and stress¹⁸. It will soon become clear to what extent agencies are helping or hindering service users in addressing these issues.

            If agencies are serious about properly involving local service users of any age in the effort towards a seamless service, then managers will invite representative people into discussions in three stages: firstly to help design survey questions; secondly to help analyse responses to see which good practice comes from joint working and which problems are caused by people keeping their work separate from each other; thirdly to help develop new patterns of support in line with the survey findings.

            A note of caution is appropriate. User-satisfaction explorations can be a painful process. When I have facilitated discussions between agencies and the families using them, I have seen managers in tears as they come to fully understand the shortcomings of the support their agency is offering. (And I have seen parents then in tears because they had not wanted to upset managers and team members.) While user-satisfaction surveys are a major concern in commerce and industry, they can be perceived as a threat in health, education and social care agencies – sometimes a threat to be avoided for as long as possible. There is need here for user surveys to be approached with all tact and sensitivity.

The experience, perceptions, frustration and aspirations of practitioners and managers in health, education and social care agencies are very important, too, and must play an important part in service development. There can be no partnership in integrating local support services without practitioner and manager surveys. Integration plans will not succeed if practitioners and managers have not been consulted and fully involved in discussions about all aspects of service development.

¹⁸ Negative states of mind in parents and practitioners are discussed in Limbrick, P. (2017) Early Childhood Intervention without Tears

 

For Discussion

• What examples do you have locally of public or voluntary agencies surveying the views of the people you are focused on?
• What examples do you have locally of public or voluntary agencies surveying the views of other groups of service users?
• What examples do you have locally of public or voluntary agencies surveying the views of people around service users?
• What examples do you have locally of public or voluntary agencies surveying the views of practitioners and/or managers?
• What are the successes in how these surveys are run?
• What are the failings in how these surveys are run?
• What good practice have you identified for your evidence base?
• From these surveys, what feedback is there to inform new or enhanced integration?
• Are service users involved in the three stages:
  • helping to design and run surveys
  • helping to analyse responses
  • helping to plan service development?
• Who needs to be contacted to allocate service user fees and expenses into future budgets?
• Other points?

 

TOPIC 16: Horizontal teamwork

Most professionals working in health, education, social care and the voluntary sector function in vertical hierarchies. This is how the Western world is organised. In this verticality, each person knows who is above them in the hierarchy as their manager and who is below them. Chief executives at the top are themselves subject to rules set by boards or committees above them. At the bottom end of each hierarchy are people who are not managing anyone else and who are subject to the decisions of all people in the various layers above them. Power is held at the top and it filters down.

            This familiar arrangement breaks down when two, three or more senior managers from the local agencies get together to plan integrated systems and pathways for groups of people who share a condition. They must operate now outside the bounds of their usual verticality alongside other managers of equal status in an unfamiliar flattened power arrangement. In my terms, they are now operating in a horizontal landscape in which some managers might feel more comfortable than others. These levels of comfort will increase or decrease when service users are involved in the meetings.

            This is horizontal teamwork¹⁹ an example of which are TAC meetings operating at the grass roots level with practitioners and parents. They are both multiagency and multidisciplinary with the people in them treating each other as equals. No one takes an authoritative role of manager in these meetings, but one person can become the facilitator using leadership skills.

            Each director, manager and practitioner will have their own response to the idea and practice of horizontality. That they will feel comfortable with it cannot be assumed or taken for granted.

 ¹⁹ Limbrick, P. (2012) Horizontal Teamwork in a Vertical World

 

For Discussion

Note: Discussions can include people’s personal experience of working horizontally, either in formal or informal situations.

• What local examples are there of informal horizontal teamwork around service users?
• What local examples are there of formally organised horizontal teamwork around service users?
• Are service users fully involved?
• What criteria apply for inviting a child to be involved in their individualised team meetings?
• Are family members, carers, and others involved?
• What are the successes in this horizontal teamwork?
• What are the failings in this horizontal teamwork?
• What good practice have you identified for your evidence base?
• What personal attitudes to horizontal teamwork have you encountered in yourself and in other people?
• How can you prepare and support service users in horizontal teamwork?
• How can you prepare and support practitioners in horizontal teamwork?
• How can you prepare and support managers in horizontal teamwork?
• How should attitudes to horizontal teamwork be explored when appointing new people to the organisation?
• Other points?

 

Topic 17: Attitudes to integration

Integration around adults and children who have special needs requires people to work together in effective relationships. This is basic human activity which gives full expression to personality, attitudes, integrity and self-awareness. Here we will find hindering and enabling factors that must be acknowledged. This section has four parts:

• Negative attitudes
• Identity
• Relationships
• Ways forward

 

Negative attitudes

Chief executives, senior managers, middle managers and practitioners all come with beliefs and attitudes. This is inevitable because they are people, not automatons. When it comes to joining their work with other people, some basic mindsets come into play: some people seem to be instinctively for integration, some are against; some take strength from a collaborative effort, some would rather do their own thing in their own way; some are confident in sharing their approach, others are not; some are ready to embrace and consider all aspects of the whole person’s condition and situation, some need to maintain a narrower focus to avoid being overwhelmed; some feel joint working is the fullest expression of their professionalism, some fear their professional standards will be compromised.

            I have met all of these attitudes in my many workshops, seminars and conferences. There are no angels or devils here, no good people and bad people. The only judgement I feel qualified to make is that people who are suffering from fragmented support will be left with unmet needs if the managers and practitioners around them persist in working separately from each other. A person’s situation can be made significantly worse when health, education, social care and other agencies are not integrated into a seamless whole, as far as possible.

            It can be valuable for directors, managers and practitioners to reflect on their present attitudes that can hinder or enable integration. I have seen practitioners who collectively long for integrated systems and pathways but whose managers resist creating them. I have met managers who are frustrated by practitioners’ unwillingness to work together in multiagency and multidisciplinary teams. I feel there are some very basic attitudes and assumptions at play here, both conscious and subconscious.

            Any new integrated systems and joint working arrangements that leaders create will surely fail sooner or later if they have not acknowledged and addressed the valid fears, apprehensions and anxieties in some members of the workforce.

Identity

When managers and practitioners are asked to integrate their work with others, there can be a perceived threat to each person’s identity. Cake baking can illustrate these threats. Once a cake is baked, the flour, eggs, sugar and other ingredients have lost their identity as separate elements. They can no longer be found because they have merged into a new whole entity. In this illustration, the ingredients are the separate practitioners and the cake is the resulting seamless support system once the ingredients are successfully integrated.

            While it is clear the cake has demonstrable value, some practitioners might resent the apparent loss of their separate identity. It can be that the child and family experience the best possible integrated support while some of the practitioners who contributed to it are no longer very noticeable. This is true when therapists and teachers join their work together into a whole-child programme. It is particularly true when a child’s TAC (Team Around the Child) opts to work through a primary interventionist. The primary interventionist model is a full expression of multidisciplinary integration but relies on practitioners being willing to be less visible in the interventions for the child. Some practitioners will be comfortable with this temporary perceived loss of identity and some will not.

            Similarly, when directors and managers work with each other across agency boundaries to create local integrated systems, some will be more prominent in the end product than others. This is inevitable when joining various aspects of health, education, social care and other agencies into a whole approach. Some managers will be prominent in the operation of the pathway while others have a supportive role in how the pathway is designed, run and monitored. People who insist on being prominent might impede processes of integration. 

Relationships

Integrated services must come down in the end to people working collaboratively with each other regardless of which agency or discipline they belong to. Their willingness or ability to do this cannot be taken for granted. Joint working depends for its success on relationships. Effective relationships include the following factors:

Familiarity: People who already know each other and can relax to some extent with each other are more likely to be able to work together.

Empathy: Practitioners can start to learn about the work of others  ̶  their training, ethics and methods and their aspirations and frustrations.

Respect: People who do not respect each other will not be willing to share their thoughts or approaches.

Trust: This can grow from familiarity, empathy and respect. Practitioners who do not trust each other will not work effectively with each other.

All of these comments about relationships to support integration also apply to chief executives, senior managers and middle managers in a locality’s public and voluntary agencies. If managers do not relate with respect and trust to their fellow managers in the other agencies, they will be unable to work with them to construct seamless integrated systems and pathways. My thoughts about relationships have been supported and clarified by the work of Professor Hilton Davis²⁰. 

 

Ways forward

It is crucial to explore, acknowledge, respect and address the apprehensions, misgivings and anxieties that people who work in agencies and services hold about integration. If this stage is missed out, many people will resist changing to new work patterns that require joint working. Service development plans should: disseminate early information about the commitment to enhance integration; survey attitudes about joint working; involve people in the discussions about service development; ensure new plans take account of apprehensions and anxieties expressed in the surveys; build feedback mechanisms into the new work with opportunities for support and supervision.

            Time is an important factor. Changes to patterns of working need time for managers and practitioners to reflect on the implications for them and for the people they support. As joint working is founded in effective relationships, there must be allocated time to allow these relationships to grow. Respect and trust are very personal responses that cannot be made to happen on demand.

²⁰ Davis, H. (2009) The Helping Relationship: Understanding Partnerships in IQJ

   Davis, H. & Day, C. (2010) Working in partnership

 

For Discussion

Note: This discussion can start with personal anxieties, apprehensions, benefits and satisfactions about past, present and future joint working.

• What are the positive attitudes to joint working amongst the people in this project?
• What are or have been their apprehensions about joint working?
• What has helped them move on from negative attitudes?
• What positive attitudes have you encountered in others around the people you are focused on?
• What negative attitudes have you encountered in them?
• What has helped convert negatives into positives:
  • support from colleagues
  • practical experience of teamwork
  • training
  • supervision
  • other?
• In planning to develop or enhance some aspect of integration:
  • how can you learn about people’s apprehensions?
  • how can you build in antidotes to these apprehensions?
  • can you collect regular feedback about these antidotes?
• What in-service training will be needed in this to prepare and support practitioners and managers for the new systems?
• How should attitudes to integration be explored when appointing new people to the organisation?
• What good practice in this do you have for your evidence base?
• Other points?