Health and Social Care in the Community 13(2), 155–163 Multi-agency working in services for disabled children: what impact does it have Blackwell Publishing, Ltd. on professionals? David Abbott LLB Hons, M. Phil, M Soc Sc, Ruth Townsley BA Hons, PhD and Debby Watson BA Hons, MSc, CQSW Norah Fry Research Centre, University of Bristol, UK Correspondence David Abbott Norah Fry Research Centre University of Bristol 3 Priory Road, Bristol, BS8 1TX E-mail: d. [email protected] ac. uk Abstract Whilst agencies in many sectors have been encouraged to work together to better meet the needs of service users, multi-agency working is now a central feature of government policy. In relation to children’s services, the National Service Framework, the English green paper, ‘Every Child Matters’ (DfES, 2003) and the Children Bill (DfES 2004) give a high priority to an integrated approach to service provision.
This paper focuses on multiagency working for disabled children with complex health-care needs, a group of children who, perhaps even more than most, require the many professionals who support them and their families, to work more closely together. Drawing on the findings from a 3-year qualitative research study, this paper examines the impact of working in a multi-agency service on professionals. Interviews with 115 professionals concluded that staff were overwhelmingly positive about working as part of a multi-agency service.
They reported improvements to their working lives in areas such as professional development, communication, collaboration with colleagues, and relationships with families with disabled children. However, whilst professionals felt that they were able to offer families a more efficient service, there was concern that the overall impact of multi-agency working on disabled children and their families would be limited. Keywords: disabled children, impact on professionals, multi-agency working Accepted for publication 5 October 2004 Introduction and background
Disabled children with complex health-care needs Children with complex health-care needs and their families have the same range of needs for services and support as other disabled children. But they also have additional care needs specifically related to the use of medical technology. This group of children typically require technical and/or medical equipment in the home, both because of their need for intensive ongoing care, and to compensate for the loss of a vital bodily function such as the ability to breathe or feed independently (Wagner et al. 1988).
The combination of this group of children’s needs for health, social care and education means that it is inevitable that several agencies will be involved throughout their lives. Research © 2005 Blackwell Publishing Ltd has shown that on average, families of disabled children have contact with at least 10 different professionals, and, over the course of a year, attend at least 20 appointments at hospitals and clinics (Care Co-ordination Network UK 2001). For families of disabled children with complex health-care needs, these numbers are likely to be very much higher.
It is well established that the range, diversity and different levels of support are, in themselves, major problems for families (Townsley & Robinson 2000; Kirk & Glendinning 1999, Sloper & Turner 1992). The sheer number of professionals who may be involved in supporting a disabled child in the community can often lead to a lack of continuity and coordination and may leave families uncertain about who to contact regarding specific problems (Kirk & Glendinning 1999, Townsley & Robinson 2000; Wilcock et al. 1991). 155 D. Abbott et al.
Multi-agency working – the policy imperative Multi-agency working became a policy imperative when the new Labour Government fixed on ‘partnerships’ as an alternative ethos to the internal market and competition in services (Alexander & Macdonald 2001). Current legislation requires professionals to find ways to move across the boundaries between health, education and social care. The concept of joint working underpins many recent policy documents and several white papers (Department of Health 1997, 1998, 2001; Cabinet Office 1999).
Working in partnership is a key mechanism for delivery of services to children at risk of poverty and social exclusion in England through the Sure Start and Children’s Fund initiatives. It is also prioritised in the National Service Frameworks for Disabled Children in England and in Wales, with an emphasis on keyworking as a means of coordinating support for families. In addition, the 2003 Green Paper, ‘Every Child Matters’ (Department for Education and Skills 2003) has proposed major changes in health, education and social services with a focus on improving and safeguarding the well-being of ‘vulnerable children’ and their families.
Despite such exhortations, there appears to be a dearth of evidence to support the notion that multiagency working in practice brings about actual benefits for children and families and the professionals that support them. Multi-agency initiatives have the potential to change working practices for professionals. As they are key actors in the delivery of services, it is important to ask what impact multi-agency working will have on their working lives. Peck et al. (2002) for example found that partnership working had led to some negative and adverse effects on staff in mental health services (Willis et al. 003). The impact that multi-agency working has on professionals supporting disabled children with complex health-care needs is the focus of this article, which draws on findings from empirical research outlined below. (For an account of the impact on families and children, see Townsley et al. 2004). study phase of the research (see Table 1 for a summarised description of each service). This involved in-depth collection of qualitative data in each service (three services in England, one in Wales, one in Scotland and one in Northern Ireland).
Each multi-agency service was composed of senior managers, project managers and direct care and support staff from a range of disciplines and backgrounds. The six services were chosen from a larger sample of 26 from which basic quantitative and qualitative data had been collected. Ensuring that each country in the UK was represented, the six service which took part in the case-study part of the research were chosen because they had the highest number of key components of multiagency working n place, e. g. a defined structure or model which set out how multi-agency working would operate; a degree of resource sharing in terms of staff time and/or money to provide services; multi-agency steering or management groups, etc. (see Watson et al. 2002 for a discussion of these components). In effect, we wanted to focus on six services which, after a preliminary analysis, seemed to be delivering the most developed and structured, family-focused, multi-agency service.
Each of the six services had some shared and some different characteristics. For example, funding arrangements differed between services as did eligibility criteria and systems for referral. However, the nature of support provided to families with a disabled child with complex health-care needs, was defined by each of the six multi-agency services in the following ways: • coordinating administration, such as coordinating care packages, funding and/or information; • coordinating services and support; and • providing services and support.
All of the six services were acting as points of coordination for either administrative, or indirect, elements of care provision. This included coordinating things like discharge and care planning, assessments and reviews. In addition, four of the services aimed to ensure that families and children had access to a keyworker to coordinate and facilitate their care and support. At each service, semi-structured interviews were conducted with professionals, families and children/ young people involved in the multi-agency initiative.
Some interviews with professionals were conducted in small groups whilst others were conducted individually. We undertook a total of 115 interviews with a range of professionals (Table 2), 25 interviews with families, and spent time with 18 young disabled people with complex health-care needs. Interviews with professionals covered their work experiences as part of the multi-agency services; the Methods The research outlined in this article was commissioned by the Family Fund and carried out by the Norah Fry Research Centre at the University of Bristol.
Supported by the Community Fund between 2000 and 2003, it sought to explore the process and impact of multiagency working on disabled children with complex health-care needs, their families and the professionals who support them. This paper draws on interviews with professionals in six multi-agency services which took part in a case156 © 2005 Blackwell Publishing Ltd, Health and Social Care in the Community 13(2), 155–163 Multi-agency working
Table 1 Overview of the six multi-agency services Service A Date established 1999 Area Predominantly rural Main aims Improving liaison between health, social services and education staff; minimising appointments and reviews for families; providing access to a named key worker for families. To provide and coordinate services and support to disabled children aged 0–19; providing access to a named key worker. To meet the needs of disabled children and their families through: Multidisciplinary discharge planning; planning and managing coordinated, home-based support packages.
Establishing a system of care coordination for children with complex needs aged 0 – 5 years through: a multi agency steering group; a single assessment and care plan tool; access to a named key worker. To provide coordinated support and services by providing families with a named key worker. Staff Full-time project manager; half-time admin assistant; one hundred staff from the three main agencies contributing time and resources. Sixteen staff from a range of professional disciplines employed directly by the service working as a team in one building.
Staff in an integrated community Health and social services trust. B 1991 Rural C 1994 Predominantly urban D 1999 Rural Full-time project manager and secretary employed by education. Sixty other staff from the three main agencies work as part of the service to support families. Part-time project manager funded by health; ? fty other staff from the three main agencies work as part of the service as keyworkers and in other ways. Three health-funded workers who train and support family carers from a wide range of professional backgrounds. E 1998
Rural county with one urban area F 1996 Large urban conurbation To make transition from hospital to home as smooth and coordinated as possible; organising and coordinating jointly funded care packages. work that the service did to support children with complex health-care needs and their families; the positive and more challenging aspects of multi-agency working and collaborating with professionals from other disciplines. The material we collected comprised semi-structured interview data in note form and on audio tape, collected via a semi-structured topic uide. This was subsequently transcribed, or summarised from the notes or by listening to the tapes. We also collated other relevant documents, including policies, guidance, training materials and so on. The data was analysed following established qualitative analysis procedures (Taylor & Bogdan 1984). This involved reading and re-reading the transcripts of field notes to identify major themes or issues. Using a constant comparative approach (Glaser & Strauss 1967), emerging themes and issues were compared for similarities or differences.
Themes were cross-checked between the three members of the research team and particular attention was paid to themes which appeared to be unusual or counter-intuitive. Themes were then grouped into broader categories which formed the coding frame for analysis. This frame was verified by each member of the research team checking each other’s transcripts for accuracy and consistency in coding. We did not examine the data to explore differences between regions.
Findings – the impact of multi-agency work on professionals Professionals spoke highly of their experiences working in a multi-agency service; they enjoyed it and found it rewarding. The overwhelming majority of professionals said that they were committed to and enthusiastic about the principles and practice of multi-agency working. The most commonly used words to describe the experience of working in a multi-agency service were, ‘rewarding’, ‘enjoyable’, ‘challenging’, ‘motivating’ and ‘satisfying’.
Impact on professional development Working across traditional professional boundaries can provide opportunities for staff to develop new skills 157 © 2005 Blackwell Publishing Ltd, Health and Social Care in the Community 13(2), 155–163 D. Abbott et al. Table 2 Numbers/types of professionals interviewed in the six services Agency type Health Professional groups Speech and language therapists Community nurses Health visitors Physiotherapists Occupational therapists Hospital nurses Psychologists Hospital consultants Operational managers Senior/strategic managers Total Social workers Short breaks workers
Operational managers Senior/strategic managers Administrative staff Early years intervention worker Project worker Community-based care workers Occupational therapist Total Educational psychologist Specialist teacher Senior educational of? cer Portage worker Operational manager Senior/strategic manager Nursery nurse Total Operational manager Senior practitioner Advisor Total Overall total of professionals interviewed Numbers of professionals interviewed 5 12 9 4 5 1 1 6 14 3 60 9 2 8 4 3 1 1 6 1 35 4 1 1 1 5 2 1 15 3 1 1 5 115 Social care Education Voluntary sector nd knowledge in a number of different ways. Prevalent among many responses from professionals in each service was a heightened knowledge about the roles of colleagues from other disciplines. They believed this to be the result of working more closely together in multiagency teams, meetings and forums: Personally – it’s been very good in terms of personal development. I’ve always felt that I was a good team player. But [the teams] have helped me develop my knowledge of what other people do. And knowing about other departments and their strengths, weaknesses are very useful. community nurse) Impact on role and professional identity We wanted to know if working in multi-agency teams and/or in multi-agency services changed how professionals perceived their own roles and their sense of professional identity. Providing a more ‘joined-up’ service to families may require professionals to work across traditional professional boundaries and possibly to expand their role. Lacey & Ouvry (2000) and Doyle (1997) discuss concepts of ‘role release’ and ‘role expansion’ which they argue are key to effective collaborative working.
Role release implies the transfer of skills and sharing of expertise to an individual or group. Role expansion involves training in the concepts and language of another discipline. Both these concepts involve a certain amount of trust between professionals in order that roles are released and expanded to allow people to take each other’s places. This is a demanding process and As well as learning about each other’s roles in relation to individual children and families, there were opportunities to reflect on issues which crossed disciplines.
So for example, in one service, there had been multi-agency fora to discuss confidentiality and consent which had resulted in a more consistent approach across agencies. 158 © 2005 Blackwell Publishing Ltd, Health and Social Care in the Community 13(2), 155–163 Multi-agency working professionals must first feel secure in their own roles and have confidence in their own abilities (Hart 1991). Some professionals may find these experiences very threatening. Brown et al. (2000) point out that the erosion of roles is both opportunistic and threatening.
In three services, some professionals said that working relationships with colleagues from other disciplines were so strong that there had been an expansion of their role. They were all prepared to take on any task within their capability which effectively supported families rather than saying, ‘I’m a social worker and I don’t do that kind of task’, for example. It’s made a big difference. I can work in different ways than just a social worker would. As a social worker I would ask, ‘how is this child getting on? ’, but now I feel we can sort out particular problems together. social worker) professional identity and status as a social worker with her developing role as a keyworker. Bit of a conflict working for social services and working for [the team]. I trained as a social worker and then come here to [the team] where it’s completely different and sometimes it’s difficult to reconcile the two. Sometimes it’s a bit of a personal dilemma – how much I am working in the [team] way and how much am I working in the social services way? (social worker) Four of the six services had created a new professional role of ‘keyworker. This involved acting as a central point of contact for a family and acting as a coordinator of professionals and support services for the family. Staff in these services said that they were forced to leave their specialties behind as part of multidisciplinary teams and instead adopt the new role of keyworker: We see ourselves less as health visitors or social workers or whatever and more as co-ordinators. (health visitor) A physiotherapist who also acted as a keyworker reflected upon how the role had impacted on her sense of professional identity: I think we do more cross-over work now.
We are more ‘generic’ in our roles – we will take on aspects of other people’s roles and pick up things that other people might normally do. There are huge benefits for families. We don’t say ‘you’ll have to wait for the OT to come to do this’ – we just get on and deal with it ourselves. ( physiotherapist) Senior managers spoke less about the process of role blurring and were more inclined to highlight their view that the specialist contribution made by various staff members in a team was significant.
One senior manager sounded a note of caution about professionals working outside of their area of expertise. This manager felt that difficulties had arisen from ‘well-intentioned people’ over-stepping their roles. Our research found evidence of role expansion and role blurring and most direct care and support staff were positive about the opportunities that this provided for them to work in new ways. However, one group of professionals felt unsure about their role in working with children with complex health-care needs.
So in four sites there was discussion about the role of social work and social services in the lives of disabled children with complex health-care needs. There were concerns about how working with children with complex health-care needs meant that medical and healthcare issues dominated. Social workers were not always sure or confident about their role in what they perceived to be an ‘overtly medical situation’. It is interesting that some social workers felt that a ‘social model of disability’ was being threatened by the dominance of medical and health issues. Revans (2003) writes that the blurring of boundaries’ synonymous with joint working between health and social services can contribute to the erosion of the social model of care as social workers’ independence diminishes. Impact on communication In developing ways to work together, it is important that professionals find practical ways to communicate with each other and to work together across agencies. This involves formal and informal structures such as meetings, reviews, away days, etc. Multi-agency working can have both a positive and a negative impact upon how well professionals communicate with each other.
In our interviews, good communication between agencies and professionals was recognised as key to the success of multi-agency working: We can quite easily block interagency working can’t we, quite easily, it has nothing to do with our profession at all; it is to do One professional discussed how he had to be thoughtful about when he was working with a family as a keyworker and when he was working with them in his role as a therapist. As a result, he had constructed quite clear boundaries around his different roles: … it changes my role with families.
It’s very task orientated – fixing meetings, conflict resolution, but this inhibits my role as therapist. They see me instead as a fixer of things. We’ve talked about this – me and my two families and now I’m clear what hat I’m wearing when I go – link worker or psychologist and that’s been good and restored my therapeutic relationship with them. (clinical psychologist) A keyworker at one service (a site where most of her colleagues discussed their positive experience of ‘role expansion’) was less clear about how to reconcile her © 2005 Blackwell Publishing Ltd, Health and Social Care in the Community 13(2), 155–163 59 D. Abbott et al. with how we engage and communicate with others really, directly or indirectly. (senior manager: health) Professionals across the sites reported that as a result of multi-agency working, there were significant improvements in communicating with other professionals. Generally, professionals said that they were easier to get hold of, easier to access information from and that the structures of multi-agency teams/services improved formal opportunities for information sharing and problem solving. It cuts down a huge amount of duplication when other professionals are there.
Cuts down on phone-calls. Makes things more efficient and easier. (occupational therapist) Some of the structures that multi-agency services had put in place (such as regular meetings, steering groups, etc. ) formalised these positive opportunities for communication. On the whole, staff were committed to attending meetings so they knew that there would be a fixed time to focus on particular children: It gives us registered ‘time out’ to meet and talk. It puts boundaries on it – here is 45 minutes to talk about one particular child. (community nurse)
As well as a reported overall improvement in communication between professionals and agencies, some difficulties remained. There was concern about the possible duplication of multi-agency fora and the challenges that this posed to good communication. In each site, other statutory assessments (looked after children, statementing of special education needs, record of needs) also led to multi-agency meetings. Some professionals were concerned that an additional multi-agency forum and meeting were creating another round of meetings for themselves and for their families.
Impact on workload It is interesting to note that overall direct care/support staff, including keyworkers, did not report a detrimental impact on their ability to manage their workload. In fact, some staff felt that the role made things more efficient because they often had a much better overview of the issues facing the family they coordinated for. Being a coordinator gives you extra information about children that you wouldn’t have as just a clinician. You get copied into all correspondence about a child which means you know so much more about how things are working out for them. It has an inevitable mpact on the quality of your own service. (speech and language therapist) reason perceived no adverse impact on their workloads. However, senior managers had more concerns about workload and were surprised to learn in feedback from the research team that keyworkers were not unduly worried about this aspect of the impact of multi-agency working. Lack of adequate, ‘ring-fenced’ time and funding may mean that workers are asked to take part in new joint initiatives in addition to their main job. Consequently, difficulties can arise as a result of time constraints and a lack of priority being given to the additional role.
Mukherjee et al. (1999) indicate that where staff volunteer to take part in multi-agency work they are more likely to feel positive about the new, or additional, role. However, insufficient time, in particular, can be an insurmountable barrier to effective joint work (Lacey 1997). Our interviews suggested that staff working directly with families felt that their work was an extension of previous joined-up working which had been formalised and therefore did not represent a significant increase in workload. However, a group of professionals in one site did not share this view and had opted out of being keyworkers.
There was also a recognition that keyworkers could only take on the role for a limited number of families. Impact on relationships with other professionals and agencies A recurring theme in our interviews was how relationships had been improved on a professional and personal level. Professionals in several sites highlighted the improvement in relationships saying that the ‘blame culture’ had gone. Staff had got to know each other better and as a result enjoyed working with each other more: No one tries to steal anyone’s thunder any more which does make a difference. social worker) In one site, the whole of a team which spanned several disciplines were accommodated in one building. Staff there found this very advantageous: We’re all here together. We know each other well. We can all help each other with problems. I can talk to an expert at a moment’s notice. (occupational therapist) The exposure to other peer professionals in meetings also meant that, as some staff highlighted, it encouraged them to make sure that they carried out tasks they said they would because it would be embarrassing not to: There’s a subtle peer pressure. It’s helpful.
You feel you can’t turn up and say you haven’t done stuff. (speech and language therapist) Professionals with a keyworker role routinely said that it was part of what they would normally do and had always done in their existing role and for this 160 © 2005 Blackwell Publishing Ltd, Health and Social Care in the Community 13(2), 155–163 Multi-agency working Nevertheless, some barriers routinely remained between agencies and professionals. Community health staff at one service said doctors and consultants in acute settings were unapproachable and did not take account of their views.
In the same site, community social workers said there was insufficient dialogue with hospital social workers around the transition from hospital to home. Social workers in this site did not feel that their views were taken seriously by medical professionals. They also reported poor relationships and conflict with education staff who they did not feel were committed to join in multi-agency practice. Education was, in every service except one, mentioned as the agency with whom it was least easy to work with in multi-agency practice.
This was not a universal statement about education staff as a whole; many individuals within education were thought to be committed and helpful. However, the very clear statutory framework that education has and the fact that staff that know children best (teachers and classroom assistants) were generally unavailable to take part in meetings meant that education was perceived as the least accessible partner. Professionals in three sites reported difficulties in getting health as an agency to take an active interest and commit to the multi-agency project.
In one service, a senior manager felt that the emphasis on keyworking had focused on staff and services in the community and that hospitals were only just beginning to think about how to work in a more coordinated way. In this service, there were significant barriers reported in working with health. This was in part resulting from the restructuring of health authorities. There was criticism of a perceived intransigence of health to expand on their role to take on board a more co-ordinated approach: They [health] have been trained to work that way at the end of the day, they haven’t been trained to work in a multi-agency way. senior manager: education) better and more effective ways to coordinate support and services for families and to coordinate contact with professionals. For example, the team meetings in one service were routinely described by professionals as an effective forum for families to have their problems resolved promptly and efficiently. Professionals felt that their relationships were enhanced with families because they were offering more coordinated services. They said that working closely with families gave them clearer insights into the issues associated with having a child with complex health-care needs.
Professionals liked the fact that they appeared as a more coherent and professional team and felt that this would enable families to perceive that they were all working together towards the same goals. For some staff, however, this enabled them to present a united front ‘against’ certain parents: For difficult families it is useful for them to see that we all talk to each other – that they can’t play us off against each other. (senior manager: social services) The overwhelming majority of professionals in each site thought that the service was making a positive difference to families’ quality of life.
Whilst the difference was thought to be positive in that things were assumed to be better than they had been in the past, the change was not assumed to be significant for families’ quality of life: It’s not a significant difference to quality of life. More coordination of what is already happening. Families are not getting things they weren’t getting before. It’s just better coordinated now. It pulls things together and makes them more effective. (health visitor)
The most discernable difference was that children with complex health-care needs were having their health needs met in a home/community setting: I think you can see a marked difference in the deployment of services say from two or three years ago. (operational manager: health) Barriers remained between certain professionals and certain agencies. When we look at some of the literature on partnership-working this is probably unsurprising. Banks (2002) argues that it isn’t possible to assume that putting structures of multi-agency work in place will automatically lead to effective partnership and collaboration between professionals.
Banks also reports that in partnerships for particular groups, there may routinely be a ‘reticent partner’, i. e. an agency/partner who is less willing to play an active role and passes responsibility onto others. Impact upon work and relationships with families From the professionals’ point of view, they thought that the structures of their multi-agency services created Although, as discussed, professionals reported positive outcomes for themselves and their agencies, there were still concerns about whether it had worked as well for families.
In one service, it was felt that this absence of any additional funding for new or existing services meant that families’ expectations had been unfairly raised. It was not possible to deliver on the care plan written with and for families. There was also concern expressed by a small number of professionals about the absence of new or additional services. A senior manager reflected upon families’ disappointment about this: … plan upon plan upon plan but no actual difference in services and you can sense the frustration. (senior manager: education) © 2005 Blackwell Publishing Ltd, Health and Social Care in the Community 13(2), 155–163 61 D. Abbott et al. Conclusion The professionals that took part in this research were overwhelmingly positive about multi-agency working. The evidence in this study strongly suggests that multiagency working can have a positive impact on the working lives of professionals. Professionals said they enjoyed working this way and importantly, felt able to provide families with better quality coordination and relationships. Virtually all of the staff interviewed welcomed changes in their work practices relating to enhanced communication and better understanding of the roles of colleagues in other disciplines and from other backgrounds.
In terms of the specific group of children being supported by these teams – children with complex health-care needs – professionals from social services reported some anxiety about the marginalisation of their input whilst at the same time welcoming the opportunities afforded by the multi-agency service that they were a part of. It also proved difficult to engage with certain professionals within health settings who were seen as not prioritising ‘soft issues’ like multi-agency approaches to service delivery. Finally, teachers were regarded as missing from the picture given their classroom commitments.
It is interesting to note however, that professionals’ views on the likely impact on families was that the difference would be positive but not significant. We were struck by the assumption amongst some professionals that if their work lives were made more effective by multi-agency working, then positive outcomes for families would follow automatically. In a cautionary note, Banks (quoted in Snell 2003) writes that there is not always enough focus on ensuring that joint working results in positive outcomes for the people who are supposed to benefit.
However, the professionals involved in this study had accepted that doing something was very much better than doing nothing. They acknowledged that multi-agency working was challenging and that evidence of benefits would take time to achieve. However, in the meantime, and to their credit, they were prepared to take action, as opposed to continuing to discuss the difficulties and problems. As one social services manager summed up: We can’t talk about this any longer, we have to do it.