Grounds for optimism

Sedgefield is a relatively small place in County Durham best known for having Tony Blair as the local MP. It has a coterminous primary care trust and borough council, but social care responsibilities rest with Durham County Council. After a Best Value review in 2002, the local partners formulated an ambitious programme to bring together front-line staff across social care, community nursing and housing support for services for older people, and physically disabled adults. These previously disparate groups would be co-located, working to a single manager and using one electronic database.

Most of the research into inter-professional working is pessimistic about what can be achieved. Three elements of this “pessimistic tradition” have been identified:(1)

  • Professional identity: people are socialised into a profession in such a way that they adopt a “professional identity” that serves to limit understanding of the views of other professions.
  • Professional status: joint working is difficult where there are perceived status differentials between team members.
  • Professional discretion: the inherent uncertainty of the professional task means that people protect their freedom to act autonomously rather than work collectively.

    These factors have helped to explain many of the dismal findings on integrated working and have even led to some scepticism as to whether the integration agenda is realistic. The requirements are certainly daunting and include the sharing of knowledge, respect for the individual autonomy of different professional groups, the surrender of professional territory and a shared set of values. The Sedgefield integrated teams programme has rigorously put the hypothesis of whether this can be achieved to the test.

    After the successful introduction of a pathway team, there are now five such teams covering the Sedgefield area, and a lengthy evaluation has been undertaken.(2)

    Perhaps the most fundamental point to make is that the findings are positive: team members function together effectively and users appreciate the service. The evaluation identifies three key features of the team activity:

  • Parity of esteem: none of the team, including the support staff, saw themselves as having higher status or importance than the others.
  • Acceptance of the judgement of others: mutual respect among team members for each other’s contribution.
  • Reorientation of professional affinity: team members often felt greater affinity to the new team than to employing bodies or professional affiliations.

    Four improved ways of working were identified: understanding (more understanding of each other’s roles and responsibilities); speed (undertaking interventions more quickly): flexibility (a willingness to “bend” professional boundaries); and creativity (tackling problems in a fresh way).

    These findings contradict the pessimistic tradition. The key issue that has allowed this to happen is the willingness to take a whole-system approach to transformational change.

    In the case of Sedgefield these interventions took place at four levels and added up to a classic illustration of the processes needed for transformational change. These are: a leadership process whereby a partnership board defines the issues on which stakeholders should work with representation from senior officers, members, users and carers; a design process, so that a design team is created consisting of middle managers from across the partner agencies to develop the structures for addressing these issues; a logistic process to create a range of work streams, bringing together kindred colleagues to work out the detailed operational implementation of the design; and a consultancy process to ensure there are dedicated staff with the right

    None of this comes cheap – between 2003-4 and 2007-8, more than 3m is being pumped into the programme. However, much of this consists of money that would have been spent anyway but in silo mode, and the partnership could also access pump-priming funding from the neighbourhood renewal fund and the Workforce Development Confederation. But whether the new arrangements will be more cost-effective in the longer run is difficult to judge.

    It would be wrong to create the impression that developing the Sedgefield integrated teams has been a consensual love-in.

    First, there has been tension around the edges of the integration remit: what is in and what is out? As noted, social care, district nursing and housing support is in, but this has still left some uncomfortable interfaces, notably with mental health services for older people, occupational therapy, learning difficulties and acute services. In all these cases the tension is between one model based on integration and localisation and another based on centralisation and specialisation. A different problem arose in services for children and families where a localised and integrated model was being adopted but was developing along parallel tracks.

    Second, integration poses a threat to established ways of working. As already seen, the potential threats to professional norms and judgements have not materialised and the threat to established terms and conditions has been insignificant.

    But the Sedgefield experience suggests that transformational change is possible, even when some important variables are not favourably disposed. It makes it possible to formulate a new “optimistic” model of integrated working with the following hypotheses:

  • That members of one profession may have more in common with members of a different profession than their own.
  • That the promotion of professional values to service users can form the basis of inter-professional partnership.
  • That association to an immediate work group can override professional or hierarchical differences among staff.

    Yet the biggest threat to the Sedgefield programme now comes not from local sources but from the government. First, by setting separate rather than integrated performance targets – investing in partnerships can easily lead to a lower organisational performance ranking with difficult consequences. Second, by creating such an unstable infrastructure that hard-won gains are put at risk – in Sedgefield, for example, the PCT will be abolished under proposals.(3) Finally – as a speech to the Social Market Foundation by John Hutton, now work and pensions secretary, made clear(4) – the government is now prioritising choice and competition over collaboration.

    It would be a cruel irony if, having achieved the holy grail of local integrated working, the government, with Sedgefield’s local MP at its head, now puts in place measures that result in its dismantling.

    Bob Hudson is visiting professor of partnership studies in the school of applied social sciences, University of Durham. He is also an adviser on partnership and integration issues to the House of Commons education and skills select committee.

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    The author has provided questions about this article to guide discussion in teams. These can be viewed at and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.

    The record on front-line integrated working is not generally optimistic. This article reports on the findings of an evaluation of the Sedgefield integrated teams programme by Bob Hudson which has involved co-locating social workers, district nurses and housing support officers in neighbourhood teams under single management. It argues that the positive results stem from taking a whole-system approach to change, and proposes a new “optimistic” model of inter-professional working.

    (1) B Hudson, “Interprofessionality in health and social care: the Achilles’ heel of partnership?”, Journal of Interprofessional Care, 16[1], 7-17, 2002
    (2) Five reports on the Sedgefield integrated teams evaluation have been produced. Full and executive versions are available from
    (3) Department of Health, Commissioning A Patient-Led NHS, 2005
    (4) J Hutton, “Public service reform: the key to social justice”, speech to the Social Market Foundation, 24 August, 2005

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