Title: Developing Multi-professional Teamwork for Integrated Children’s Services
Authors: Angela Anning, David Cottrell, Nick Frost, Josephine Green and Mark Robinson
Institutions: The research was based at the University of Leeds and was funded by an independent body, the Economic and Social Research Council. The research team was multi-disciplinary in terms of professional backgrounds, being drawn from health, including child psychiatry, education and social care settings
Available: The research is published by the Open University Press, 2006
This volume provides one of the few accounts of multi-agency and multi-disciplinary work in the context of services for children and families. It looks in particular at multi-agency teamwork for children’s services (MATCh) teams, spanning the statutory and voluntary sectors.
The activity of the five teams covered youth crime, child mental health, special needs nursery, neuro-rehabilitation and child development. The research team set out to describe and explore the daily realities of practice in these teams. These included: how they made decisions and managed conflict the relationship of different spheres of professional knowledge in the teams and the extent to which new knowledge came out of these collaborations. Finally, the authors sought to identify the exemplars of good practice.
A key strength of this study is that the authors undertook this research within a clear and explicit theoretical framework. They drew upon the work of the social psychologist Wenger who argued that, when professionals worked together effectively, they could begin to develop a “community of practice”. The features of such communities include mutual engagement, shared accountability and a shared perspective from which to understand, (in this case) work with families.
When professionals from different backgrounds worked together they learned together and could form new professional identities. The authors related this to Engestrom’s “activity theory”. Engestrom argued that integration inevitably resulted in conflict between individual and groups of practitioners, as professional tasks were re-assigned and redefined. He argued that this conflict can be managed only if these different ways of working and ideas about professional practice are debated and resolved in an open and non-defensive manner and acknowledged as an important part of the process of change.
The researchers focused on this process of change and sought to understand how teams function. Although the outcomes and impact of services are crucial, the primary focus was on the experience of professionals working in these services.
Various methods were used to collect data. Documentary material was examined from each team and there were also observations of team meetings. One-to-one interviews were carried out with team members from different disciplines and “critical incidents” were examined. These included “emergencies” where the authors noted that multidisciplinary teams were tested in a way that was not the case with ordinary work routines. They therefore provide a valuable insight into the dynamics of these teams and how they resolved such difficulties.
The move towards the integration of children’s services has been at the heart of the reforms introduced by Labour over the past 10 years. Inspection reports, research findings and the conclusions of inquiries consistently highlight the danger of fragmented, unco-ordinated services.
This lack of co-ordination can lead to serious breakdowns in individual cases and can undermine progress towards improving the outcomes for vulnerable children. Every Child Matters and the Children Act 2004 created the infrastructure for the integration process that has included the formation of children’s departments, children’s trusts and specific initiatives such as the lead professional and common assessment framework. The creation of the Children’s Workforce Development Council has sought to bring a sense of realism, unity and coherence to the children’s workforce.
Many practitioners have welcomed the move toward more “joined-up working”. However, the complexities and difficulties that can arise in the process of integration and partnership working between agencies can be underestimated. There has been debate reflecting the different perspectives on what constitutes a vision of integrated working and what priorities should drive service design and delivery.
Angela Anning and her colleagues acknowledge and explore this complexity. They first recognise that language must be used precisely. Terms such as multi-professional, inter-professional, interagency, multi-agency and multi-disciplinary tend to be used interchangeably. However, they all have different meanings that can reflect different models of integration. From looking at different teams they constructed a series of organisational typologies. These can be seen along a continuum of integration, with professionals organised into fully integrated teams and co-located with a unitary management structure at one end, and much looser networks of professionals lacking a formal team structure at the other. The authors state there is no conclusive evidence for the design of an “optimum model”.
Neither this study nor the national evaluation of Sure Start provide a “magic solution” and the researchers argue that different organisational models will be appropriate in different settings. But they make a strong case for co-location of professionals.
However, they caution against merely siting workers together in one building and then expecting integration to occur automatically. Drawing on activity theory, they argue that this process can occur only if there is an explicit leadership strategy in place. In addition, this process must acknowledge the different roles and perspectives of professionals and ensure that a hierarchy of professional status does not develop. The risk is that such a hierarchy can result in some professions being seen as “expert”, such as psychiatry or psychology, while early years or youth work are perceived as relatively less skilled. Social work may end up sitting uneasily in the middle.
Such a hierarchy can also find expression in more mundane issues, including levels of pay and annual leave, and opportunities for training and development. Beyond this, there can be major differences in the degree to which practitioners can exercise professional autonomy in decision-making. These factors can be compounded when some workers are part-time or spend significant periods in other teams. Effective leadership in integrated teams therefore needs to recognise the reality of these differences but in so doing attempt to ensure the contribution of all practitioners is equally valued.
In the last analysis, however, the diversity of professional values and identity in teams can have more influence than differences in employment conditions. Anning and colleagues argue that what underpins the challenges of integrating services for children is managing the different conceptual frameworks that underpin practice. A police officer, social worker, psychiatrist and teacher, for example, will all construct an understanding of the well-being and needs of children and young people in very different terms. This diversity can be reconciled and positively exploited within the framework of the five Every Child Matters outcomes.
But practitioners and managers need to ensure that both the medical and social models complement one another. They do not need to reinforce a hierarchy of technical and professional credibility. On the basis of some of the exemplars highlighted in their research, Anning and colleagues argue that integration can take place at a conceptual as well as procedural level, helping to develop the “communities of practice” envisaged by Wenger. Such communities of practice not only enable the successful implementation of multi- professional and multi-agency work but can also lead to the development of innovative and creative models of practice with children and their families
Developing local practice and procedures
When developing and implementing local policies and procedures Anning and colleagues stress the importance of involving practitioners and mangers from all participating agencies. This pooled expertise is itself key to integration but is also important in terms of developing a shared sense of ownership of practice. If there is a perception of a dominant agency or discipline imposing practice this will undermine collaboration. Local practice also needs to be constructed in such a way that integration takes place within a structure and each practitioner is clear about their specific role and responsibility.
The process of integration is complex and needs careful management. Above all, the management of the process needs to convey a strong sense of a vision which professionals from all backgrounds will buy into and be inspired by.
Valuing all team members
The strength of integrated needs is their diversity. However, this also creates tensions that even co-location in itself will not overcome. Structures need to value both core and peripheral members of teams and services to achieve a balance of promoting integration and the unique contribution of each practitioner. This is a challenge not only to mangers but also to those who inspect services. The research argues that the teams that carry out these inspections should also be multi-disciplinary.
Awareness of the impact of change on service users
As services undergo complex and, at times, stressful reorganisations, it is easy to lose touch with the experience of the client of the service being delivered. Also, both this research and other studies reinforce the importance of consulting clients about the form services should take and how they can be delivered more effectively. Service-user involvement is not supplementary to service development but should be central to it.
James Blewett is attached to the Social Care Workforce Research Unit at King’s College, London
Links and Resources
● The National Evaluation of Sure Start has been the biggest such evaluation and as such offer much rich material on the process of integrating services. For further information see www.ness.bbk.ac.uk
● The evaluations of the pilot children’s trusts and the common assessment framework are also helpful in terms of recent findings on what are the most effective models of integration. They were both based at the University of East Anglia, further details of which can be obtained at www.everychildmatters.gov.uk/strategy/nect
● A recent CWDC commissioned report, A Scoping Study of the Family Support Workforce (Tunstill, Thoburn and Tarr, 2007), also provides useful insights in this area www.cwdcouncil.org.uk/projects/index.htm
This article appeared in the 26 July issue under the headline “The challenge for partnerships”