As the government presses ahead with its agenda of permanent revolution for health and social care services, breaking down the proverbial Berlin Wall between the two has emerged as a key theme. Staff have been left in no doubt that old professional rivalries must be cast to one side as joint working is now the name of the game.
But so far much of the emphasis has been on structural change – the sort of reorganisation that is attractive for politicians as it can be set up relatively swiftly and makes it look as if they are doing something. But there can be a tendency to neglect the importance of building partnership working on a firm foundation which addresses deeper issues such as the cultural differences between professions.
Social workers and nurses are a case in point. They are members of two tribes and they speak a different language, so is it any wonder there is trepidation on both sides when they are told they must work together?
Joint training obviously helps but setting that up for pre-qualification students has proved problematic and, even for qualified staff, provision is patchy.
Bob Hudson, principal research fellow at the Nuffield Institute for Health at the University of Leeds, says even where there has been joint training there is a tendency for people to retreat into their organisational cultures when they are back among their own. And those that do try to embrace joint working, for example by going to work in a primary care trust, are sometimes seen by their former colleagues as “going native” and abandoning their professional values.
“The record so far on joint working is not impressive,” he says. “Interprofessional relationships have either been ignored or assumed to be better than they are. It’s a real problem.”
Hudson has studied the differences in values and approaches between community nurses, social workers and GPs. Although he found consensus on opposition to institutional settings and a high commitment to issues such as joint assessment and working in the same building, on deeper investigation there were rifts.
He says: “Perhaps the most striking was that each of the three groups were convinced that they were the ones best placed to view the client holistically. Social workers, nurses and GPs seem to find it difficult to complement each other.”
Part of the solution must be to build mutual trust and respect. But social policy analyst John Eversley fears there is too much “naivety” over the difficulties this involves. “There seems to be a lack of understanding over just how much thought needs to go into developing shared values, processes and structures.”
He believes that although there is great emphasis on “collaboration, co-ordination, and co-evolution” the issue of competition is often overlooked. “But it should not be underestimatedÉpeople don’t always see their interests as coinciding.”
Penny Banks, fellow in health and social care at the King’s Fund, says there is not enough focus on ensuring that joint working results in a positive outcome for users and clients. “All the effort goes into setting up teams and sometimes you can lose sight of whether they are delivering a truly integrated service along the lines of what the client wants.”
But Paul O’Halloran, director of practice development and training at the Sainsbury Centre for Mental Health, and a clinical psychologist by background, is optimistic about the future.
“We have come from a tradition of being isolated, competing professional groups to a new world of working in teams in the community. It’s an uncomfortable time of change but we have more in common than we do differences. A lot comes down to forging good relationships, but the lack of shared learning is feeding a clash of models.”
Carol Glendinning, professor of social policy at the national primary care research and development centre, University of Manchester, says: “Some of the barriers are to do with professional anxieties and staff feeling threatened. This can be an issue where social care professionals are in a minority compared with health staff. So schemes such as awaydays where social workers and nurses can find out more about each other’s jobs are helpful.”
Her centre evaluated the first pilot sites using flexibilities under section 31 of the Health Act 1999 and found that those who had had the most success had opened up training opportunities to all staff so they came to view integration as helping to broaden their career options.
The researchers also found that none of the first sites that were trying to create integrated organisations were fully successful within the first two years.
“This was often due to nitty-gritty problems around transferring terms and conditions to one employer,” says Glendinning. “There was a tendency to second staff instead but that can be messy as you end up with a team working together but on different terms and conditions.”
But secondment is a step on the road and there are more than 200 sites using flexibilities under the Health Act as well as five care trust demonstration sites plus other proposals including new children’s trusts.
The optimists believe the likes of community nurses could become key allies with social workers in the same way that primary care trusts could help forge an alliance with social services in countering the dominance of the acute sector.
But it is clear that many of the issues around closer working between the professions, such as client confidentiality, problems with information technology, workloads and lack of funding remain unresolved. Meanwhile, somewhere in the middle of all this are the service users.
How mental health does it
Mental health is said to be the area that has made the greatest strides towards integrating health and social care. Helen O’Neill, approved social worker and practice supervisor with the community mental health team for Brighton and Hove, outlines how she and her colleagues tackled some of the hurdles.
“One of the big issues for us is preserving people’s professional identities. We have nurses supervising social workers and I supervise three community psychiatric nurses (CPNs). So that has to be handled sensitively and we have set up a mentoring scheme to ensure it is. “We have a monthly professional development group for all members of the team where they can discuss cases in detail. And then we have other professional development meetings just for social workers or just nursing staff because there are separate issues to consider like different statutory responsibilities.
“The reality is that professional ideas in nursing and social work are coming together but the whole thing stops short of generic mental health workers as that would be a step too far. There are some tensions around issues such as the fact that social care staff don’t do depot injections or the suggestion that CPNs should be able to section people. But in general everyone is much more open to the whole idea of joint working and integration.
“Small changes make a difference. When I started the CPNs had their own office but now we work in a mixed office and that helps cement the feeling of being part of the same team.
“In multi-disciplinary working you get away from the idea of ‘this is my responsibility, that is your responsibility’. We work co-operatively and have shared clients and shared agendas and we see ourselves as all working together for the benefit of clients.
“In the past CPNs would monitor people’s medical condition and social workers would handle issues such as benefits or housing. But now we take a much more holistic approach.
“The fact is joint working is happening because the government wanted integrated teams and one point of contact for clients.
“The team here is new and enthusiastic and they don’t have any hang-ups about it though I know other people do. But we are evolving all the time and all I can say is, in our experience, this way of working is benefiting practitioners and service users.”
The district nurse’s story
A district nurse chose to move from the acute sector to primary care as she felt she could no longer deliver the quality of nursing care she had been trained to give, writes Charlotte Alderman.
Her caseload includes people with intractable wounds and severe health needs. With shorter hospital stays, more patients are being discharged into the community, which requires more acute technical care.
She believes this has implications for the district nursing service and presents social services with an even bigger problem.
“In the past few months I’ve come across cases where patients desperately needed social care but it couldn’t be provided because of lack of care staff,” she says. As a result, the district nurses have often taken up the slack as they have with occupational therapy. “There’s a long waiting list so district nurses have been going out and assessing patients and ordering basic equipment such as grab rails.” District nurses have traditionally acted as “sponges”, absorbing elements of other people’s roles, she says. “It just hides the problem so it never gets addressed. The NHS is classic for running on goodwill. Nurses don’t jump up and down and district nurses are even worse because they are geographically separated and they don’t have a collective voice or even a clear idea of what their role is.”
She receives many inappropriate referrals which eat into her working time. “And once you put your name on a referral it just bounces back to you. I have to say quite strongly sometimes that it’s just by chance that I got that referral.”
There is no regular contact between the district nurses and social workers, she says – it is purely an ad hoc arrangement. “If a patient has complex health and social needs I’d contact social services informally and ask whether they want to do a joint assessment or say I’ll do the assessment and let them know what’s needed. Where a patient has a lot of needs then it is to be hoped we’d work together.”
This “faceless bureaucracy” contrasts with her previous experience working on a rehabilitation ward for older people, where she had more face-to-face contact with her social work counterparts. But there were still frustrations.
“Social workers work in a different way from us and in a different system,” she says. “Even then, when working together, there is still that divisiveness of health and social care being separated. You’d agree a plan and then nothing happened and the patient was still sitting on the ward for another week. Sometimes the social worker hadn’t been able to organise a package of care and sometimes they hadn’t had time to sort that case out.”
She adds that she is sympathetic to the lot of social workers and believes charging social services departments for delayed discharges could cause an even wider division.
“I think they are under-resourced and understaffed,” she says. “I’m sure everybody is knocking on their door saying they need care urgently and social services just haven’t got the care staff or access to care agencies. I don’t think they have any choice but to be reactive. But even in crisis cases they sometimes can’t mobilise the care.”