Integration in north east England: Durham learning disability services

Partnerships are at the root of modernisation. But what about the next step – integration? Commissioning manager Tracy Joisce tells Sarah Wellard how it is working in the North East

Curriculum vitae

Name: Tracy Joisce.
Job: County-wide commissioning manager for Durham learning disability service.
Qualifications: DipSW and MA in Social Work from Salford University
Last job: Team manager, North Durham integrated learning disability team.
First job: Care assistant in a nursing home force.

In Durham, learning difficulties professionals have been working in multidisciplinary teams since 2001. Tracy Joisce, county-wide commissioning manager for learning disabilities says: “In many respects we pre-empted the Valuing People white paper because of concerns in the county. We were ahead of the game on person-centred planning and designing services around the needs of individuals who were being moved out of big institutions.”

In the early days, while social workers, nurses, occupational therapists, behavioural therapists and speech and language therapists were based in the same buildings, they were far from working as fully integrated teams. “We were co-located but we were still separate. We weren’t even all sitting together. When I said I wanted to mix everyone up there was resistance. But people say how much better they work together. The dynamics of the service have changed and staff now support each other.”

Joisce makes no bones about that fact that saving money through more effective use of resources was imperative. “More disabled people are coming into the service and their level of needs is increasing. Nurses in particular weren’t used to considering how much they spend and working within limited budgets.”

At first nurses were reluctant to spend less time doing core nursing work. “We had to teach them how to work with eligibility criteria and to understand why targeting is necessary. But now they are taking on a holistic commissioning role and we’re using resources much more effectively.”

Aside from saving money, Joisce says that integrated teams make for better communication between professionals and a more responsive service for users. “If a person’s behaviour becomes more challenging, a service provider is likely to ask for extra money to move from one-to-one to two-to-one support. But throwing money at the problem might not help. It could actually make things worse if the person feels they’ve got two people following them around. A better response might be to bring in a behavioural therapist to work alongside the support workers.”

Because the behavioural therapists are now part of the integrated teams, managers find they can respond quickly to prevent problems escalating.

Bringing together professionals from different services and working cultures presents enormous challenges. The health professionals remain health trust employees while social care staff are employed by the council. Leadership for everyone in the team except psychologists and psychiatrists is provided by social care. The team has worked together to develop joint supervision and appraisal mechanisms to support integrated working. Joisce observes: “This was an issue for us. We had to have one system.” She organised an away day to let people develop their own performance profiles, based on the model being used in health. “Social care staff could see that it could work for them. Health care staff felt we were trying to bring in something positive about their service, and helped redevelop it so it could be used for social care.”

Getting psychologists and especially psychiatrists on board has been particularly challenging, as the new way of working represents a radical departure from the traditionally dominant position enjoyed by consultants within the health service. In Durham, both groups of professionals remain managed by health, but are now very much part of the integrated teams. Joisce believes the progress achieved has been to a large degree down to the excellent working relationship she enjoys with senior management in health. She adds that peer support and leadership within the county have also been important.

Joisce doesn’t claim that integrated teams are a panacea and at the moment the council is reviewing the way the teams are working. A possible outcome of the review is fewer integrated teams with additional specialist teams to provide more time for therapeutic work, or there may be no changes at all. Even so, the benefits for people using the service are clear. “Carers tell us that there aren’t so many different professionals coming in. They now have a single worker who is their care co-ordinator and they are getting a more consistent service.”

TOP TIPS
● Staff need to feel they have influence but be clear that some things are non-negotiable.
● If you say you’re going to do something, make sure you achieve it.
● If something isn’t working, look at it again.

RUBBISH TIPS
● Joint working is just a matter for professionals – you can forget about the other stakeholders.
● Expect to see rapid results.
● The most successful changes cost a lot of money.