‘I have seen therapists being unwilling to share ideas with portage workers because of differences in levels of training. The portage workers characterised this as professional snobbery.’
In the September TAC Bulletin I made informal observations about a recent paper from England’s Council for Disabled Children, ‘It takes leaders to break down silos: CDC's new report on integrating services’. The paper had intended to identify the key factors enabling or hindering progress towards integration of services for children with SEND (special educational needs and disabilities). I argued that the paper had fallen short in this ambition by omitting disability prejudice as a hindering factor and omitting initial professional training in universities as a potential enabling factor. I also suggested that there should now be a serious effort to fully involve parents and family members in discussions to solve this long lasting problem of how to integrate health, education and social care.
In my informal observations, I said:
In my view, for a variety of conscious and subconscious, spoken and unspoken, logical and illogical reasons the generality of managers and practitioners are content to stay within the bounds of their discipline or training.
I now want to explore this particular hindering factor further using my experience of promoting integration in the UK and other countries. While the CDC’s paper seemed to exclude babies and pre-school children, I will try to be relevant to children of all ages who have disabilities and special needs ̶ the problems caused to children and families by fragmentation do not wait for the child to enter school.
Chief executives, senior managers, middle managers and practitioners all come with beliefs and attitudes. This is inevitable because they are people, not automatons. When it comes to joining their work with other people, these basic mind-sets come into play. Some people seem to be instinctively for integration; some are against. Some take strength from a collaborative effort; some would rather do their own thing in their own way. Some are confident in sharing their approach; others are not. Some are ready to embrace and consider all aspects of the whole child and of the family’s situation; some need to maintain a narrower focus to avoid being overwhelmed. Some feel integration is the fullest expression of their professionalism; some fear their professional standards will be compromised.
I have met all of these attitudes in my workshops, seminars and conferences. There are no angels or devils here, no good people and bad people. The only judgement I feel qualified to make is that a child and family who are suffering from fragmented systems will be left with unmet needs if the managers and practitioners around them persist in working separately from each other. The child and family’s situation can be made significantly worse when health, education and social care are not integrated into a seamless whole.
Having characterised some joint-working mind-sets in the way that I have, practitioners and managers at all levels in their service hierarchies can reflect if they wish on their present attitudes and actions in hindering or enabling integration. I have seen practitioners who collectively long for integrated systems and pathways but whose managers resist creating them. I have met managers who are frustrated by practitioners’ unwillingness to work together in multiagency and multidisciplinary teams. I feel there are some very basic attitudes and assumptions at play here, both conscious and subconscious.
While managers certainly have a key role in breaking down silos to promote integration, any new systems they create will surely fail if they have not acknowledged and addressed the valid fears, apprehensions and anxieties in some members of the of their workforce.
I will continue this discussion under three interconnected headings:
When managers and practitioners are asked to integrate their work with others, there can be some real or perceived threat to each person’s identity. Cake baking can illustrate these threats. Once a cake is baked, the flour, eggs, sugar and other ingredients have lost their identity as separate elements. They can no longer be found because they have merged into a new whole entity. In this illustration, the ingredients are the separate professionals and the cake is the resulting seamless support system once the ingredients are successfully integrated.
While it is clear the cake has demonstrable value, some professionals might resent the apparent loss of their separate identity. It can be that the child and family experience the best possible integrated support while some of the professionals who contributed to it are no longer very noticeable. This is true when therapists and teachers join their work together into a whole-child programme. It is particularly true when a child’s TAC (Team Around the Child) opts to work through a primary interventionist. In this model, one practitioner steps forward for a time to work with the child and parent while the others support that practitioner from a more ‘back seat’ position. In TAC, each practitioner has the choice of working directly or indirectly with the child. The primary interventionist model is a full expression of multidisciplinary integration but relies on practitioners being willing to be less visible in the interventions for the child. Some practitioners will be comfortable with this temporary perceived loss of identity and some will not.
Similarly, when chief executives and managers work with each other across agency boundaries to create local integrated systems, some will be more prominent in the end product than others. This is inevitable when joining various aspects of health, education and social care into a seamless pathway with a single point of entry. Some managers will be prominent in the operation of the pathway while others have a supportive role in how the pathway is designed and run. People who insist on being prominent might impede processes of integration.
Integrated services must come down in the end to practitioners working collaboratively with each other regardless of which agency or discipline they belong to. Their willingness or ability to do this cannot be taken for granted. Joint working depends for its success on relationships. The factors in this include:
Familiarity: People who already know each other and can relax to some extent with each other are more likely to be able to work together.
Empathy: Practitioners need to understand the work of others, to know something of their training, ethics and methods and of their aspirations and frustrations.
Respect: People who do not respect each other will not be willing to share their thoughts or approaches. I have seen therapists being unwilling to share ideas with portage workers because of differences in levels of training. The portage workers characterised this as professional snobbery. I have seen psychologists struggling to treat nursery workers as equals in discussions about a child although both have important contributions to make.
Trust: This can grow from familiarity, empathy and respect. Practitioners who do not trust each other will not work effectively with each other.
Additional important factors in this list must be ‘time’ and ‘training’. Time is needed to build these positive relationships. This must be included in the planning stages of new local integrated systems. When they are in place, teamwork around children provides on-going opportunities to build and grow these relationships.
I argued in my previous observation that initial training for health, education and social care professionals should include the topic of integration. Even better if this could happen in universities in which health, education and social care departments were integrated to some extent! This sort of training would set the scene for positive collaborative relationships across the disciplines. (My thoughts about relationships have been informed and supported by the work of Professor Hilton Davis. I recommend this essay of his.)
All of these comments about relationships to support integration apply to chief executives, senior managers and middle managers in a locality’s health, education and social care agencies. If managers do not relate with respect and trust to their fellow managers in the other agencies, how can they work with them to construct seamless integrated systems and pathways? By the same logic, voluntary agencies must be fully included so that they can take their place in the design and operation of local integrated systems.
Most professionals working in health, education, social care and the voluntary sector function in vertical hierarchies. This is how the western world is organised. In this verticality, each person knows who is above them in the hierarchy as their manager and who is below them as ‘underlings’. Chief executives at the top are themselves subject to rules set by boards or committees. At the bottom end of each hierarchy are people who are not managing anyone else and who are subject to the decisions of all people in the various layers above them. Power is held at the top and it filters down.
This arrangement breaks down when two, three or more senior managers from the local agencies get together to plan integrated systems and pathways for children with disabilities and special needs. They are operating now outside the bounds of their usual verticality and are of equal status in an unfamiliar flattened power arrangement. In my terms, they are now operating in a horizontal landscape in which some managers might feel more comfortable than others. These levels of comfort will increase or decrease when parent representatives are involved in the meetings.
The same applies to TAC meetings which are by definition both multiagency and multidisciplinary. The practitioners and parents treat each other as equals in horizontal teamwork. There can be no managers in this but one person can become the facilitator using leadership skills.
The senior managers in their multiagency meetings are working horizontally with each other with the task of creating a safe local horizontal landscape in which integration can flourish at all levels between health, education, social care, voluntary agencies and parent organisations. This is a massive task for managers which I have described in Horizontal teamwork in a vertical world.
The essential point here in response to the CDC’s paper is that each professional will have their own response to the idea and practice of horizontality. That individual managers and practitioners will feel comfortable with it cannot be assumed or taken for granted.
There is another aspect of integration that should not be ignored. In the field of childhood disability there is always a good supply of ideas, observations and theories. These can come from people with direct experience and from academics, philosophers and others. For the sake of the children and families we are all trying to support, it is essential to have processes that can integrate all this new thinking. This means that people working to promote integrated services must first integrate ideas and theories about integration so that they can start with a sound and harmonious theoretical base. These informal observations of mine are written in the spirit of integrating knowledge and ideas about integration.
In this second part I have suggested that while leadership is an important factor in enabling integration, service managers will not succeed in implementing new multiagency and multidisciplinary integrated systems if they do not explore, acknowledge and accommodate the many and various attitudes, doubts, anxieties, assumptions and aspirations of staff members in all levels of the local agencies.
I imagine there will be a third part to these informal observations. In the spirit of integrating experience, knowledge and ideas about integration, I welcome all contributions from family members, professionals and academics.
Peter Limbrick, October 2019
Limbrick, P. (2012) Horizontal Teamwork in a Vertical World: Exploring interagency collaboration and people empowerment. Clifford: Interconnections
Limbrick, P. (2018) Primary Interventionists in the TAC Approach: A guide for managers and practitioners supporting families whose baby or infant has a multifaceted condition. Clifford: Interconnections
The third part of these informal observations can be found here.