Collaborative Working 21 st April Working with Adults Rob Goemans

Objectives To look at some of the common themes running through current policy that promote partnership working To look at some examples of partnership working To consider some of the barriers in the way of working effectively together To consider the important ingredients of effective collaborative working

Quality assurance agency: Subject benchmark statements Contemporary social work commonly takes place in an inter-agency context, and social workers habitually work collaboratively with others towards inter-disciplinary and cross-professional objectives Honours degree programmes should, therefore, be designed to help equip students with accurate knowledge about the respective responsibilities of social welfare agencies and acquire skills in effective collaborative practice between these.

What is it? Collaborative working Working in partnership Multi-disciplinary teams (MDT) Inter-disciplinary working Joint working

Partnerships between? Providers & users Health & social care Statutory & voluntary Commissioners & providers Policymakers & services Health & mental health Different age based services Different geographically based services Different professions within same teams

Policy OHOCOS, 227 pages – Partnership96 – Integrated110 – Social in/exclusion18 – Mental health72 – Independence184 – Choice141 – Inequality45 – Social work18 – Nurse67

Our Health, Our Care, Our Say, 2006 Health and social care working together in partnership The majority of this White Papers proposals for local authorities are about better partnership working with stakeholders to deliver more effective services, while also achieving better value for money from existing resources. Good partnerships are built on common aims.

Our Health, Our Care, Our Say, 2006 Good partnership working requires clarity about what each partner will contribute to joint work towards agreed targets and goals, and mechanisms that help them plan to achieve them. People with complex needs require an integrated service, involving support from both health and social care professionals.

Putting People First, 2007 Ultimately, every locality should seek to have a single community based support system focussed on the health and wellbeing of the local population. Binding together local Government, primary care, community based health provision, public health, social care and the wider issues of housing, employment, benefits advice and education/training. This will not require structural changes, but organisations coming together to re-design local systems around the needs of citizens.

Darzi report, 2008 The duty is based on a formal assessment of peoples needs developed between primary care trusts, local authorities and other local partners, including police authorities and local hospitals, to tackle the most important factors in improving health. These plans focus not only on tackling clear health priorities such as smoking, childhood obesity and teenage pregnancy, but also on broader factors such as poor housing, education, local transport and recreational facilities.

Darzi report, 2008 Partnership working between the NHS, local authorities and social care partners will help to improve peoples health and wellbeing, by organising services around patients, and not people around services. This will lead to a patient-centred and seamless approach. This is important not only for people regularly using primary, community and social care services, but will also help peoples transition from hospitals back in to their homes. It will also reduce unnecessary re-admissions in to hospitals.

Older Peoples NSF: Standard 3 The NHS Plan set out a major new programme to promote independence for older people, through developing a range of services that are delivered in partnership between primary and secondary health care, local authority services, in particular social care, and the independent sector. One of the critical elements in this programme is to develop new intermediate care services.

New Horizons, 2009 only a robust partnership across the public, private and third sector working with local people will deliver the necessary change to improve mental health and wellbeing for individuals, families, carers and communities of all ages and backgrounds.

Examples of collaborative working Within one organisation – MH partnership trusts, CMHTs – Phys. Dis. teams Between similar organisations – MH liaison teams in A&E – Primary care Between different organisations – private sector/NHS joint tendering – YOT teams, MAPPA, adult safeguarding boards – SAP, CHC, ICS – Embedded housing workers

Partnerships for Older People Projects (POPPs) A two-year programme led by the Department of Health with £60 million ringfenced funding for local authority- based partnerships to lead pilot projects to develop innovative ways to help older people avoid emergency hospital attendance and live independently longer. The overall aim is to improve the health, wellbeing and independence of older people For every £1 spent on POPP, an average of £0.73 is saved on the cost of emergency hospital bed-days. People using the services see their quality of life as improved. The POPP programme appears to be associated with a wider culture change within their localities, with greater recognition of the importance of including early intervention and preventative services focused toward wellbeing.

Mental Health Section 31, Health Act, 1999 Section 75, NHS Act, 2006 – Pooled funds - the ability for partners each to contribute agreed funds to a single pot, to be spent on agreed projects for designated services – Lead commissioning - the partners can agree to delegate commissioning of a service to one lead organisation – Integrated provision - the partners can join together their staff, resources, and management structures to integrate the provision of a service from managerial level to the front line

Section 75 Partnerships Who can be involved? – Health bodies, such as strategic health authorities, NHS foundation trusts, NHS trusts and primary care trusts, together with any health-related local authority service such as social services, housing, transport, leisure and library services, community and many acute services. How will this help improve services? – The aim is to enable partners to join together to design and deliver services around the needs of users rather than worrying about the boundaries of their organisations. These arrangements should help eliminate unnecessary gaps and duplications between services.

Next 8 slides courtesy of Ruth Allen

Models of integration #1 ditch and run! Local Authorities gave mental health over to the NHS and got the hell out!

Models of integration #2 the narrow funnel TRUST COUNCIL HR/ INVESTIGATIONS/ COMPLAINTS/FIN ANCE/ GOVERNANCE/ STANDARDS/ KPIs.…

Models of integration #3 tug of war

Models of integration #4 amicable divorce Emerging models of de-integration: Prompted by… e.g. – Safeguarding concerns – Budget management and pressures – LA Dissatisfaction with community care planning – Personalisation challenge Risks e.g. – Maintaining seamless services? – Managing risk across service and information systems? – NHS no longer pressured to become more socially focused – Bad feeling

Models of integration #5 solid partnerships Full devolution to Trusts: ie TUPE, full budget devolution/pooling, joint commissioning, LA performance management Interwoven systems: ie 2 systems working in close harmony, seconded staff, variety of budget management arrangements and commissioning, partnership problem solving

New forms of integration Improving mental health outcomes is about the whole system – Health care: specialist and other – Social care across the spectrum – Welfare benefits – Housing – Education – Community organisations – Business and employment – Citizens

(ADASS, Mental Health, Drug and Alcohol Subgroup 2008, Into the Mainstream p 5) Over the last decade, many Councils have devolved significant areas of mental health commissioning and service provision responsibility to NHS organisations – increasingly mental health has been seen as a health issue... we believe that social cares retreat from mental health has gone too far and that we need to re-assert the connections with the wider local government agenda and Local Strategic Partnerships so that people with mental health needs can have better access to housing, education, work, leisure

Ingredients for a successful social work and social care workforce - Clarity of role and purpose -Commitment to practice excellence rooted in human rights, equalities and distinct skills -Understanding of the evidence base -Good quality management -Practitioners willing to innovate and be flexible -Staff feeling valued and appreciated -Career and practice advancement structures -Leadership

How do you do it? Knowledge of professional roles Willing participation Confidence Open & honest communication Trust & mutual respect Power Conflict Support & commitment at a senior level Professional culture Uncertainty Envy Defences against anxiety – Barrett & Keeping, 2005

How do you do it? Define roles & boundaries Be aware of power dynamics Taking decisions Different professionals have different views Input from service users – Payne et al, 2005 (Comm. Care 27/10/05)

Barriers to collaborative working Defining roles & responsibilities Developing skills for effective collaboration Working with people from a range of social & professional cultures & backgrounds Differences in terms and conditions Adapting to a new organisational culture Working with new systems & processes – Quinney, 2006

Problems Collaborative advantage v collaborative inertia Conflict v challenge Soup v salad

Is it working? (CSCI, 2009) Joint working arrangements with health and other partner organisations are seen as a strength in one-third of councils but as an area for improvement only in three. In councils judged as excellent or good there is evidence that development of intermediate care services is helping prevent admissions to hospital and maintain low levels of delayed discharges.

The great majority of councils have partnership agreements in mental health (81%), learning disabilities (85%) and integrated equipment services (94%). Just over half of councils (53%) have agreements for older people with mental health needs and delayed transfers of care. Councils with adult social services responsibilities are the predominant leads for learning disabilities and equipment services, and NHS agencies for mental health. The lead on delayed transfers of care is more equally shared.

Coordinating services and taking an effective whole-person approach to support people with multiple and complex needs was challenging for all the councils in this study. Although there have been steps to improve the transition from childrens to adult services for people with multiple and complex needs, some of the key agencies (particularly health) tend to take a very rigid approach at odds with the personalisation agenda.

People with multiple and complex needs frequently have needs that cross established professional and organisational boundaries. A CSCI inspection report noted that 10 agencies and carers had been involved in one project for people with high support needs. Developing an effective whole-person approach to support people with multiple and complex needs proved to be very challenging for all the councils in this study. Several key boundaries were identified: at the transition from adolescence to young adulthood; between adult social care and the NHS; and between individual budget income streams.

The problematic area is getting the involvement and commitment from health colleagues around anyone moving from childrens services into adult services. They have different criteria that Im still not clear about. It just all works so differently. There is now an expectation that we will contribute. The standard formula is 30% from social care and 20% from health if the person has a significant health need. We pay but some authorities dont.

Given the high cost of supporting people with multiple and complex needs, it is unsurprising that where disagreements arose they tended to be about funding. …Typically, Continuing Healthcare was reported as an area of ongoing contention: There is a real steer coming from the SHA saying that people with learning disabilities probably generally wont be eligible under CHC. I find that bizarre and we will be resisting that manfully. Thankfully we now have a little more consistency since the National Framework was introduced. Prior to that it was a nightmare, an absolute nightmare. But a lot depends on each nurse assessor team. You can have very different types of people, sometimes leading to very different types of working relationships and different decisions.

Carpenter et al, 2003 Integration showed little effect on professional identification Staff in integrated & non-integrated services identify with team rather than with profession Social workers: – Identified less strongly with profession – Perceived teams as less participative – Experienced higher role conflict and stress

Conclusions As problems are viewed more holistically, interventions need to be provided by a wider range of services working closer together Economic downturn requires efficiencies to be made, services can be provided cheaper by organisations working together Tendencies for defensive practices and loss of professional identities need to be avoided through strong leadership and cultural change