Defining integration and integration working
Percy-Smith (2005) defined integration as agencies working together within a single, often new, organisational structure. The Integrated Care Network (2004) defined integration as a single system of service planning and/or provision put in place and managed together by partners who nevertheless remain legally independent. But it also observed that the term integration can mean different things to different people and that there is a lack of clarity about its meaning (Integrated Care Network 2004). While integration of public services has been a priority of the UK government during the past decade, most initiatives have focused on building better collaborative relationship between professionals and agencies, ensuring seamless services, providing more effective partnerships and also for supporting learning-disabled children, providing care to aged persons, young offenders or vulnerable children (Sloper 2004). Conventional care or support systems were found to be inadequate in meeting such special needs of underprivileged communities. Atkinson, Wilkin, Scott & Kinder observed in 2001, after a detailed study of multi-agency activities, that providing effective services, responding to special needs of target groups and improving joined-up working constituted the major aims of such activities in local government.
Various authors define and describe integrated working in various ways. Thus, Thistlewaite (2004) describes integrated working as a single system for assessing needs and the commissioning and/or provisioning of services. The Children’s Workforce Development Council or CWDC (2008) defines the same as an arrangement in which those supporting young people and children work together towards effectively prioritising the needs of the target community and help it effectively attain end-results as also improve the lives of the children and young adults. Essentially, such arrangements are driven by the need to assess the requirements of children with complex needs and help them achieve better outcomes through improved participant and user focus, and better coordination and collaboration across functional services and between participatory services and agencies. An integrated working arrangement attempts to achieve positive outcomes through better partnership among stakeholders and such a system is both flexible in arrangement as well as retains some amount of autonomy for the partners. The common work arrangements are composed of various service layers, functional units, agents and collaborators, all of which are better coordinated through the integrated working system. Such an integrated work arrangement can better facilitate the attainment of the diverse objectives of the different functional parts of an organization and work towards achieving the overall organisational goals. It can also facilitate better alignment of organisational policy, better training of workforce, an improved child care system, and an innovative but effective education system, but can also help organisational management across diverse fields achieve efficient and effective activity outcomes.
Integrated Working: the various models
Integration, partnership working, joint or joined-up working, inter-agency or multi-agency working, multi-professional or inter-agency communication, intra or inter organisational collaboration as well as collaborative working are the terms often used for discussing integrated working (Percy-Smith 2005, Sloper 2004). The Scottish Office (1998) defined and adopted an integrated approach to new community school projects and which process essentially comprised the partnership and collaboration of multiple agencies and the coordinating of various services so that the school and its students could derive better results from such integrated activities. The Integrated Care Network (2004) stressed on partnership as different from integration but at the same time realised that improved partnership was necessary to create an integrated system. It also felt that the coordination of the different activities could not be sustained over the long term although it felt that better coordination was necessary for promoting better integration. Essentially, each model differs in the amount of autonomy and coordination among and as between agents and services. Most organizations have been found to adopt a position in-between full autonomy and full integration, with coordination located in the continuum somewhere in the middle. Mukherjee, Beresford & Sloper (1999) also suggest co-ordinated working as being somewhere in-between autonomous working and integrated working. Coordinated working involves professionals who plan and support the target community or group and generally involve all stakeholders in the process. But in integrated working, services are designed and coordinated such that professionals merge in the background and their role, although necessary, gets blurred in the whole (Mukherjee, Beresford & Sloper 1999). Others even suggest that pooled budgets and singular goals drive integration (Integrated Care Network 2004; Stewart, Petch and Curtice 2003, Townsley, Watson and Abbott 2004).
There are also working models, which have been proposed in order to describe how agencies work together (Cameron & Lart 2003, Atkinson et al. 2001). Strategic level working is one such wherein joint planning and decision-making are resorted to. There are also the so-called placement schemes for supporting primary care workers, a centre-based service delivery system in which various agency professionals collaborate for achieving a common objective, a system of coordinated service delivery whereby a central coordinator effectively coordinates the different services, multi-agency teams in which professionals work together as a team, and also a case management method for achieving better coordination and optimal output to target groups. All such models are driven by professionals and may not actually utilize coordination as the underlying factor (Sloper, 2004). Again, Watson, Townsley and Abbot (2002) propose another model in which members of multiple agencies works together for a common objective and in the process share all information, tasks and responsibilities. Such a working model is similar to those proposed by Percy-Smith (2005) and the Integrated Care Network (2004). Sloper (2004) even considers collaboration and coordination as followed in such multi-agent systems as being not mutually exclusive of each other.
The need for Integrated Working
An integrated service essentially functions as like a community service hub for by offering a single point range of services, whose practitioners then work as multi-agents for delivering integrated support to children and their families (www.everychildmatters.gov.uk). The UK Government regards integration as a panacea for the fragmentation of services, which has been identified as a barrier to more effective care. A simpler and more user friendly support system providing for greater continuity of services and a single point of access wherever possible is increasingly being seen by governments across the world as the only means to achieving optimal outcomes. For instance, the NHS Plan of the UK government (2000) even wanted to implement a radical redesign of the entire care system while the Green Paper Every Child Matters (2004) had declared the Government’s intention to integrate core services with a single long term organisational focus. In fact, even the World Health Organisation (WHO) has described integration as a way for helping improve services in relation to user satisfaction, quality, access, and efficiency and as consisting of four major elements, viz., horizontal integration, vertical integral, continuity of care and integrated care. While the WHO definition is based on these four elements for providing an enhanced health and care system, the implementation of an integrated care or service system is generally driven by the need for linking similar care levels, overcoming barriers to desired outcomes, planning strategies for achieving desired results across the various hierarchical levels in an organization, evolving a user focussed or user friendly mechanism for delivery of care or support services, as well as improving managerial, technological and economical aspects of support services. There is a clear distinction between coordination and integration as envisaged by WHO and other international health, care, educational or governmental agencies.
Generally, the adoption of common service models, processes and procedures help achieve an integrated working system. The practitioners of integrated working tap their professional knowledge and specialized skills and involve with focus groups like children, young adults and persons with special or complex needs. The outcomes of an integrated work arrangement can better identify their needs earlier, focus upon the service users and deliver better coordinated supportive activities that can help them obtain improved outcomes. Integrated working can be successfully achieved by means of collaboration and coordination at all levels, in case of diverse services and by utilizing multiple agencies, through strong leadership and management. The system mainly attempts to support the educational and job related needs of children and young people, particularly those having complex needs (www.integratedworking.com).
The benefits of integrated working
The integration of services results in some beneficial outcomes for service users. Integration makes access to service easier. It also helps improve the response-time to identified needs of the users. Fewer people are involved which speeds up processes and also simplifies the decision making process. Responsibilities can be affixed accurately, a ready and effective communication system is facilitated and available resources can be better and cost-effectively utilized. The system facilitates increased user and agency participation in the entire process. Organizational and service value is added by way of enhanced brand image, greater staff preferences for the services and more positive responses from users. The organizational processes are more efficient in sharing of support services among partners, integrating the managerial processes, and streamlining the administrative processes. Also, the system has better fixation of individual accountability, improvement in transparency, greater user-focussed approach, more robust arrangements, better team work, fresh opportunities for investments, and greater availability of resources and capital, as well as greater autonomy and control.
Key integration processes
The common set of activities that comprise an integrated working framework include several elements like Common Assessment Framework (CAF), Lead Professional, Service Directories, ContactPoint, improved information sharing and inter-agency working arrangements. An integrated working arrangement necessarily incorporates these critical elements for achieving a specific objective, generally pertaining to development or care of children and young adults in education, career development r social services. A brief description of each of the elements as followed by various local and national governments would be in order in order to present how an integrated system functions and what outcomes it can achieve.
Common Assessment Framework or CAF
The CAF is a national initiative that combines good work practices with improved documentation so as to facilitate better and quicker needs assessment of children and young adults. It envisages that a single agency cannot attend effectively to the special needs of the targeted underprivileged children or young persons with special needs and tries to effect an early assessment of the needs. The CAF has evolved as a uniform and standardized method for assessing a child’s additional needs and planning for meeting those needs. CAF identifies a child’s such additional needs as early as possible and aims to put in place a mechanism for meeting such needs in a timely and integrated manner. Essentially, a CAF is an integral component of a multi-agency framework that is designed to improve the outcome of the entire integrated working arrangement. It functions according to three fundamental principles- helping build and maintain, till required, a functional team around the target children or young adults with special needs, introducing services based upon emergent need and helping maintain updated feedback to lead Practitioner, and the vesting of the entire responsibility for the integration processes in the Lead Practitioner who coordinates all services, ensures CAP sharing, updating and review. By maintaining appropriate documents that can facilitate common language and understanding of needs of the target children or their families for better inter-agency involvement, management and support services, CAF can achieve improved outcomes by way of child care or development. Focused on children needs, CAF is a frontline, standardized tool and key element of the UK government’s “Every Child Matters: Change for Children Programme”. CAF mainly aims at understanding the additional needs of children or young adults, which are unmet by the conventional and universal system, and also at meeting such needs in time and through better coordination. CAF comprises three major activities viz, preparing a pre-assessment checklist of activities to perform so as to enable practitioners identify suitable target children or young persons for the integrated system, designing a process for undertaking a common assessment of children’s needs based on personal interactions with child or its family, and generating a standard format by which to record and or share the results of assessment so as to facilitate the meeting of the unmet needs of the children or young adults. The government has already planned an electronic or eCAF version, which will enable trained and authorized practitioners to create, store and effectively share CAF information that can be used to improve outcomes for children and young adults having special needs.
CAF covers both the child and family assessment framework as described above as well other assessment frameworks. CAF covers activities like the development of the child pertaining to health and physical development, speech and language development, communications development; emotional, behavioural and social development, building one’s self esteem, self-image and social preservation, maintaining family and social interrelationships, developing special care abilities, gaining independence, learning and problem solving, achieving higher learning, education and employment, fulfilling aspirations, developing careers and family, attaining basic health, care and security, gaining guidance, stimulation, etc., caring for environment and conserving the same, obtaining housing, financial stability, etc.) CAF emphasizes a holistic approach in identifying the child’s need and strengths and helps put in place need-based car and support structures.
CAF provides for a standardized assessment model, helps implement a common language spanning diverse services, supports better understanding of the child’s needs, fosters understanding amongst practitioners, facilitates timely and early interventions, and also speeds up service deliveries. A common documentation format is also established that can be utilized by all agencies and enables accurate and timely information sharing between services and across locations. CAF is basically made to cater to unborn babies, children of all ages and young adults who are aged between 18 to 25 years of age and who may have learning disabilities. Effective CAF implementation means successful early intervention and timely support to children and young adults with special needs or disabilities. It is based on first identifying the additional or unmet special needs of the target persons, assessing the same, and also understanding the strengths and concerns of the child and its family. CAF also involves the child and its family who retain a copy of the CAF documents, which is written in a language understood by them and empowers them to contribute to and take leading roles in the entire process. CAF also focuses on practical support in the short term and also facilitates sustainable development. CAF adds value to the child’s life, ensures better communication across services, and ensures smoother delivery of all services to the children and family. The practitioners can also utilize CAF to help prepare their knowledge and responses to situational needs. The number of inappropriate referrals is also minimized, and multi-agency working is improved, Children and families get better involved in the integration process and are better placed to understand the various interventions and mechanisms.
A tool developed by the government as an essential part of its Every Child Matters: Change for Children program, ContactPoint is intended to help support the work of children’s services in entire England by middle of year 2009. ContactPoint is felt to help practitioners identify a child, better assess the universal services like education and health care that it is receiving and to which it is entitled, ensure early needs assessment, plan and implement early intervention, and also facilitate better collaboration and coordination amongst professionals and practitioners. Initial pilots have proven promising and it is hoped by government that the tool will stabilize and achieve desired objectives. A ContactPoint is essentially a national IT based system, which enables the professionals to assess whether anyone else is involved with a particular child. A ContactPoint arrangement makes it all the more convenient to practitioners in lending better coordinated support to the child with unmet needs, ensures vital time and energy is not lost in finding suitable practitioners. ContactPoint details include the information like name, address, gender, and date of birth of the child, the number of such children, contact details of parents and carers, the educational settings in which the child is situated, the name of GP, etc. The Contact Point functions as an online directory, which authorised staff, can use to do their jobs.
Sharing information is vital for ensuring early intervention for persons needing additional services and for achieving positive outcomes. Effective sharing of vital information facilitates for an effective and efficient service framework which can be built around a person’s needs, can try and safeguard the child and family, and also ensures confidentiality or communication of information across services or between multiple agencies. Practitioners are required to assess the situation so that they can decide when, how and what information to share for achieving positive outcomes in shortest possible times. The government has adopted information sharing as a fundamental mechanism based on which it hopes to improve outcomes for all sections of the population. Information sharing is thus a part of the Every Child Matters strategy (2003), HM Government Information Sharing Vision Statement (2006), the Children’s Plan (2007) and the Think Family reports (2006, 2008). The government is seized of the need to keep the information safe and secure as well the need to maintain the individual’s privacy rights while sharing information in order to facilitate better service delivery. The government also brought out its first information sharing guidance for practitioners in 2006, which now covers children, young adults, grown-ups as well as their families. Appropriate sharing of information is a vital requirement of all integration processes and cross-government as developed by the government helps practitioners understand how, when, why and why not to share information.
Lead professionals actively help coordinate the provisioning of care and support services for children and young people with additional and often complex needs. Duplicity in provision of such care and support by multiple practitioners is thereby avoided. The UK government’s Every Child Matters: Change for Children (2004) program defines the role of the lead professional and prescribes three essential functions viz, being a single point of contact for the child and its family, coordinating appropriate and timely service delivery, and helping reduce duplicity of services of care given. Lead professionals are responsible to their home agency for their lead professional actions. Any adult person who cares for or supports a child or its family can be a lead professional. A lead professional must be well able to coordinate the providing of services to the target group of persons and can function as a teacher, social worker, parent, guide or mentor. They must be knowledgeable, confident in their job, be competent and be able to develop a successful and result oriented relationship with the child and its family. His communication skills must be both simple and effective. He must be able to lead and manage other practitioners, be able to work from within the CAF and develop result oriented support plans. He must also be expert at coordinating the various services, ensure timely and effective needs assessment and intervention to deliver positive outcomes, and also collaborate smoothly with other practitioners. A successful lead professional can optimise activities, improve coordination and communicate effectively. The lead professional thus essentially helps deliver an efficient and effective integrated working arrangement. His priorities also include building a trusting relationship with the target child and family, securing their involvement in the integration process, co-ordinating the effective delivery of result oriented actions and establishing a process of review regularly. A lead professional helps plan and intervene early and in time also help the child with special needs develop in education and career well.
Multi-agency working is the effective coordination and collaboration of various services for helping prevent problems from occurring. Multi-agency working can effectively support children and young adults with additional or special needs and help achieve required positive outcomes. Multi-agency settings include health, youth work and justice, social care, voluntary and community sector and other children’s services in which the various agents and services work together to attain an integrated working system for early intervention and child development. Multi-agency working is well effective in resolving problem issues that act as barriers to attaining better outcomes for children and young adults. There are many models of multi-agency working. Mainly three such models are in use across UK and elsewhere. These include the multi-agency panel, the multi-agency team, and the integrated service. In a multi-agency panel, the practitioners are employed by their home agencies, meet regularly amongst themselves as a panel or network, identify the children needing special interventions, discuss their additional needs, often adopt strategies, employ workers to resolve the cases, etc. A Youth Inclusion and Support Panel is an example of such a multi-agency panel arrangement.
A second model, the multi-agency team model is more formally constituted, with the practitioners inducted into the working team for acting according to a common agenda and goal. There is a team leader who manages the other team members. They get training from their home agencies and are able to work with a broader group or community. Behaviour and Education Support Team and a Youth Offending Team are examples of such a model.
A third model is the integrated service model. In this model, a range of separate services are offered from a single location and share a common and all the agencies work together in the manner of community service hub. Such a model has a management structure that facilitates integrated processes, with the services being driven by partner providers and delivered through early years of schooling itself. Examples are the Sure Start children’s centres and the extended schools offering various integrated and multi-agency services.
The Professional Development Programme for Educational Psychologists in Scotland has even produced a paper on multi-agency working and defined the same as a system in which three or more agencies work together and have shared aims in attaining previously defined outcomes for children. Fischer (2003) observes that multi-agency working is functional both at strategic and operational levels and also adds that joint funding, shared budget responsibilities, joint workforce planning, information sharing and service delivery responsibilities are involved in such an approach.
Major success factors and barriers
Several authors like Cameron and Lart (2002), the Integrated Care Network (2004), Park & Turnbull (2003), and Johnson et al (2003) have noted the various factors and barriers to successful implementation of integrated working. Key factors are outlined below for understanding better the issues.
Financial uncertainty is one of the common barriers to integrated working (Sammons et al 2003, Cameron & Lart 2003, Wilkin et al 2003, van Eyk & Baum 2002, Johnson et al 2003, Tisdall, Wallace, McGregor, Atkinson et al 2001). Funding is often perceived as insufficient by community school management. Lack of funding prevents suitable permanent staff from being appointed. Johnson et al (2003) also observe that the greatest barrier to joint working between the NHS in England and the social services is the high cost factor and the non-availability of sufficient budgetary funds.
Lack of Professional Culture
Cultural differences between professionals are also often perceived as barriers to integrated service delivery (Cameron & Lart 2003, Wilkin, White & Kinder 2003, van Eyk & Baum 2002). Johnson et al 2003, Coxon 2005, and Crouch & Johnson 2003 even observe differences between health and social care in regard to terminology, attitudes to information sharing and professional principles. These authors feel that such issues are crucial in developing an integrated working model. Craig, Huber and Lownsbrough (2004) too observe that tension between public sector professionals are also un-reconciled and often impede the judgement capability of such professionals. Increasingly professionals are being called in to work in unknown sectors, which are causing more tension among them. Also, appointment of integration managers or coordinators is not effective in resolving such tensions.
Lack of clarity of roles and responsibilities
Professionals often have blurred vision and goals, which act as barriers to attaining effective integrated working. Cameron and Lart (2003) effectively bring out the importance of clear, well-defined goals that are realistic and achievable and are clearly understood and accepted by the partners. Similarly, Rushmore and Palls (2002) also stress on clearly identified roles and responsibilities as being crucial factors for avoiding work overlaps and gaps in provision so that blurred professional boundaries do not impede the positive outcomes from integrated multi-disciplinary working arrangements. McCulloch et al (2004) even support the view that successful collaborative working depends upon establishing clear boundaries between each party. They find that collaborative working is most successful from a school perspective when other partners are seen to have added value to the efforts of the school. Rushmore & Pallis (2002) even observe that joint-working relies upon the merging of the skill, experience and knowledge of each partner with reliance upon team members for the outcome that only working together can achieve. Difficulties in defining boundaries amongst professional groups were also noted in the Scottish Centre for Social Research’s study exploring effectiveness of early year’s policies (Wasoff et al 2004). Negative fallouts include disputes over responsibilities, lack of equity, increased stress and bad comparison among the parties. Blurred boundaries even result in ambiguity of roles and also impact job satisfaction levels, levels of trust between parties, etc., and this may ultimately lead to relationships that can not be sustained (Rushmore & Pallis 2002). Formalisation of policies and procedures can serve to clearly define and affix the roles and responsibilities of partners involved in a joint working arrangement (Rushmore & Pallis 2002); it may also provide the workers time and support for them to achieve an effective collaboration among themselves (Wasoff et al 2004).
Lack of shared understanding
A common occurrence is ambiguity caused in integrated working. For example, there ma be confusion relating to the very purpose of the partnership, insufficient definition of partner roles or responsibilities, and insufficient knowledge or information sharing on plans and meetings (Stewart et al 2003, Percy-Smith 2005). Webb & Vuillamy (2001) even evaluated a 3-year project in which some home-school support workers were placed in secondary schools and were observed when they worked with other agencies. The authors reported on the ineffectiveness of the strategic advisory group meetings in this particular study. Group participation appeared to decline over time, the capacity to cooperate and innovate by the agencies was seriously undermined. Even the National Audit Office (2001) brought out clear guidelines for promoting accountability through prescribing clarity of roles and responsibilities of partners in a work arrangement. For ensuring sound accountability, the National Audit Office stressed on clearly defining roles and responsibilities of each organisation, setting out unambiguous service delivery targets and also setting out a party responsible for taking action in cases of below par progress. Percy-Smith (2005) too hold the view that reviewing and evaluating evolving partnerships can also contribute to greater clarity of purpose and roles of the partners (Percy-Smith 2005).
Key Success Factors
Obviously, key success factors behind an effective integrated work arrangement include, among others, clarity of aims and objectives that are well understood by participants, clear identification of practitioner roles and responsibilities, strong commitment from all stakeholders, sound leadership and management, enhanced and effective communication, better information sharing, as well as structures for joint planning being put in place (Sloper 2004, Integrated Care Network 2003, Cameron & Lart 2003, Rushmore & Pallis 2002). Sloper 2004, Percy-Smith (2005) and Craig et al (2004) also emphasize joint training, staff support, recruitment of staff having right skills and shared resources, and better monitoring and evaluation as being essential for a successful integrated working mechanism.
Organisational climate is also identified as a major contributing factor in making for a successful integrated work arrangement. Johnson et al (2003) report on organisations that support teamwork, flexibility, and better communication and shared vision as being better able to deliver positive outcomes for users and also in providing improved integrated care or support services. Gardner (2003) mentions a vital link between organisational climate and improved outcomes for clients. He also identifies organisational identity and staff confidence in the working practices as vital factors in helping the organization better integrate with other organisations. Atkinson et al (2002) also support this. Rushmore and Pallis (2002) add that proper guidance, support, leadership and commitment are vital to make the integrated work arrangement a success and these have also been so identified by Sammons et al (2003) as essential factors for ICS success. In fact, the Integrated Care Network (2004) states that without a strategic vision and support, frontline collaboration for effective service delivery cannot be optimised in spite of the practitioners’ best efforts.
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