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I will approach this assignment from a political view. Firstly critically evaluating the legislation and policy context behind inter -professional practice and inter agency working within Mental Health, Discussing the key pieces of historical legislation that have been most influential in social work practice today. I will critically evaluate how professionals work together, taking into account a variety issues with reference to the Modernisation Agenda. Discussing the overall impact this has on the provision of Health and Social Care services, with particular reference to the service users, identifying high profile cases within the UK that have become a fatal consequence of professionals and integrated services not working effectively.
Secondly I will demonstrate a clear analysis of inter-professional working drawing on my own personal experience within the mental health services, identifying and critically examining key issues of working inter- professionally and inter agency, from possible barriers to strategies to promote inter -professional practice.
Legislation and policy requirements over the past decade have required health and social care agencies to work together closely and collaboratively. In the UK Major changes have taken place within the Health and Social care sector, with the transformation and growth of the many new acts being implemented and amended to meet the needs of a diverse and ever changing contemporary society. The birth of the NHS Act (1948) was the initial development brought in by the Atlee government, which brought about the hugely ambitious plan to bring hospitals, doctors, nurses, pharmacists, opticians and dentists together under one umbrella of organisation to provide services that are free for all at the point of delivery. It was the largest integrated service which required professionals to work closely together, although the link between health and social care needs were not yet focused on. (Miller,C.2001 pg4-7)
The achievements from the development of the NHS were impressive and have impacted health and Social services dramatically with productive and innovative partnerships with bodies in both the public and private sectors today.
Further developments began to emerge with the reviewed provision of social services in Britain with the Seebohm report 1968. The report highlighted that community health services and welfare services were being developed by separate departments with, poor communication and little co ordination. Therefore it was the development of a unified Social Services department and generic training. (Carnwell,R.2005 pg21)
Initially, the NHS had a three part structure, with three branches hospitals, primary care and local authority health services.
The NHS reorganisation Act 1974, a ‘unified’ structure was introduced, with three main levels of management, at Regional, Area and District level.
In the 1980s, Enthoven, (1985),an American economist, made an influential criticism of the NHS, arguing that it was inefficient and resistance to change. The reforms
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Which followed were based in the belief that the NHS would be more efficient if it was organised on something more like market principles. The NHS administration was broken up into quasi-autonomous trusts from which authorities bought services. The role of Regional Health Authorities was taken over by 8 regional offices of the NHS management executive. For the first time, the NHS became truly a nationally administered, centralised service. (R Klein, 1995). Sited (Bishop, M The regulatory challenge 1995 pg 36). The two acts which had a huge impact on Mental Health Services were the Mental Health Act 1983 it provided safeguards for people in hospital. Section 117 of the Act imposed a duty on district health authorities and social services departments to work inter professionally and alongside voluntary agencies to provide after-care services for people discharged from hospital. The second was the NHS and Community Care Act 1990 it made all the legal changes necessary for the implementation of the ‘Caring for people’ White Paper. Local authorities, in collaboration with health-service and independent-sector agencies, now became responsible for assessing need, designing care packages and ensuring their delivery. Both these developments required a strong collaboration between health and social care but the government believed that partnership working was so crucial, in order for the developments to be effective.
1997 one of the New Labour policies was the focus on the ‘Modernisation ‘of all the government sectors. With this came the promotion of partnership working within different areas of government and the collaboration of private and voluntary sectors, (Giddens,1994) described this new modern way of thinking as the third way and reflecting on this came the governments first health service white paper,
‘The new NHS: Modern and dependable’ which stated the end to centralised command and control of the 1970’s and instead there will be a third way of running the NHS, a system based on partnership. (Secretary of State for Health, 1997).
As part of improving services for Mental Health, the aim was to tackle the root causes of ill health whist promoting independence and providing excellent quality of care with regard to treatment, protection and partnership working in integrated health and social care.
Partnership in Action (DOH 1998) discussed improved outcomes on integration.
The Government made a commitment to encourage more joint working between health and social services. The paper made plans to make partnership working a reality, breaking down barriers between local government and health authority services.
The Health Act 1999, addressed legal barriers and introduced new powers with the aim to enable partners to join together to design and deliver services around the needs of service users rather than worrying about the boundaries of their organisations. These arrangements were geared to help eliminate unnecessary gaps and duplications between services. It provided pooled funds, lead commissioning, and integrated provision. One of the most recent publications was the 2007,Publication of Mental health: new ways of working for everyone – a report aimed at all mental health staff, looking at ways they can work more flexibly within teams, produced by the NIMHE National Workforce Programme. The report builds on previous guidance and promotes a model where ‘distributed responsibility’ is shared amongst team members and can no longer be delegated by a single professional such as the consultant. The report was published alongside the ‘Creating capable teams’ approach (CCTA), which provided practical guidance, and New ways of working with service users and carers.
The aim the developments in policies and frameworks was to provide a ‘seamless service’ (Griffiths,1988:Doh,1989) which the government believe can only be possible with a multi professional approach to health care, with all professionals contributing and working alongside ‘inter professionally’. The main objective is that services users can be cared for within the community or within a hospital without any barriers or gaps within the service and with a range of different professionals who are well informed of their history of intervention.
With patient care being the centre point of inter professional practice it is important to understand what effective team work consists of. It has been stated that the whole point of team work is to bring individuals knowledge, opinions, and personalities and thinking styles together, that will seek to find the best possible solutions to the matter at hand. (Paul Gorman 1998). (Thompson 1998) stated four ways in which health and social care professionals can move forward in a way that embraces diversity and learn from each other, embrace partnership, adopt a value position where anti discriminatory practiceis central and reflect on practice.
The importance of effective partnership working was central to Labours New modernisation agenda (1997), with new ways of working inter professionally and new ways of delivering integrated services working closer together, providing packages of care (Department of Health 1999b). The Labour government believed that the previous way services were delivered were considered unhelpful with professional and organisational divides, or ‘Berlin Walls’ (Parrot2002).The government argued that the existing configuration of health and social care was contributing to an artificial segregation of services.
Labour believed that in order for the modernisation agenda to be effective, professional and organisational autonomy but be completely broken down in order to achieve effective care to service users.
Poor teamwork skills in healthcare have been found to be a contributing cause of negative incidents in patient care, while effective teamwork has been linked to more positive patient outcomes. (Runicman et al., 1993).
(Barrett, Sellman and Thomas, 2005) stated that good team work requires regular reflection and supervision, education and training, reinforcement of identity, evaluation, effective managerial support and having realistic expectations.
There is a large amount of literature on inter professional working that has focused on the potential difficulties in achieving effective working relationships between practitioners from different professions. All professionals working in integrated teams face challenges due to different codes of behaviour and understandings of ethical and moral rules, this can have implications to partnership working.
(Mc Laughlin2004) argued that it remains questionable as to whether different professional groups will be able to make ideological shifts, as the Modernisation agenda required a fundamental culture shift and attitude change by all professional groups at all levels. (Aswell 2003) stated that a clash of professional culture and objectives ways of dealing with client groups is still an area that exists.
(West and Markiewicz 2006 ) suggest ways in which these problems may be avoided by using seven dimensions to achieve effective partnership working, they believe by having, shared commitment and goals, inter professional support and respect, true co operation; focus on quality and innovation, cultural congruity role clarity and independence of outcomes.
(Iles and Auluck, 1990:Gibbon,1992:Field and West,1995) also researched multidisciplinary working and stated that in order to achieve effective teamwork, not only do individual professionals need an appreciation of other members roles and their contribution to patient care, but they also require a clear understanding of their own role in the team.
There are many principles of successful multi agency working identified by the Every Child Matters, agencies and practitioners need to work together with agreed and achievable aims and objectives. Partnership working can only be effective if there is a clear purpose, good communication; co-ordination; protocols and procedures set in place and effective mechanisms to resolve conflict when it arises. Multi disciplinary working functions better when professionals are working in an organisational culture that supports teamwork and has strong leadership and effective administrative support. ( )
Effective teamwork can only be achieved when all levels of the healthcare systems work together. Effective leadership is important but practitioners are aware that this is a demanding role. There is considerable support for joint training at both the pre- and post-qualifying stages .Evaluation and monitoring is vital in ensuring common outcomes are achieved and interagency working is successful.
Findings from high profile inquiries in the UK, such as the Lamming Report (2003) into the death of child Victoria Climbie and the Ritchie inquiry into the care and treatment of mental health patient Christopher Clunis (Ritchie et al., 1994). These cases highlighted the lack of communication and poor information sharing between agencies as contributing to these tragedies. Policy documents focused on the need for better cooperation and communication between professionals in order to enhance service provision. There are a number of costs of poor integration. Perhaps the most extreme costs were reinforced by a series of enquiries into murder cases.
The inquiry into the killing of Jonathan Zito by Christopher Clunis, who was diagnosed as having schizophrenia, was notorious. At a London underground station in 1992. It highlighted the difficulties inherent in joint working between services, the duplication of effort and indeed the potential for no-one taking ultimate responsibility. The Ritchie Report did not, on the whole, blame individuals but noted that Christopher Clunis was in some sense a victim of the health and social care system since he had spent over 5 years being sent between different facets of the health and welfare service, between hospital, hostels and prison with no overall plan for his care and inadequate supervision for many aspects of the health and social services.
Victoria Climbie died at eight years old as the result of horrendous physical abuse. The neglect and the vicious beatings were carried out by her great aunt, Marie Therese Kouao, and her boyfriend Carl Manning. But she was also failed by social workers and others who could have stepped in to protect her. Victoria died of hypothermia in February 2000. She had 128 injuries. The Home Office pathologist who examined her body, Doctor Nathaniel Cary, stated that it was the worst case of abuse he has seen in his career. The inquiry heard that there was little exchange of information between the hospital and Social Services which led to a battle of conflicting assumptions, where each body believed that the other was fully aware of the situation. Doctors believed that Victoria had been abused but did not realise that neither Social Services nor the police were aware of the evidence. These cases are clear cases of breakdown in communication between multi disciplinary teams and agencies within integrated services.
In 2003 the Government published a Green Paper called ‘Every Child Matters’. This was published alongside the formal response to the report into the Victoria’s death. In addition training for professionals was vital for integrated services and tools such as information sharing need particular attention.
The Common Assessment framework (CAF) was implemented it provides an easy to use assessment that is common across agencies. It has helped to embed a shared language, support better understanding and communications amongst practitioners; facilitate early intervention; speed up service delivery and reduce the number and duration of different assessments that have been used in the past
Working for the Community Mental Health Team for Older People I worked within a multi disciplinary setting. The team consisted of Social Workers, Occupational Therapists, Community Psychiatric Nurses, Care workers, Administrative staff and a Consultant Psychiatrist. Our services were integrated as we worked closely with other agencies to deliver integrated care packages.
Over the duration of the placement I witnessed a strong work ethic amongst the team as they all shared the same common goal, which was to deliver the best possible care package. I felt that the team worked effectively, updating their training skills on a regular basis, and implementing changes where applicable with regards to developments in government legislation, frameworks and policy documents. There were clear boundaries of confidentiality and, this was highlighted in the team’s policies and procedures which I was made aware of immediately. The team’s manager held regular supervision sessions for all the team practitioners which gave everyone the chance to discuss any areas of concern. Communication was vital and regardless of your position within the team your opinion or suggestions were taken on board and would be implemented within the weekly multi disciplinary team meeting. When there was a mixture of opinions held over possible intervention strategies the case would be discussed further until there was a shared agreement. The Consultant Psychiatrist usually held the final say alongside the team manager. It was compulsory for all practitioners to attend as it was the time when all new referrals were allocated.
Each member of the team discussed new and existing referrals, providing support and advice for any concerns mentioned. Every member of the team was aware to a degree of new and existing cases, which helped during annual leaves or sickness. There team was made up of individuals with a mixture of cultural backgrounds, religious beliefs, values, training backgrounds, experience and skills therefore there were times slight clashes of personalities occurred on a personal level but as professionals the differences never seemed to get in the way of their main objective. Being community based the team held an in dept knowledge of local resources available, constantly incorporating assertive community treatment within care plans. The team respected and acknowledge the contribution of each other and worked towards a common goal. The patient’s records included shared care plans and joint decisions following consultation with the patient.
Unfortunately I noticed that working alongside other agencies did not run as successful as the team did. There were increasing numbers of complaints about information sharing, duplications, workloads, and communication. I believe that a lot of this was due to lack of awareness of roles and functions of other agencies. I also felt that because of large workloads a lot of the communication was done via email, letters or telephone therefore relationships were not established initially face to face which seemed to have a lasting effect.
Community Mental Health Teams supply effective care within the community but I strongly believe that there is the need for further training to develop better relationships with external agencies. I feel optimistic about current developments and changes as there are many opportunities, with policy emphasis on age equality, self-directed support, improved education, training and support for those who work with older people, I believe it will facilitate change. I believe there is a need for stronger professional, managerial and leadership within the team as is the effective targeting of much-needed investment and resources. This to me is a vital point, inadequate resources with particular regard to the reduction in acute bed numbers adds a certain amount of pressure for practitioners and service users.
Tyrer et al (1998) found that the advantages of community care were overshadowed by the unavoidable use of out-of-district admissions if local provision was inadequate. Beck et al (1997) demonstrated that even within a well-established community mental health service, there was often no alternative to admission for a large majority of patients admitted to acute wards. Adequate numbers of acute beds are therefore absolutely essential for the provision of effective mental health care. High volume workloads made community working more stressful making it more difficult for practitioners to develop more effective relationships externally
Inter professional practice is viewed as problematic to many as they feel the level of expertise held by many professionals will become diluted and generic training may even disappear. The Five categories of major barriers in joint working and planning in Health care services are structural issues, procedural matters, financial factors, and professional issues. (Harley et al (1992).
(Leathard, 1994), analysed inter professional collaboration and describes rivalries between professionals in terms of power and professional identity. It was stated that the power of more experienced practitioners over less experienced practitioner would result in a barrier to inter professional working. He also made reference to barriers in finance and resource allocation, stating that, professionals have different pay scales according to their professional group and their role within it. Resource allocation can be a source of conflict. There is the issue of funding for staff. Seeing funds being used to employ staff from one group to provide a service normally provided by another can cause resentment. Staff shortages can also damage interaction as groups withdraw in an attempt to limit demands made upon them.
In addition there is the fear that multi professional collaboration is designed to reduce costs. Leathard (1994) also highlights further suggestions that one of the advantages of inter professional working is ‘more efficient use of staff’.
(McPherson et al 2001), critically examined barriers and suggested that, the barriers preventing inter-professional working include a lack of knowledge of the capabilities and contributions of other professionals, and existing rivalries and resentments amongst qualified professionals. This is compounded by the wide range of stakeholders with their own aims, objectives and priorities inhibiting Inter professional working. There is also a misunderstanding among qualified practitioners who worry that Inter professional working will lead to blurring of differences between professions.
( Borrill 2002, Camron et al 2000, Watson et al 2002, 2004) argued that joint working brings many benefits but when different agencies follow different methods of working, training , goals and priorities the effect can ultimately be less effective . Sited (journal, barriers and facilitators).
Other areas that may affect effective partnership practices are geographical location, equipment, financial arrangements, referral systems, recruitment, workloads, and organisation of work, extent to which there are opportunities to challenge attitudes and change practices and failure to consider the practice of a team as a team. Responsibility without accountability, lack of leadership preparation and Resentment and lack of trust ( )
Inter professional practice has been clearly promoted through legislation and policy documents ever since The NHS 1948 Act. There are many Acts which draw on the relevance and importance of joint working when delivering an integrated service. Legislation and policy documents over time have emphasised the need to make partnership a reality throughout Britain by removing barriers which exist, and by introducing incentives of joint working to achieve better monitoring of progress towards joint objectives. There is also the importance of inter professional practice and the need for professionals to work together to develop and improve the delivery of care, by sharing the same a core objective. (Partnership in Action white paper (1998)).
The new Labour government (1997) aim was to promote and improve joint working between health and social services. This will allow for pooling of budgets and other ways to deliver truly integrated care that is geared to the needs of individuals. There was also the promotion of partnership working to improve housing and other services, and the development for stronger children’s services and planning requirements to ensure more effective co-ordination of services for children. All the changes were radical steps to modernise and promote their commitment to improve inter-agency working between social services and the NHS.
The Community Mental Health Team worked alongside Service user groups, referring people appropriately to specified groups within the community.
Age Concern offered a wide range of services for clients within the community all clients who attend the groups need to be referred by a Social Worker or a Doctor. Many clients suffered from organic or functional illnesses therefore there were services to provide support from both aspects. The services offered a wide range of facilities, depending on the needs identified in the care plans. The service user groups were essential to many clients as it gave them a sense of community feel. Services were designed to support people and to help them to maintain their independence, enable them to play a fuller part in society, protect them in vulnerable situations and manage complex relationships. The groups I had contact with also aimed at enhancing choice and control for service users and enabling them to lead meaningful lives.
Service user groups include lunch clubs, drop-in centres, befriending schemes and other social groups for older people with mental health problems. Day care has been shown to delay institutionalisation for older people with dementia. The range of interventions provided in day care settings must be increased to meet older people’s varied needs. It is vital that the correct services are implemented in order to help people live a comfortable life free from risks and neglect. Because people with dementia need a complex mix of health and social care support to help them remain healthy and independent, I found that joint working was vital and needed to be approached effectively to ensure quality of care.
Throughout this module I have become more aware of the importance of inter professional and inter agency practice and the barriers that make partnership working difficult. I have gained a clear understanding of legislation , frameworks and policy documents that have been implemented over time that draw upon the impact insufficient team working can have on service users.
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