By Elizabeth Rylan*

After almost two years of debate and delay, the local authority I work for has recently co-located with community health colleagues. It was a day that some of us – myself included – were sceptical would ever arrive with move dates set, then postponed to the extent that as I was packing up my desk, I wondered if I would be unpacking it in exactly the same place the following Monday morning.

The benefits for clients of closer working with colleagues from other sectors is well-known with improved outcomes achieved through professionals delivering a more streamlined, efficient and ultimately more effective service.

In my career so far, I have worked in a joined-up service that then split (or disintegrated, as we decided to call it) and later in a well-established, fully integrated setting. So I have seen for myself the pros and cons of different ways of working. This is my first time being in a service as it edges closer to integration, which has prompted me to pause and reflect on how I have found the experience from a practitioner perspective so far.

Environment is key

For me, co-locating involved a move to a different part of the building. I was initially apprehensive because the layout is completely different to our previous set up and I was dreading being in a loud, busy, hot-desking environment.

I was concerned that I was going to get distracted and frustrated by those around me, and that this irritation wouldn’t be very conducive to joint working. Fortunately, I have been proved wrong and, in fact, I have found that the way the space is organised has been one of the most useful parts.

It was surprising to find that paying attention to details such as which way the desks face can make a real difference. It might seem obvious, but sitting in small groups and facing each other does promote interaction. Also, it might sound like a small thing, but having communal areas has helped. As well as the ‘luxury’ of a proper kitchen and seating area, there is nothing like queuing for the kettle to make you realise how much people dislike standing in silence! Embracing the small talk is a great way to get to know each other and put faces to names, more so than a formal meet and greet.

Camaraderie through challenge

It is often said that understanding the roles and remits of other professional groups is a way of breaking down barriers and learning how to make best use of our colleagues. However, I have learnt that as much as we can talk about our experiences, it often isn’t until we see this in practice that we really grasp the importance of this principle.

Quite soon after the move, I had a situation arise with a client who is well known to both health and social care services, alongside his wife who was unfortunately critically unwell in hospital.  An urgent call came through to the community matron who sits behind me from the health care support worker who was with the client at the time. The community matron’s mobile was passed to me to speak to the client with the health care support worker supporting him to convey his wishes, while one of my colleagues was on another phone to a care provider.

It was quite an intense, multi-way conversation but in the midst of a very sad and potentially distressing situation, together we were able to achieve an outcome in less than 30 minute, whereby additional assistance was arranged so that he could visit his wife for what would prove to be one of the last times.

Fears and frustrations

While it’s been enlightening being in such close proximity to my health colleagues and given me a real insight into the day-to-day activities of others, the flip side is that it can lead to some uncertain situations. One area in particular where we are more tentative is in relation to information sharing. There can be benefits to hearing snippets of other people’s case discussions but sometimes we may overhear more than we need or indeed want to.

We have generated questions about how much we can say, how much is recorded and if clients are or should be aware of these interactions, which can make people nervous about where they stand in relation to information governance. Unfortunately we are generating more questions than answers, but I am reassured that at the very least this means that we are all mindful of this as a potential issue, erring on the side of caution and not treating client information with any lack of respect. At the moment, queries tend to be raised on an ad hoc basis or in team meetings; I feel it would be useful for everyone to have a more formal review in the coming months.

Despite co-location, processes still lag behind our practice particularly in relation to referral pathways. It is great that I can simply swivel my chair and ask a physiotherapist or a nurse for their advice. But to request their formal input, I still have to go through a time-consuming process and suffer the vagaries of the central access point, for it then to be typed up by the call handler and sent to one of the people sat behind me. I appreciate that there needs to be a way of ensuring a consistency of approach and management of workflows, but this does seem rather ridiculous at times.

Conclusion

Overall, I am pleased to report that I have found co-location to be a positive experience so far and the benefits have far outweighed the annoyances. I am still disappointed that certain teams weren’t part of the co-location and cannot help but feel that there are some real missed opportunities, particularly as some of the services that we often find hardest to work with aren’t part of the set-up at this stage.

I don’t doubt there are several more political and logistical hurdles to overcome before fully fledged integration finally becomes a reality. However, it does now feel that the ultimate goal is in sight, not least in terms of a shared willingness from different sectors and an openness to consider alternative working practices. I’m sure this mindset will stand us in good stead for the future.

* Elizabeth Rylan is a pseudonym for an adults’ social worker based in a local authority in the south of England.

By Robin Miller and Catherine Mangan, senior fellows at the Health Services Management Centre and Institute of Local Government Studies, University of Birmingham

“Some GPs are very prescriptive. They think if someone’s got dementia they need 24/7 institutional care, which isn’t always the case” – a social worker.

“Social work training is varied – they go to college, not necessarily university, I’m not sure there is a university degree for social work” – a GP.

Health and social care professionals all have perceptions about one another. But to make integrated care a reality, it’s important to unpick some of the issues behind the stereotypes.

We know the relationship between GPs and social workers is crucial, but it is often difficult. These services have existed in parallel and communicated only when necessary. In many ways, we have just accepted this as a consequence of their different approach and interests.

Power is also an issue – general practice and social work are the main professions within their respective services and perhaps don’t like to compromise as a result. Both professions have the best interests of the service user at their heart, but often have alternative views on how someone should be supported.

The two services are also very busy and the increasing demands can be a barrier to learning about the other – even though this will make their work more efficient in the long run.

Action research project

We were funded by the West Midlands Academic Health Science Network to undertake an action research project that would explore what the relationship between adults’ social workers and general practice teams is like in today’s policy and practice.

The project had two major components. We undertook some qualitative fieldwork with groups of professionals from the two services, which looked at the current perceptions and experiences of collaboration with one another. The second part was to develop some training materials that would enable the two services to work better together. These materials are hosted exclusively on Community Care Inform Adults.

What did we find?

The negative perceptions professionals had of each other really outweighed the positives and impacted on the working relationships that they had.

There was a very big gap in terms of knowledge and understanding of each other’s roles. For example, GPs didn’t understand the day-to-day social work roles, the cases they hold, funding constraints, or the training they have to undertake.

There was also a very strong sense of hierarchy. Social workers felt GPs were at the top of this hierarchy and this meant there was a lack of constructive challenge between adult social work and general practice teams.

Overall, there was a lack of effective inter-professional working relationships, a lack of effective communication and as a result the joint decisions being made were not as effective as they could have been.

Top tips to help social workers and GPs work better together

1. Don’t be afraid to ask other professionals about their roles and professional backgrounds – if we don’t understand each other, it’s harder to work well together.
2. Encourage your team to share insights into how the other services work – and make sure someone finds out any details no one is sure of.
3. Don’t assume that others will have been kept up to speed with changes within your organisation – be proactive in checking that they understand new initiatives and structures.
4. When a new staff member joins the team, ensure a visit to other health and social care services is part of their induction. This is a great opportunity for someone to start developing contacts and to ask questions that others may benefit from.
5. Incorporate some ‘socialising’ into multi-disciplinary team meetings. This helps to develop that vital personal connection. It might not feel like the best use of time, but deepening your understanding of one another will improve the effectiveness of working relationships.

Final thoughts…

Challenging other professionals is often a hard thing to do, but constructive disagreement is an essential part of developing a holistic response to a service user’s needs.

The government is to provide local councils with £433 million this financial year to pay for the cost of implementing the Care Act.

In a letter to directors of adult social services, the Department of Health said the money is earmarked for specific duties arising from the Care Act during 2016-17.

Of the total £121.1 million will go towards implementing funding reforms, including the deferred payment agreements that let people to use the value of their home to pay for home care.

Local authorities will also get £10.45 million to help meet their duty to assess and meet the care and support needs of prisoners.

Another £114.6 million will be added to the Better Care Fund and earmarked for supporting carers as required by the Care Act and to ensure carers get information and advice about what support is available to them.

The remaining £186.6 million will fund other new duties under the Care Act including carer assessment and support, access to advocacy support, adult safeguarding and ensuring care continues when people move between local authority areas.

Councillor Izzi Seccombe, the Local Government Association’s community wellbeing spokeswoman, said: “We are pleased that the Care Act funding is continuing. Councils have long called for reform but now we need the resources to deliver the changes we need to make to improve the support our elderly and vulnerable population receive.

“However even if councils face a flat-cash settlement over the next four years, there are still significant challenges ahead for councils who will have to make efficiency and other savings sufficient enough to compensate for any additional cost pressures they face. Inevitably adult social care, being the largest single budget within some councils, will have to make its share of these savings.

“These include those arising from general inflation, cost pressures in the care sector, increases in the number of adults and children needing support and rising levels of need, increases in demand for everyday services as the population grows.

“This is why the LGA continues to call for £700 million of the funding earmarked for social care through the Better Care Fund by the end of the decade to be brought forward now, to ease the severe strain on services supporting the elderly and vulnerable.”

Iris Benson, a service user rep at Mersey Care Mental Health NHS Trust has had involvement with social workers since she was very young. In this video, she explains why she stands up for social work as much as she possibly can:

‘They’ve walked in my shoes’

Iris was very keen to make this video, even though it involved looking back to her early experiences of severe abuse and trauma which have had a significant impact on her mental health in adult life.

She was very scared of social workers as a child. On the two occasions she was temporarily placed in children’s homes, the medical examinations, itchy uniform and strict regime made her think it was she because she’d “been bad”. However, Iris says in the video, the social workers who have supported her as an adult literally saved her life.

This article is part of Community Care’s Stand up for Social Work campaign. We’re standing up for social work by being honest, offering support and providing inspiration.

The things that social workers have done – asking questions gently rather than pushing, coming back even when Iris ‘tested’ them and told them to go away, spending time with her in hospital after episodes of self-injury – may not sound huge but have made a big difference.

“They’ve had staying power, and they’ve walked in my shoes, even at the most difficult times,” she says.

Iris says her journey to recovery is ongoing. For example, her social worker helps her avoid the retraumatising trigger of pine disinfectant (a smell she associates with abuse by her mother) by making sure it isn’t used in places she goes.

But Iris is also now in a position to help social workers and other professionals better understand how to support people, in her role as an ‘expert by experience’ at Mersey Care. As well as co-producing and delivering training on, for example, implementing the Mental Capacity Act, she is involved in recruitment of staff at all levels and is service user lead on Mersey Care’s No Force First programme which aims to eliminate the use of restrictive interventions such as seclusion and restraint.

She has joined Emad Lilo, social care professional lead at the trust at numerous conferences and events to highlight how they work together and uses every opportunity to advocate for how important she believes social work is.

“We need more social workers. But we also need people like me to speak up for them too,” Iris points out.

“I think we lose people because they’ve become burned out with their passion.

“If teams like ours had been around when I was little, my life would have been very different. We need to look after our social workers, not frighten them off.”

Ofsted recently rated Cheshire West and Chester as one of the top-performing children’s services in the country.

While the council is rated good overall rather than outstanding – a feat no council has achieved since Ofsted changed its inspection frameworks in 2013 – it did get top marks for its adoption work and its leadership.

Community Care caught up with the authority’s strategic director for children and young people Gerald Meehan to find out about work that helped the authority get the thumbs up from Ofsted.

1. Adoption planning

“Adoption is involved intimately with all our children’s cases from a very early stage,” says Meehan.

“We have a dedicated family finder who tracks all children in pre-proceedings, follows them through the legal planning meeting and keeps abreast of assessments of all potential family members.

“The culture is adoption isn’t something you think about when other things have failed, you think about it right at the beginning.

“And because our adoption team know the cases coming through so well at such an early stage, we are able to better identify families who will be a good match.”

2. Adopter recruitment

Ofsted reports that Cheshire West and Chester’s “highly successful” adopter recruitment strategy means the authority has more than enough adopters to meet demand.

An effective part of that strategy, says Meehan, is how the service goes into workplaces to find would-be adopters. “We’ve gone out and worked with, for example, Vauxhall Motors,” he says.

“The companies give us permission to talk to their workforce. It’s about going out and engaging the public in a different way. We need something much more, given the increased volumes, than just doing the traditional ‘Would you be able to adopt?’ advert.”

More adopters means better, more stable placements too.

“We’ve always got a pool of adopters much bigger than we need at any given time so there’s choice and we can think about a much more sophisticated match so that you reduce the possibility of breakdown.”

3. Multiagency support

In 2013 the council created an Integrated Early Support team, which Ofsted says reduced demand on children’s social care by 10%.

The team is a multiagency service – “a public sector service, not a council service,” notes Meehan – that assesses families and arranges support from services including adult social care, Troubled Families and careers advice.

“We’ve seen quite a significant reduction in police second-time call outs on domestic violence,” says Meehan.

“We’ve been able to deal with issues earlier on at source and maybe challenge some dysfunctional behaviors in families which has reduced some of the demand coming through and is great for children, partners and others.”

4. Information systems

Ofsted’s inspectors report that the council’s efforts to develop an electronic case management system for early support that can be accessed by relevant agencies is improving services.

“We have a range of data to tell us about volumes and issues we are dealing with but also, importantly, what is the difference we are making,” says Meehan.

“From where we were five years ago we have quite an imitate knowledge of need and how it differs in different localities and that means we can be more sophisticated in assigning resources.”

“For example one of our three locality areas is generating around a third more referrals than the others. We know roughly why and we are able to talk with partners about what we can do and we can move the centre of gravity to that particular area since that is, demand-wise, presenting particular challenge for social care and police and health colleagues.”

5. Child sexual exploitation

Ofsted found that the approach to tackling child sexual exploitation in the authority has “led to successful disruption of activity” in the local area.

Working with a wide range of partners is crucial to this, says Meehan, and those partners go well beyond social care and other services that are part of the integrated early support service when it comes to help identify where young people at risk are.

“We have very good corporate relationships with other areas of the council’s activities that can help us: housing, taxis, takeaways, the nighttime economy that young people sometimes gravitate to,” he says. “We know where the greatest risks are.”

Alongside working with other public services in Greater Manchester, Liverpool, North Wales and the rest of Cheshire, this approach has allowed for a “forensic” approach to disrupting sexual exploitation activity, says Meehan.

By Denise Cheung

Coming from a community social work background, I joined the hospital social care team approximately six months after they became an integrated team. Three years later, I’m looking back on my experience and reflecting on some of the key issues I’ve come across. Does integrated working work and what has changed?

‘What do you do? Understanding roles and overcoming frustrations’

This may sound obvious, but I think a key starting point when the integrated team began to carve out its foundations was learning what each member of the team actually did.

I had personally picked up a sense that other members of the multi-disciplinary team had, at least on one occasion, thought: ‘Why does it take so long for a social worker to get anything done? And I’ve heard people say: ‘Why are social workers always typing?’

Having no choice but to collaborate in order to make a discharge happen, our health colleagues learnt the ins and outs of daily social work practice, and vice versa. They soon became aware of the ‘three p’s’ – policy, procedure and paperwork – that constitute a major part of our work. I believe this helped to reduce colleagues’ frustrations with each other and created a more supportive and understanding working relationship.

‘Keeping the patient’s voice alive’

Much of my work consists of completing mental capacity assessments and making best interest decisions on the patient’s behalf regarding residency and care. With contributions from multiple professionals and family members, there is an abundance of information and varying proposals for discharge plans.

Here, key social work values come alive. Autonomy, choice and control, the service user being the expert on their own lives, personalisation, and advocacy.

When unable to reliably contribute due to the impact of dementia, the patient can literally lose their voice in the assessment and decision making process. Even patients that do have the cognitive ability to make decisions regarding their own discharge can have their voices drowned out by people who know the process better and think they know best.

It is my role as a social worker to ensure that the patient remains at the centre of the assessment and to address power imbalances.

‘Managing conflict’

It is a blessing to have multiple experts contributing to the assessment and decision making process because this enables more informed, holistic and robust outcomes. This is particularly wonderful when all involved professionals, and even the patient and family members, agree on the discharge plan!

However, where there is conflict, particularly with my additional responsibility as the best interest decision maker, the role of the hospital social worker can be a lonely and daunting place. You have to of course be willing to continually review all of the available information and the conclusion you have drawn.

How can we make integration work? At Community Care Live an expert panel will discuss the latest evidence on how pioneering areas are overcoming challenges and achieving success in this difficult area.
Find out more

But I’ve learned that when you feel you have reached the appropriate conclusion, it’s important to stand by your professional judgement, even though the pressure can be palpable. The easier option would be to follow the majority but I believe that would compromise the purpose, principles and values of social work itself.

‘Positive risk taking’

There are key principles of the Mental Capacity Act 2005 to consider, such as the least restrictive option and positive risk taking as appropriate. A point that has stayed with me from training on the act is: ‘What is the point of minimising all risks if you have no quality of life?’

In a hospital environment, I’ve found these are not often favourable approaches and there is a general tendency to over-protect patients to avoid the dreaded ‘failed discharge’. But the role of the social worker is not to make your fellow colleagues happy by agreeing to everything they recommend, or to appease demanding family members.

Our number one priority is the patient, their safety, and their quality of life. After all, no one ever became a social worker to win a popularity contest. Just remember, evidence and record everything!