Managing Multi-Agency Working in Elderly Care
Managing Collaboration & Multi-Agency Working for older people’s services
Executive summary and introduction
Collaboration in the field of both welfare and healthcare, on one level, can be expedient, efficient and economical. On another, more practical level, it can be a minefield of legislative, practical and interpersonal difficulties. (Arblaster. L. et al 1998)
This report will consider these aspects in direct consideration of collaboration of the various aspects of care related to the elderly.
It has to be viewed as being within the spirit and the legislative restriction of the NHS Plan (DOH 2000) and therefore considers the methods of collaboration with the PCTs in some detail, and also in the spirit and legislative requirements of the National Service Framework for the elderly. (Rouse et al 2001)
What is collaboration between organisations?
The transition from the concept “Empire” culture to the “Seamless interface“ culture is effectively based on the concept of practical and effective collaboration. (Powell, J. & Lovelock, R. 1996)
The changes that were proposed in a number of recent pieces of welfare based legislation (after the 1993 changes in the community care organisation and the National Service Frameworks to quote just two), have all espoused collaboration as their raison d’etre. Clearly, in consideration of the elderly, there are numerous organisations that can potentially collaborate (Appendix Two), and all have their strengths, weaknesses and pitfalls. Let us examine one important area as an illustration.
If we consider the welfare/health service interface. Primary healthcare teams control access to secondary and community health services through patient referrals. Social Services equally manage funding for home care and residential services including nursing home facilities and control access through assessment and care management. (Glendenning C et al 1998).
When it is the case that, in terms of professional organisations, one depends upon another for access to services, their ability to obtain their own organisational or professional objectives can be severely compromised. (Haralambos M et al 2000).
In practical terms, the GP is dependent on the social services to fund the appropriate facility whether it is a nursing home, domicillary enhancement services to keep a patient out of an acute medical hospital bed, or other forms of social support to facilitate the timely discharge of a patient from hospital. The arguments for collaboration are so overwhelmingly obvious that they hardly need repeating here.
In real terms, the consideration of collaboration between organisations more analytically hinges on the question, “which organisations?”. The example that we have given is a fairly common collaboration and is therefore enshrined in both common working practice and also with legislative and regulatory boundaries. The advent of the National Service Frameworks have helped promote commonly recognised goals and objectives across the health/welfare spectrum of care, although a number of financial issues and problems with the organisational culture interface can commonly difficulty in everyday practice (Wierzbicki & Reynolds 2001).
Other organisations have to liaise and collaborate with the Social Services Dept. such as local and national voluntary support groups and specialist interest support groups, (often disease process based,) and these generally have much looser procedural issues and practices which may need different considerations. We shall discuss these in greater depth elsewhere in this essay.
What are the problems?
Taking a broad overview of the scope and possible nature of collaborative enterprises. Problems can arise from a number of organisational areas. Financial considerations, especially financial accountability, cause problems when this eventuality has not specifically been legislated for. Appendix Three sets out many of the potential pitfalls in this area. We observe that the health based services are essentially free to the patient whereas Welfare is largely means tested and thereby rendered vulnerable to changes of political direction and pressure. (Audit commission 2004)
Another major area of potential difficulty stems from the historical development of professional language, terminology and working practices that each collaboration can interface. Client, patient , in need, deserving, dependent – all are terms frequently used by various healthcare professionals, but with different interpretations and nuances of meaning. Collaboration will inevitably require a more exact and specific vocabulary to be evolved and agreed. (Garlick C 1996).
Collaboration inevitably means information sharing. The “Empire” concepts and constructs take a long time to die and be eradicated, but the seamless interface can only realistically be expected to work if all available information is shared. This raises serious problems of confidentiality if information is expected to be shared between healthcare professionals and collaborating agencies from the voluntary sector for example. (Cameron,A et al 2000).
What are the solutions?
Management solutions can be both complex and difficult to introduce or impose. By virtue of the potentially disparate nature of the collaborative partnerships that we are considering, there is clearly no “one size fits all” solution. It is for this reason that general principles are more useful than specific suggestions.
The management of change (and therefore the solutions) is perhaps the most fundamental element in the discussion. Visions, ideas and directions are of little value if they cannot be translated into reality. (Bennis et al 1999).
We can turn to the writings of Marinker (1997) who points to the fact that systems change, and indeed change management itself, are responsive to the acceptance of a division between concordance and compliance. People generally respond better to suggestion, reason and coercion rather than imposition of regulations and arbitrary change. The models that rely on publication and dissemination of information are generally more likely to be well received and more fully implemented, particularly if it is peer driven. (Shortell SM et al 1998)
This is perfectly illustrated by the Davidmann Report (Davidmann 1988) on the debacle of the introduction of the Griffiths Reforms in the 80s.
(Griffiths Report 1983). His major findings were that the Reforms failed because changes were imposed rather than managed
Collaborative solutions should only realistically be made after a careful consideration of the evidence base underpinning that proposed change. (Berwick D 2005).
Modern management theory calls for appropriate evaluation of the need for collaborative proposals by considering the evidence base on which the situation could be improved, its implementation by making managers aware of the need for change and proactively encouraging them in the means of implementation, and then instituting a review process to evaluate the effectiveness of the measures when they have been in place. (Berwick D. 1996) (Appendix five)
Models of Collaboration
There are a great many models of professional collaboration cited in the literature. In order to make an illustrated analysis, we will return to the specific example of the Health/welfare interface to consider some of the models in that area. In general terms, all of the models follow the functional structure – Plan, Implement and Review (expanded in Appendix Five).
The Outreach (or Outposting) model appears to be a commonly adopted model (McNally D et al. 1996), whereby a social worker is attached to a primary healthcare team. In terms of our analytical assessment here we should note that such arrangements, if subjected to process evaluation, generally promote progression towards a seamless interface in areas such as:
The sharing of information and in mutual understanding of the different professional roles, responsibilities, and organisational frameworks within which social and primary health services are delivered.
It is also noted that such benefits are generally greater if the implementation of such models is preceded by exercises including team building or joint training exercises. (Pithouse A et al 1996)
Other models include the Joint Needs Assessments model in which service commissioning between primary health and social services teams have a common assessment base (Wistow G et al. 1998). This does not appear to have been as successful as the outreach model, and has had a rather variable history (Booth T 1999).
Collaboration here has involved a variable number of agencies but not always the primary healthcare teams. The new primary care groups will have a strategic role in the commissioning of a broad range of health and welfare services. All NHS organisations have a clear imposed duty of collaboration and partnership with the local authorities (NHSE 1997)
Collaboration in the form of joint commissioning models have also been tried. They tend to fall into one of three patterns including
Area or locality as basis for joint commissioning
Joint commissioning at practice level
Joint commissioning at patient level
None have been in place for long enough for a realistic assessment of their relative strengths and weaknesses to be evaluated yet. (Glendenning C et al 1998)
Models- Interprofessional/teams
One of the more successful models of collaboration is that of the multidisciplinary pre-discharge assessment team which, when it works well, can be considered a model of good collaborative working (Richards et al 1998). This requires all of the elements referred to above to be successfully implemented and to be in place if the optimum result for the client is to be obtained. Such a model calls for professional integration and collaboration of the highest order if National Service Framework Standard Two is to be fully realised. The framework calls for all concerned professionals to:
Ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries.
It is, in our estimation, the crossing of these boundaries that, perhaps, is the key to collaboration.
Review
Collaboration as a concept is comparatively easy to define. Any dictionary will give a reasonable definition. As a workable model of practice, it is far more nebulous and hard to achieve. In this review we have tried to consider the barriers and management problems that make it harder to achieve together with the mechanisms which will militate towards successful implementation.
We have identified financial and cultural barriers, as well as structural and organisational ones equally we have pointed towards models of collaboration which appear to be working well. It would appear to be the case that the prime factor in the success or ultimate failure of a collaborative exercise, is the success and management skills with which it is initially introduced.
References
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