Cierre del proyecto

The integration of health and social care in mental health services has been complex. The UK government policy has placed considerable emphasis on the need for inter-professional working in mental health (Huxley et al., 2008, Larkin and

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Callaghan, 2005). Leathard (1994:338) identified Government documents, such as „The Community Care Act‟ (Department of Health, 1990b), „Building Bridges‟ (Department of Health, 1995), „The New NHS: Modern and dependable‟ (Department of Health, 1997), „Our Healthier Nation‟ (Department of Health, 1999c) and „Partnership in Action‟ (Department of Health, 1998b), as some of the key documents in driving forward the inter-professional agenda. Further to these documents, Huxley

et al. (2008:476) report that „The Health and Social Care Act‟ (2001) promoted

integration through the development of care trusts between health and social services, and the 2006 White Paper „Our Health, Our Care, Our Say: A New Direction for Community Services‟ (Department of Health, 2006) offered further opportunities to develop a more joint approach, to strategic needs assessment, finance, inspection and other infrastructure elements needed to support better integrated working between health and social care. As Huxley et al (2008:476) explain “these legislative measures are designed to remove statutory barriers to closer integration of health and social care, but contain very little guidance about the active promotion of new ways of working together”. Since the election of the New Labour government in 1997, integrated, multi-disciplinary working has remained a central feature for UK health and social care provision.

It is important to understand here the rationale for multi-disciplinary teams. Couchman & Dawson (1995) explain that multi-disciplinary teams have been considered as being a means of achieving the co-ordination that is required to achieve effective community care. As described by Columbo (1997) the rationale for multi-disciplinary teams is to solve a range of complex problems in the treatment, management and care of service users with Serious Mental Illness (SMI) by a group of professionals with different disciplinary backgrounds through an open exchange of their skills and ideas.

Social workers have been working in multidisciplinary CMHTs, while employed by LAs, for more than two decades. However, the decision to go for integrated trusts was announced as part of the NHS plan in 2000. The government publication „Positive Approaches to the Integration of Health and Social Care in Mental Health Services‟ (2002) stated that the integration of health and social care in mental health has been a central plank of government policy for a number of years. Most importantly service users have consistently said they value receiving services from

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one integrated organisation (Department of Health, 2002). This integration process has been very complex and has varied from Trust to Trust. A major aspect of team working includes the integration of different professionals working in the same multidisciplinary team. However, the literature suggests that there are many implications for social work practice as a result of integrated approaches to care delivery. Davies (2007:56) explains, “within CMHTs the „forging‟ of an integrated approach to service delivery has had a number of implications for the delivery of services and for the professionals themselves, including social workers”. Davies (2007:57) further describes these implications as follows:

The organisation of CMHTs is central to their functioning (Onyett et al, 1997) as by bringing together this range of skills from the different professional groups, it is anticipated that a more effective care-coordination can be achieved, compared to professionals acting independently in the delivery of services to people with SMI. In principle, this inter-professional working is considered to provide a number of benefits including: the expansion in the range of skills that are available to meet the complex needs of service users and the creation of tension within mental health services that is required to facilitate an innovative practice environment.

Davies (2007:54) citing (Atkins & Walsh, 1997) emphasises that:

To this end, an integrated approach between different professionals and agencies is considered an important element in improving service quality (For example, in order, that „services move around the person, not the person around the service‟), service delivery needs to be integrated and meet continuity of care. People should experience their services, as being well co- ordinated in order for them to make a difference in the quality of their lives. The aspiration of this approach is to „provide service in which the boundaries between primary health care, secondary health care and social care do not form barriers seen from the perspective of the service user‟ (Department of Health, 1990). Thus, in policy terms, agency and professional boundaries were perceived as barriers to continuity of care and the creation of teams the chosen method of overcoming them (Davies, 2007).

Different scholars have described the benefits as well as challenges in integrated working. Hannigan (1999:28) points out, “Distinctions between the concepts, values and consequently the activities of professional groups in CMHTs present both challenges and opportunities for joint work”. Sheppard (1990:73) describing the opportunities offered by working in unified teams explains the „encouragement of

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„seepage‟, a process in which values and concepts flow from one professional group to another‟.

Hannigan (1999:30) sees that the involvement of different professional groups in the provision of mental health services presents both challenges and opportunities for effective joint working. He reveals two challenges that need to be overcome for effective joint working:

1. The limited understanding by professionals of the concepts, values, language and activities of other disciplines.

2. The encouragement of inter-professional boundaries by separate initial training.

He also reveals the opportunities that exist by placing workers from different traditions in unified CMHTS which are:

1. The „seepage‟ of values, concepts, knowledge and skills from one professional group to another

2. Shared inter-professional education and training

(Hannigan, 1999:30)

Whatever the benefits integrated work bring into CMHTs, it is important to understand that for the effective functioning of any team, certain aspects of team working have to be completed. Davies et al.(2007:65) citing Borill et al. (2000) explain that; “for teams to be effective there should be clear, shared team goals with build-in performance feedback, as where teams are set clear targets at which to aim and they receive feedback on their performance, their performance is generally improved”. As they further explained:

Consequently, this lack of clarity and set aims had made workers unclear about the benefits that came from working in integrated teams so that the „present arrangements [were] actually encouraging boundaries rather than eroding them‟. In this way, staff were also found to be personally defining their own professional boundaries and had an overly restrictive sense of professionalism (seen as a barrier to effective team working) so that on occasion, strategies were identified where staff regulated and limited the demands made on them” (Davies, 2007:65).

Some other scholars also point out the importance of having clear cut aims and goals in the teams, as well as the importance of conducting training programmes to

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develop understanding on each other‟s professional roles and challenge some of the professional identities. Davies (2007:65) explains:

“For collaboration to occur, it is necessary that individuals are both confident in their own role and respect the expertise and roles of other professionals. In order for professionals to construct identities of themselves and an understanding of others, „it is necessary to establish both uni- and multi- professional developmental training programmes at local level, to allow professions to see themselves as others see them, and so challenge and modify their own professional identities‟ (Jones & Norman, 1998). This is also more likely to occur when professionals are clear about the aims of the team and their own personal role as a practitioner.

Hannigan (1999:30) further explains that; “It is not the case that effective joint health and social care provision can necessarily be achieved through „goodwill and co- operation‟ alone, as the Audit Commission (1992:23) has suggested. The previous government‟s Green Paper, „Developing Partnerships in Mental Health‟ (Department of Health, 1997) acknowledged that fundamental problems in care co-ordination do exist, at structural, financial, organizational and professional levels”. The Green Paper proposed four options for change and invited comments on each.

Option 1

A single mental health and social care authority, with sole responsibility for planning and commissioning services.

Option 2

Either health or local authorities be designated with the responsibility for planning and commissioning both health and social care services.

Option 3

Joint health and social care bodies would unite mental health budgets and be accountable to local authorities for the planning and purchasing of social care and be accountable to health authorities and GPs for the planning and purchasing of health care.

Option 4

Health and local authorities agree to delegate particular responsibilities from one agency to another.

(Hannigan, 1999:30) Huxley et al (2008:477) referring to the „Modernising Adult Social Care‟ research programme, explain that; “health staff‟s unfamiliarity with social care perspectives,

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and lack of knowledge of referral and other processes, can act as a barrier to partnership or service integration”. Further, referring to Cestari et al.‟s 2006 study Huxley et al claim that; „they had found evidence that assessments of mental health and social care needs are being kept apart in some services, which was not the policy intention‟. In further describing this issue Huxley et al (2008:477) explain:

Implementing Fair Access to Community Services (FACS) in an integrated setting was made even more challenging by the culture difference between health and social care, producing resistance on the part of nurses to incorporate FACS into their initial screening assessments. Some health staff do not necessarily see meeting social care needs as a priority, and those who define the health service and themselves as not providing social care may not make appropriate judgements about the necessity for an assessment of social needs. There may also be staff whose background and training focused insufficiently on the ability to detect and assess social needs, whose assessment may therefore be cursory and/or out of line with FACS criteria. Kings Fund Commission (1997) has also pointed out some issues with relation to multi-professional working. As Norman & Peck (1999:217) describe:

“the Commission points to disagreements between mental health care professionals about what constitutes mental health and illness and sees debates about effective approaches to treatment as a particularly divisive issue, which causes tensions in joint working at agency and team level. The results are communication difficulty, and conflict about leadership, effective team management and role identification, issues that stunt the development of community mental health teams.

The commission has further recommended that „multi professional training and education‟ as a long term possible solution to overcome these issues. Norman & Peck (1999:219-220), in looking at „why the staff in many CMHTs do not strive towards achieving good inter-professional working‟, had identified the following reasons.

1. Loss of faith by mental health care professionals in the system within which they work;

2. Strong adherence to uni-professional cultures;

3. Absence of a strong and share philosophy of community mental health services;

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They further clarify this as follows:

“Roles and responsibilities of mental health staff are integral to the professional persona and are likely to be defended vigorously. In seeking an identity, a sense of worth, mental health care professions will seek to distinguish their roles. These roles and responsibilities are reinforced by professional ideologies, models of working, professional training, status and reward” (Norman and Peck, 1999:228).

It is also worth stating here some ideas from Onyett (1999:79) that “the amount of time team members spend with each other will be influenced by operational features such as whether the team has a shared physical base, how much time they spend in meetings together and whether the team has a policy of joint working”. Price & Seagal (2005) cites by Davies (2007:64), have also suggested:

In order for service provision to be more effective, following the move to integration, a combined approach in which the medical model is used in combination with other models of care may be the most efficient way of working with people who have SMI. Although the approach recognises the challenges that can impede inter-professional collaboration, intertwining the medical model with other models of care has distinct limitations, as well as merits!

Lankshear (2003:61), cites by Davies (2007:61), identifies the areas for possible conflict and confusion between the professional groups who comprise a multidisciplinary CMHT, as follows:

1. Differences in world view 2. Professional identity 3. Pay

4. Educational Background 5. Status and attitudes

6. Assertiveness of members of the team, and the assumption that the doctors would be the leaders

As Davies (2007:61) reports Lankshear (2003) has identified „that the sources of conflict that largely appeared to affect professionals were predominantly caused by external forces‟. Thus, workers in teams had formed strategies to deal with the new ways of working as: „demarcation‟, which refers to professional groups establishing

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clear professional boundaries in order to preserve the „professional identity‟”. Davies (2007:61), presenting data from his research, explains that Lankshear (2003), had identified a small number of social workers who adopted this strategy as they felt „like cuckoos in the nest‟ due to a feeling of isolation and the loss of support from others of a similar background”. Rogers & Pilgrim (2001) report that „clinical psychologists are more concerned than other professions about being drawn into inter-professional teams, „perceiving that this would entail losing professional status and jeopardising their apparent ambition of becoming as powerful and autonomous as psychiatrists‟. Onyett et al. (1997), Craik et al.(1998) and Peck & Norman (1999), cited by Davies (2007:62), suggest that “The fear and loss of professional identity in CMHTs has also been widely documented for occupational therapists who have been advised against assuming a generic key worker role by their own professional body”. This indicates that integrated working in CMHTs has led different professionals to many issues with their professional identities.

Some scholars emphasise the change of roles that integrated working brings into CMHTs. Onyett et al.(1995), cited by Davies (2007:64), emphasises that “With the introduction of integrated working within CMHTs, workers have been required to move away from their traditional professional roles and into newly designated roles that are more generic”. Davies (2007:64) further explains about „role blurring‟, by giving the examples of a social worker who has to monitor the side effects of medication and a clinical psychologist who has to help to organise accommodation for clients. He emphasises that “any member of the team can deliver many of the critical ingredients of good care, even if the aspect of care being delivered is not traditionally associated with that profession”. Wall (1998), cited by Davies (2007:64), reports that „when staff share tasks and operate outside of their area of expertise there is resultant loss of efficiency with consequential detrimental outcomes for service users‟. However, Davies (2007:64), citing Burns (2004), suggests more positively that the willingness of „highly trained staff members to „stretch‟ themselves outside of their job description (but within their personal competence) is viewed as a preferential option, in that not too many individuals are involved in the care of one patient‟. Davies (2007:64) reveals that “this approach to working was viewed by Singh (2000) as being a facilitator to improving the effectiveness of running an effective community mental health team”. Davies (2007:64-65) in referring to

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research conducted by Brown et al. (2000), which was based on „professionals view shortly after moving to integrated teams‟, reveals that, “there had been a „blurring of roles‟ in the teams following integration, so that staff were required to undertake tasks for which they had not been specifically trained”. As Brown et al (2000) further reports, “practitioners in this research also showed concern towards „the agendas and policies of their senior colleagues and a lack of leadership to provide the various professionals with clearly defined goals”.