Developing and Managing High Quality Services for People with Learning Disabilities

Mark Burton, Mike Kellaway

• Publisher: Taylor & Francis
• Year: 2018
• eBook ISBN: 9780429856365
• Edition: 1
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

First published in 1998, This timely book describes the challenges that need to be met in bringing together health and social services into a partnership to create effective and responsive services. It presents the reader with both conceptual frameworks and practical examples on how change can be managed and the momentum maintained towards the development of a quality service. The authors present practical examples and reflect on what worked and what was not successful. Over twenty writers (staff and managers, senior and junior, qualified and unqualified) describe focused work in particular areas which will be of interest to any service for this user group. Throughout, the emphasis is on how to deliver an accessible good quality service and how this can be safeguarded in the future. Fifty years after the establishment of the NHS, and nearly twenty five years since the establishment of British Social Services departments, this book articulates a modern, practical and principled vision of community based services to vulnerable people.

Part I
Organisational Issues

Introduction

The two chapters in this Part, both by Mark Burton and Mike Kellaway, concern the structures of the service.

Chapter 1, 'Joint Working' addresses the split in the UK between social care and health care. As might be expected, given its origin in a joint provider organisation, a key theme of this book is the indivisibility of health and social needs and issues. Although the organisational split between health and social care is by no means inevitable, in the UK the division between central and local government responsibilities tends to exacerbate it. Given this separation, joint working arrangements between health and welfare organisations become necessary if people with learning disabilities and their families are to receive coherent services. Chapter 1 reviews the issues involved in enhancing joint working and illustrates these with the development of the joint provision model in Manchester and its implementation in the Joint Service.

Chapter 2, 'Designing the Organisation', deals with the internal structure of the organisation. As Pettigrew (1986) pointed out before the last upheaval in health and social provision, changing organisational structures alone will not deliver significant benefits, but in conjunction with other 'management levers' - strategy, process, systems, beliefs and behaviour, and capability - fundamental change (for the better) can take place.

Reference

Pettigrew, A. (1986), 'Managing strategic change' in G. Parston (ed.), Managers as Strategists: Health Services Managers Reflecting on Practice, London: King's Fund,

1 Joint working

Mark Burton and Mike Kellaway

People with learning disabilities have many different needs. Some of these are commonplace and some are special.

Derek is a young man in his late twenties. He is described as having a profound learning disability, but he walks and we believe that his vision and hearing are unimpaired. He lives in an ordinary house in the community and is supported by staff 24 hours a day. Staff believe that he enjoys swimming and walking. Left to his own devices Derek will do little, except acquire food and drink. He will occasionally get up and change his position. He can do little for himself, although he has learned spoon feeding, door opening and masturbation in the last 15 years. He exhibits a great deal of self-stimulatory behaviour, and this shades into head-banging, particularly when there is little to stimulate him in his immediate environment.

From the time we have spent with Derek, we have good reason to think that his needs include the following:

Ordinary needs	Special needs
• nutritious food	• help to overcome his head-banging
• a comfortable house
• people that know, understand and care about him	• protection from dangers he does not understand
• being in ordinary places in the community	• effective teaching of new skills
• a guaranteed income.
• alternative activities to self-stimulation.

Meeting needs is not the exclusive preserve of one single organisation, and our experience teaches us that people are best supported where staff with different skills, experiences, knowledge and backgrounds work closely together. In Derek's case this means deploying the 'ordinary' skills of making a comfortable, welcoming home and sustaining his relationships, in concert with the more specialist skills of analysing his repetitive behaviour and self-injury, and creating effective and sustainable interventions to reduce them. The task, then, is one of enabling the different employing organisations to work together effectively so that people with learning disabilities and their allies experience 'seamless' provision - that is, provision without artificial barriers, boundary disputes or rivalries.

However, while the idea of enabling the different organisations to work together sounds simple, it is rarely straightforward in practice. In this chapter we explore the development of joint working consider key issues in its realisation and provide guidance on how to make it happen, with illustrations from our own experience in Manchester.

The long and slow development of joint working in the UK

In 1948 the National Health Service (NHS) was established, and provision for people with learning disabilities was reorganised. One consequence was that the 'colonies' and similar institutions which had been run by local authorities were taken into the new NHS, and, overnight, some staff were redesignated as nurses. This was followed by a period during which intellectual disability was 'medicalised', with 'mental handicap nursing' only gradually working its way into a more social and developmental model.

Meanwhile the care of those people who were not in institutions became the responsibility of the mental health departments of the local authorities. They employed mental welfare officers, and ran services such as adult and junior training centres and, eventually, hostels.

This division of labour changed slowly in the first two decades after 1948. In 1959 the new Mental Health Act heralded a policy shift towards caring for people in the community. In 1971 the 'Seebohm' reorganisation led to the establishment of local-authority social services departments, which combined a variety of functions including child protection, mental welfare and the social care of older people. In 1974 the NHS was reorganised with the establishment of regional and area health authorities, which hesitantly began to change focus from hospital provision to the meeting of health care needs on a population basis. There was some realignment of responsibilities between the NHS and local government with these two reorganisations, and the transfer of staff in both directions. Unfortunately, one consequence of 'Seebohm' was a switch in most authorities to generic social work. The skills, experience and knowledge of mental welfare officers was often lost within these new generic teams.

Other changes were taking place at the same time. Many were underpinned by a 'philosophical shift' in the way in which people with intellectual disabilities were perceived: new psychological and educational research increased expectations, the 'community option' began to become a reality in several different countries, and positive ideologies such as 'least restrictive alternative', personalisation and 'normalisation' became influential, partly in the wake of the 1960s civil rights movements. Notable developments in the UK were:

• 1971: Government White Paper, Better Services for the Mentally Handicapped. Emphasised the goal of community-based provision (but in a limited way).
• 1971: Education Act gave all children the right to education. Junior training centres were redesignated as special schools.
• 1974: The Joint Finance scheme was established. This was a ring-fenced budget allocated to health authorities but spent jointly with local authorities. Joint planning structures were set up to make decisions.
• 1975: A National Development Group and a National Development Team were set up following several hospital abuse scandals. The National Development Group published a report, Teams for Mentally Handicapped People, which recommended an interagency and interdisciplinary community learning disability team model.
• 1979: The Jay Committee report on the future of nursing care for people with learning disabilities, influenced by the early staffed housing models, emphasised homemaking skills and proposed a merger between the registered nurse, mental handicap (RNMH) training and the Certificate of Social Services qualification. Although resisted by the nursing profession, it became influential for its model of care.

In the 1980s joint working developed slowly and to different extents between authorities. Professionals in NHS community services and in social services departments often established good working relationships despite their employing organisations. Before the mid-1980s very few NHS community-based professionals specialised in learning disability. The 1983 Care in the Community circular extended the Joint Finance scheme and also enabled health authorities to transfer funds to local authorities and the voluntary sector. This became the basis for the resettlement dowries (cash-linked with people discharged from hospitals) and gave health and social services authorities a considerable incentive to agree a vision and jointly plan to resettle people. Again, the development was uneven across the country: regions which required agreed plans between local authorities and district health authorities achieved greater commitment to, and experience of, interagency working.

Just as the joint approach seemed to be maturing at the end of the 1980s, health and social services were thrown into a period of uncertainty and upheaval with the National Health and Community Care Act 1990 which led to purchaser-provider splits, increased outsourcing in the independent sector and a loss of continuity in many areas as staff and managers changed jobs. In many areas this weakened joint working.

Key issues

Promoting joint working involves considering a number of issues, concerning what is to be attempted and what local factors will help and hinder the effort. These issues can broadly be broken down into the following:

• the degree of joint working intended
• role clarity, division of labour, overlaps and gaps
• leadership, responsibility and management
• markets and the purchaser-provider split
• the political dimension.

How joint?

What degree of joint working is to be attempted? As is shown in Table 1.1, the degree of joint working can be rated from low to high on two dimensions - staff working practices, and organisational collaboration. Table 1.1 seems to demonstrate a developmental progression from low 'jointness' to total integration, and this may be a useful perspective. However, it is sometimes possible to jump stages, if the will is there.

Role clarity, division of labour, overlaps and gaps

This issue concerns the focus of each organisation's effort. In some places health and social services have very different functions and responsibilities, while in others there can be overlap. For example, in Manchester, a decision

Table 1.1 Degrees of joint working

Rating	Staff working together	Organisations working together
Nil	Staff work entirely separately, in ignorance of each others' roles.	No liaison, duplication of functions. Ignorance of other organisation.
Low	Staff refer to one another and meet at reviews and case conferences.	Liaison at the margins (for example, through mandatory forums).
Mid	Staff involved in joint ventures such as joint training. Attempts to use common systems of case coordination, registers and so on. Increasing understanding of each others' roles.	Shared strategy but separate management: likely to be some collaborative joint problem-solving leading to flexibility of resources (for example, loan/secondment of staff).
High	Co-location of staff, but still mostly under separate management. Staff increasingly working together as one team. Increasing respect for each other's skills.	Some experiments in full collaboration – for example, some management and coordination across organisational boundaries
Total	Staff managed together as one team.	Organisations have joint management agreement, with single manager/management team.

taken early in the 1980s led to the NHS concentrating on the provision of a variety of professionals through community teams, while social services emphasised 'hard provision' such as day services, 24-hour care, and unqualified staff providing practical support to families (as well as employing specialist social workers). As a result, the services complemented one another, and it soon became obvious that joint effectiveness would be improved by integration.

In some other nearby districts, the NHS had provided large-scale housing-based residential services and had only a minor investment in professional staff other than nurses. Meanwhile social services provided traditional hostels, newer dispersed residential services, day services and (largely generic) social workers. This resulted in a duplication of residential function and gaps in the professional and non-building-based practical care elements, making the integration of services perhaps less easy to arrange, even though it was no less desirable than in Manchester.

Leadership, responsibility and management

What can be achieved in the short term will partly depend on the leaders in both organisations. Here is a set of questions tha...

Table of contents

• Cover
• Half Title
• Dedication2
• Title
• Copyright
• Contents
• List of figures
• List of tables
• List of contributors
• List of abbreviations
• Foreword
• Note to readers
• Introduction
• Part I Organisational Issues
• Part II Equipping, Supporting and Leading Staff
• Part III Developing the Service
• Part IV Safeguarding Quality
• Appendix