If P? rtn??rsh??p Working Has B????n Central to H??? lth ? nd Soc??? l C? r?? Pol??cy for M? ny D??c? d??s, Why h? s ??t not b????n Successfully Ach????v??d ??n Pr? ct??c??
The notion of ???p? rtn??rsh??p??™ has become imbedded in the Labour government??™s rhetoric in relation to h??? lth and soc??? l c? r?? (Gl??nd??nn??ng, 2002). Resulting in partnership working becoming increasingly central to government initiatives and policies, and although difficult to define, many professionals would agree that partnerships involve an element of shared goals, trust and respect (ref). The title therefore may suggest that org? n??z? t??ons or occupations are to blame for the lack of partnerships or lack of effective partnerships within health and social care. It evokes a critical discussion into the success or lack of success of partnerships in practice. This paper will take the position that partnership working has been unsuccessfully achieved in practice for many decades, and that this pattern of failures will probably continue for some time to come. This position has been taken as it is clear, as will be demonstrated in this report that much progress is still to be made. In discussing the title further there is a clear relationship between policy and partnership working, as policys underpins the effective delivery and provision of services offered by health and social care partners on the operational level. It could be argued however that both political and professional pressures that aided the development of partnerships has also compromised its effectiveness
This report will critically discuss the factors that aid or hinder partnership working, by selecting and analysing theory??™s, professional codes and various practice issues to demonstrate success, failure and areas of improvement. An evaluation of legislation,
policy initiatives and organisational frameworks will be given, moreover the impact of the above on partnership working where service users are involved.
Finally a critical evaluation of the central concepts of partnership working will be offered and applied to practice.
Factors that aid or hinder
The historical differences between health and social care disciplines can be seen as a potential hindrance to partnership working as conflicting views about the service users??™ interests and roles can be a barrier to effective partnership working (Brechin et al, 2000). Health professionals are inclined to seek an explanation of emotional and behavioural problems using the medical model. However the model fails to take into account the impact of social and economic factors on people??™s lives. For example disabled people feel the bio-medical model is never enough as it leaves them in the role of passive, tragic individuals with no model of how to achieve change (Brechin et al, 2000). The medical model incorporates the view of the Wanless Report (2004) which emphasises that the individual is ultimately responsible for their own health. . There is tension between this notion of individual responsibility and the social model that takes into consideration the impact of environmental conditions and poverty on poor health. Social workers may be more inclined to use the social model, in consideration of the social context and the individual??™s life experience.
Differing values as a professional issue is cited by Balloch and Taylor (2001) as one of the complexities of partnership working. Professional codes of practice have many functions which help to promote partnership working such as, providing guidance around duties that protect the public through the setting of standards. Professional codes can be used as a tool of negotiation and can serve as the justification for taking a particular course of action (Hussey, 1996). However codes can hinder partnership working with service users as they can often be contradictory, for example the code may expect the practitioner to work with families, clients, patients as well as other professionals. However this is a complex undertaking as the interests of these differing groups may not be the same (Brechin et al, 2000).
Effective partnerships must be underpinned by a set of shared values. A team is described as a group that shares a common purpose and common goals (Hayes, 1997). Wilmot (1995) compared the 1992 UKCC statutory code of professional conduct for nurses with the (1986) code of ethics of the British Association of Social Workers. He found that although there were similarities the two codes differed in important aspects. The relationship between the state and society appeared as being a legitimate area for action by social workers but not by nurses. Social workers responsibilities were overtly political and challenging. The third area of difference was the notion of respect and uniqueness where it was found that a social worker would be more explicitly required to locate people in their collective and cultural context.
Schon (1991) suggests that the way we understand a situation and how we respond to it, depends very much on the frame in which we choose to see it. The concept of critical practice enables the practitioners??™ to become active participants in creating meanings, understandings and dialogue across difference and remaining open to alternative ideas, frameworks and belief systems, recognising and valuing different perspectives (Brechin et al, 2000). An ethical consideration of inter professional working is clarity about what particular values are held by your own profession and the shared values base by other agencies Where differences are acknowledged and there is confidence in that distinctiveness, but not to be used as a boundary or barrier (Beckett, 2006). The value of sharing knowledge and expertise are the positive aspects of interprofessional working (Leathard, 2003).
Another complexity of partnership working is budget differences between organizations. Ambrose points out that partnership working can be compromised when agencies are working to different financial agendas with different lines of accountability (1999). The previous government (New Labour ) moved a contract culture to a partnership culture driven by performance where resources may be made available but only for specific types of initiative (Balloch and Taylor, 2001) as a result different agencies have different jobs to do with some having limited resources whilst others have bottomless resources to perform their roles. For example, tensions that prevent the development of effective partnerships between health and social services arise from differences in charging policies, with the health service being free at the point of consumption while social services must be paid for in accordance with local policies (Henwood and Wistow, 1993). Within social services the phenomenon of cost shunting and the use of eligibility criteria to control entitlement to public services, have indeed inhibited effective joint working (Balloch and Taylor, 2001).
The Health and Social Care Act (2001) facilitated the development of combined partnership between health and social services. The previous government attempted to develop an integrated approach to the organisations and the delivery of services. Care trusts offer to promote partnership working by binding all partners into corporate shared responsibilities for commissioning and delivering services for older people. This allows for one party in the partnership to take a lead role as commissioner and managing pooled budgets. There remain conflicting views on whether pooled budgets promote or hinder partnership working. A study that assessed children with disabilities who attended a residential school demonstrates that the ability of social services and education to work effectively in partnership could be undermined by the inevitable pressures of individual budgets (Abbott et al, 2000). Additionally, the Means et al (2002) study of local authority services for older people found that joint finance became a source of conflict rather than a route to partnership working because the local authority were anxious about the ability to pick up the revenue costs once the period of short term funding ended. Interprofessional work itself may appear as a cost cutting exercise but little evaluation of the outcomes has been undertaken as the costs of health and social care are based upon a complex arena of increasing needs and changing structures (Leathard, 2003).
Therefore organisational budgets are susceptible to the changing nature of policy and government priorities, which may inadvertently result in either an overlap or gap in service provision this could lead to difficulties, particularly in a climate of budget constraints (Quinney, 2006).
Adkins et al (1999) note that partnership working between agencies is not seen as desirable by service users, particularly if the information is perceived to being one sided. Wilmot (1995) argues that differences in professional values could be treated as an advantage for service users as it offers alternatives and therefore options enhance autonomy. In recognition that in some instances the mere construction of a team may limit the choices available to the user. It may be doubly difficult for the service user to alter or challenge decisions of professionals who represent a collective front as the team. The team may not express their differing professional views in order to maintain good teamwork, which can reduce the options available to users and carers (Mackay, 1995). Collaborative working and information sharing increases their collective power therefore may enhance the feeling of powerlessness experienced by the service user. Clarity about boundaries around privacy and confidentiality are crucial in inter agency work and about the information that will be shared by other agencies (Beckett, 2006).
Partnership in action (DOH, 1998b) highlighted the importance of shared information. The death of Victoria Climbie in 2000 illustrates that despite clear guidance it is possible for the spirit of the guidance to not be followed by practitioners. Almost every inquiry into mental health tragedies called for better communication between professionals and agencies it is hard to argue against the idea of information sharing between professional agencies (Stanley and Manthorpe, 2001). Several writers have cited the importance of effective communication systems within agencies (Hardy et al, 1992; Rogers, 1999; Ovretveit, 1997). Firth-Cozens (1998) and molyneux (2001) described communication and the management of information as one of the indicators for effective partnership working. The development of reliable and user friendly information technology offers possibilities for rapid responses to enhance collaboration at any distance. The pace of computer systems slows down the exchange of information about clients (Balloch and Taylor, 2001). Yet given the variety of methods used to gather information it is extremely difficult for agencies to compare information with one another. As one user put it, information gets passed over and often it gets confused or muddled up (Stanley et al, 2001). In a review of 40 reports of serious incidents of child abuse undertaken by Bullock and Sinclair (2002) cited inadequate sharing of information as one out of the six most common practice shortcomings. Balloch and Taylor (2001) suggest the problem is compounded by the variations in which the different agencies update the information they collect, and
when agencies are protective of their own data sources. They also cite geographical boundaries as a factor that could hinder partnership working preventing the face to face communication on which a shared culture depends.
Policy REMEMBER DOH 2010
Legislation and policy initiatives are central in defining and promoting partnership working. Increasingly, social workers operate within trusts or inter agency teams, which promote different agencies working in partnership alongside other professionals. This government guidance demonstrates that despite professionals working within different value bases there is scope for partnership working. The formation of health and social care partnerships reduce the capacity for strategic disagreements by clarifying roles and areas of joint working (DOH, 1998; DOH, 1997). At the heart of the Modernising agenda are the convictions that what matters is the quality of service outcomes, not the structures in which the services are delivered. The changes being made are an attempt to provide a seamless service DOH (1998) issued guidance on strategic planning, service commissioning and service provision. As Cree states, the recommendation is for a third way, one that promotes independence, protection, equality and efficiency (2002). The intention was to break down the organisational barriers in order to put the needs of the patient and user at the centre of the care process. A model of inter professional working describing inclusive development from Barton (2003) states that there has been a marked shift from fragmented services, separated by rigid boundaries to services working together in a person centred joint approach.
Behind these policy proposals lies the assumption that there is a lack of understanding or misunderstandings and communication problems between different professions or different agencies (Beckett, 2006). It assumes an overarching common interest but can underplay the difficulties in bringing together different interests and cultures (Balloch and Taylor, 2001). In applying the values held by each profession, in particular the commitment to developing user-centred services and forms of empowering practice, there lies a genuine opportunity to place the user at the heart of decision making therefore lessening the scope for partnership working to be negatively affected. To provide the best services for the client professionals must face the challenges of working collaboratively. As Balloch and Taylor (2001) have argued, when partner agencies are not working effectively together, it is the user that suffers
(DEFINITION FOR PARTNERNERSHIP AND COLLABORATION)
Professionals are accountable to legislation and policy-makers as legislative frameworks define power and duties. A source of tension when working with service users is interpreting and applying legislation, especially when there are issues of civil liberties or involuntary service users. For example the framework for the assessment of children in need and their families (DOH, 2000) rightly places an emphasis in working in partnership with parents and children, but gives very little advice on situations in which social workers might feel that parent??™s views have to be overruled (Beckett, 2006).
The inequality of power relations within child protection has been explored (DOH/SSI 1995; Thoburn et al, 1995). The introduction of the Children Act (1989) presented important opportunities to incorporate research into practice and as a result, achieve working in partnership with children and their families yet this legislation and subsequent associated frameworks has struggled to achieve these opportunities. The absence of service users in the development, design and piloting of practice focused material has ensured that child protection remains a professionally dominated and determined framework of services (Adams et al 2002).
Service users are the most important participants in the collaborative process. Service users are pressing for more direct influence and involvement both in decisions about services and decisions that affect them personally (Beresford, 2002).
A factor limiting the effectiveness of partnership concerns the relationship between professional, users and carers (Balloch and Taylor, 2001). The achievement of inclusive partnerships is often compromised by a lack of appropriate skills (Balloch and Taylor, 2001). There are many ways in which social workers, their agencies and their professional collaborators can disempower the users of their services. Empowerment means working in a way that is aimed to increase people??™s sense of power and control over their own lives (Beckett, 2006). At the practice level users are more or less disempowered in their relationship with professionals unless shared decision making is actively embraced (Brechin et al, 2000). Patients may be asked to express their view, but often do not take part in the decision making process. For example in the traditional practice of a ward round, patients may be asked how they feel and whether they are ready to go home, but the clinical decision about when to discharge is left primarily to the expert professionals involved (Brechin et al, 2000).
The clearest instance of user control is the use of direct payments. Direct payments systems provide service users and in some cases carers with cash to purchase their own support. The direct payments system embodies the principles of choice and empowerment, particularly as local authorities have a duty to provide direct payments under the Community Care (Direct Payments) Act (1996). Empowering them to eliminate their dependence on professionals, relatives and carers.
There are benefits and constraints to direct payments, giving advice and appropriate support to service users worried about becoming employers. The involvement of groups and service users in planning services and involvement of service users in research is clearly the direction that policy is headed towards. In fact initiatives such as direct payments, demonstrates that the service user can be included at the strategic level and in terms of service delivery. This is consistent with the idea of empowerment and it will result in a more efficient service (Beckett, 2006).
Often the rhetoric of partnership fails to acknowledge the huge difference in capacity that exists among service users and carers. For example there would be limits to the concept of partnership for people who do not have the capacity to be able to make judgments about their long-term interests for instance people with profound learning disabilities, children or people with motor impairments which makes speech difficult. These people are harder to communicate with therefore require a higher level of skill, confidence and expertise from a practitioner. Specific communication skills are therefore important to ensure that some groups of service users are adequately involved in the delivery of their own services. This is where advocacy and the idea of empowerment are valuable. A clear commitment to Anti- oppressive practice offers the opportunity to understand the service user in relation to the broader circumstances that impact on life chances. Matched by an organisational culture of listening, involving users and carers, and developing a capacity for partnership, flexibility in order to maximise the opportunities for improving outcomes. An inclusive partnership would ensure that the practitioner demonstrates creative responses to meet the particular needs (Balloch and Taylor, 2001).
Clarity about the need to demonstrate respect to the service users is important in situations where conflict can occur (Balloch and Taylor, 2001). Inclusive partnerships are characterized by the active participation of all interested parties, including service users and carers, in decision-making and conflict resolution (Balloch and Taylor, 2001). An inclusive partnership would ensure that the service user and carer are listened to and facilitate clear expectations and explanations of any failure to meet particular needs or to respond to user??™s and carers expressed wishes. Empowerment depends on respect for users and carers views, and their involvement in decision making at all levels (Balloch and Taylor, 2001). The practitioner should facilitate and develop person centred plans to address specific needs (Horner, 2003).
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