Challenges to working well together with adults
In this section we explore challenges to working well together, with an emphasis on how health and social care services work together for adults.
Activity 6.7 What are the challenges?
Watch the panel event and then use your learning log to answer these questions:
- What challenges do the panel members and the questioner identify as getting in the way of health and social care working together?
- What do they think needs to happen to enable services to work together better?
A number of challenges are discussed by the panel: Etienne talks about the need for 'a massive cultural change' and the development of a shared service culture that values human rights, independent living and citizenship. Kirsten Rummery emphasises the need for personalised approaches such as self-directed support to be mainstreamed, especially in the health service. And Colin, the questioner, reminds us that money is a key issue: a shift towards personalisation, of people having control of their own budgets, means a loss of control of funds for large organisations like the health service (much the 'dominant partner' when thinking about health and social care). Interestingly, it is suggested that the introduction of self-directed support legislation may be an important driver for better service integration.
We now go on to explore in more detail three of the key challenges that the panel identified:
- professional cultures
- structures and organisations.
There may be many reasons why different practitioners and organisations find it difficult to work together to provide a coherent service; one of the key challenges is money. Money can be the root of argument in even the most intimate of relationships, and the same is true for organisational bedfellows. This is particularly true of the funding of health and social care.
In 1999 the Royal Commission on Long Term Care reported that:
The current system is particularly characterised by complexity and unfairness in the way it operates. It has grown up piecemeal and apparently haphazardly over the years. It contains a number of providers and funders of care, each of whom has different management or financial interests which may work against the interests of the individual client. Time and time again the letters and representations we have received from the public have expressed bewilderment with the system – how it works, what individuals should expect from it and how they can get anything worthwhile out of it. We have heard countless stories of people feeling trapped and overwhelmed by the system and being passed from one budget to another, the consequences sometimes being catastrophic for the individuals concerned.
Since this was written there have been some important funding changes in Scotland (such as the introduction of free personal care for people who are over 65), but many of the same problems persist. Thirteen years on, the Scottish Government stated that addressing the challenges of separate – and sometimes disjointed – systems of health and social care will demand:
commitment, innovation, stamina and collaboration from all of us who are involved, in different ways, in planning, managing, delivering, using and supporting health and social care services.
The passing of the Public Bodies (Joint Working) (Scotland) Act 2014 is an important step in the Scottish Government's steady move towards greater health and social care integration.
All professions develop particular ‘cultures’ – sets of values, beliefs, attitudes, customs and behaviours that evolve over time. These reflect the history of each profession, the characteristics of the people that join the profession (like gender and social class), and how professionals are trained. Professionals tend, for example, to develop their own language – or jargon – that can be difficult for members of other professions to understand. Differences in professional cultures create potential for the fragmentation of health and care services.
Professional cultures can also exclude professionals themselves from decision-making processes. Viewpoints that do not share the knowledge base of the dominant profession in a particular setting can be more easily dismissed. Status boundaries, for example, between nursing and medical staff, and social care and health care, and the public, private and third sectors, are, as you learned in Section 1 , continually being negotiated and renegotiated.
Of course, the need for working together is not new and a lot of work has been done in Scotland and elsewhere, to try to make sure that services ‘join up’. This is particularly important when a person must frequently use both a number of different services. For example, when somebody has a long-term mental health problem they are likely to need a range of different kinds of supports, including medical, nursing and social care. Sometimes these services work well together, but differences in knowledge base, power and professional cultures may frustrate collaborative working – to the detriment of a good service for the person who is being supported.
In this section we’ve emphasised the difference in professional culture between ‘health’ and ‘social’ care. This distinction is important but it is not the only cleavage between professional groups. For example, how an occupational therapist ‘sees the world’ and how a social worker ‘sees the world’ may differ – and this can create difficulties in collaborative working even if they work for the same local authority department.
Structures and organisations
Sometimes difficulty in collaborating is not about different professional cultures; rather, it is about how a whole society thinks things should be organised.
Demand for government-provided services, such as health, grew at a great rate during the 1950s and 1960s, and at the same time people increasingly felt entitled to these services as a matter of right. The organisations responsible for service delivery grew and became ever more complex and expensive, and there have been regular restructurings of health and care services in response to successive changes in community care policy.
Whatever the motivation for structural change, if the organisational structure becomes central to the desired change then service users cannot be central, as these quotes from Alison Petch at the Institute for Research and Innovation in Social Services (IRISS) and Chris Ham at the Nuffield Trust indicate:
There is clear evidence that structural integration does not deliver effective service improvement. The emphasis should be on service integration rather than on organisational integration. Moreover the focus should be on the specific aspects of individual partnerships which deliver particular outcomes for identified groups.
The journey towards integration needs to start with a focus on service users and from different agencies agreeing a shared vision for the future, rather than from structures and organisational solutions.
We now go on to look at the potential consequences for service users and carers if services do not start with the service user, but instead work separately with differing aims and working practices.