Exploring the evidence base for integrated children's services

3. Defining Integration

The area of inter-agency working has been referred to, understandably, as a "terminological quagmire" (Lloyd, Stead and Kendrick 2001). The term integration can mean different things to different people and there is a lack of clarity about its meaning (Integrated Care Network 2004).

Reflecting such muddiness, terms such as partnership working, joint-working, joined-up working, inter-agency working, multi-agency working, multi-professional working, inter-agency communication, intra and inter-organisational collaboration and collaborative working are often used interchangeably when discussing integrated working (Percy-Smith 2005, Sloper 2004). Percy-Smith (2005) found a similar landscape when attempting to define "partnership" from such terms, accepting that overlap is likely to be inevitable. Attempting to distinguish partnership from other terms and at least define what partnership is not, the author uncovered a number of terms and concepts related to partnerships (Annex A), and defined integration as "agencies working together within a single, often new, organisational structure".

The Integrated Care Network's guide on Integrated Working similarly recognises from the outset that the term integration should be handled with caution and encourages professionals to challenge others about its meaning when the term is used. The Network defines integration as "a single system of service planning and/or provision put in place and managed together by partners who nevertheless remain legally independent" (2004). Such a single system would unite mission, culture, management, budgets and accommodation and could apply at any level such as at the team, service or organisation level. Likewise to Percy-Smith's attempt to define partnership, the Network differentiates integration from partnership although recognises that a partnership is needed to create an integrated system.

The Integrated Care Network took a similar approach to differentiating integration from better co-ordination, although recognises that the latter can deliver many if not most of the benefits to users of an integrated system. Better co-ordination, however, is possibly not sustainable over time leading to the need for strategic decisions about whether a single integrated system would be more appropriate than continuing to co-ordinate separate activities that rely upon the informal co-operative network of practitioners.

The term "integrated approach" was adopted in the New Community Schools prospectus (Scottish Office 1998). This required agencies to bring together a single team of professionals from a range of services. Working in partnership with other agencies and services was seen and is still seen as fundamental to taking such an integrated approach. However, the evidence suggests that the early attempts to take such an integrated approach in new community school pilots would have been more accurately defined as better co-ordination of services, such as the Integrated Care Network defines. The importance of leadership for success was highlighted from the evaluation evidence on the early pilots with difficulties such as pulling budgets and a lack of commitment from partners to the agenda all suggesting the limitations of more ground-level co-ordination (Sammons, Power, Elliot, Robertson, Campbell and Whitty 2003, HMIe 2004).

Much of the literature within the field suggests the use of a continuum, with organisations working autonomously within their own boundaries at one end and full integration at the other end. For Scotland's Children (Scottish Executive 2001) set out an action plan for better integrated children's services but was not prescriptive about what is meant by integration, leaving decisions about how far along the continuum of integration local authorities, health boards and others consider necessary (Fisher 2003). The Integrated Care Network's guidance on integrated working suggests co-ordination to be somewhere in the middle of such a continuum. Mukherjee, Beresford & Sloper (1999) also suggests co-ordinated working as somewhere between autonomous working and integrated working. Rather than services being separate, often leaving families to take on the role of co-ordinator, co-ordinated working involves professionals working together to discuss and draw up a package of support albeit that they may assess the child separately. With integrated working, services are "synthesised and co-ordinated" with the expectation that the roles of different professionals will be blurred according to Mukerhjee et al's definition. Others suggest pooled budgets and single objectives characterise integration (Integrated Care Network; Stewart, Petch and Curtice 2003, Townsley, Watson and Abbott 2004).

Different models of working have also been proposed to describe how agencies work together (Cameron & Lart 2003, Atkinson, Wilkin, Stott and Kinder 2001). For instance, strategic level working where joint planning and decision-making takes place; placement schemes where posts cross the organisational divide such as social workers working in primary care divisions; centre-based service delivery where professionals from different agencies work together in the one site although not necessarily in an integrated manner; co-ordinated service delivery where there is a co-ordinator to pull together different services; multi-agency teams where professionals from different agencies work together on a day-to-day basis as a team; and case management models where a key person has responsibility for ensuring a co-ordinated service to families.

Such models focus primarily on the organisation of professionals and as Sloper (2004) highlights, will not necessarily ensure that families receive a co-ordinated service. Another, broader model suggested by Watson, Townsley and Abbot (2002) is transdisciplinary working where " members of different agencies work together jointly, sharing aims, information, tasks and responsibilities", a definition that does not seem contradictory to either Percy-Smith's definition or the Integrated Care Network's definition. In his review of multi-agency working, Sloper (2004) discusses the need for agencies to improve their co-ordination and collaboration but does not appear to make any theoretical distinction between co-ordination and integration as other authors have done.

The Professional Development Programme for Educational Psychologists in Scotland produced a paper on multi-agency working and defined multi-agency working as "three or more agencies working together, having shared aims in securing defined outcomes for children…whole agencies are involved in this, not just individual representatives. It follows that multi-agency working needs to be considered both at strategic and operational levels…joint funding…shared budget responsibilities, joint workforce planning, information sharing and service delivery responsibilities are all involved in this approach" (Fisher 2003). Such an all encompassing definition of multi-agency working reflects a number of characteristics often associated with integrated working and yet again confirms the difficulties with terminology in this field.

Conclusion

It can be concluded from this discussion that terminology within the field of integration is muddy and there may be merit in considering integration along a continuum or on a spectrum as a number of authors have previously done (Percy-Smith 2005, Townsley et al 2004). Given the varied terminology in the field there may also be some gains from clearly articulating what is meant by integrating children's services both at a strategic and planning level and at a local delivery and planning level. Atkinson et al (2002) conclude that "there might be value in refining descriptors and vocabulary associated with inter-agency activity to advance general awareness and understanding of its processes and outcomes." The difficulties in the language around integration also create challenges for gathering evidence on integration. Without a clearly defined concept it may be difficult to establish whether integration has in fact been achieved and in relation to children's services what this has delivered for young people and their families.