The Partnership Initiative In Nursing And Social Services .
The Partnership Initiative in Nursing and Social Services:Practical Collaboration in Services for Older PeopleMark Lymbery, Associate Professor in Social Work, School of Sociology & Social Policy,University of NottinghamAbstractThis paper reports on the Partnership Initiative in Nursing and Social Services (PINSS), aproject that placed community nurses within social services Assessment and CareManagement Teams (ACMTs) within two Social Services Departments (SSDs) within the EastMidlands. The project aimed to assess the impact of the nurses on the social servicesenvironment and the parallel effects on the nurses of working in such contexts. The paperobserves that the nurses had a positive impact within the ACMTs and they reported havingfound the experience both stimulating and valuable for their own development. Although theproject was felt to have been highly successful, questions remain about the extent to which thelocation of community nurses within social services assessment and care management teamsrepresents the best way forward for inter-professional working in social and health care forolder people.KeywordsCommunity nurses, social services, inter-professional work, organisational structureIntroductionThe Partnership Initiative in Nursing andSocial Services (PINSS) located communitynurses in Assessment and Care ManagementTeams (ACMTs) in two east midlands socialservices departments (SSDs). These teamshave the primary responsibility, withincommunity and hospital settings, forassessing the social care needs of(predominantly) older people, and inestablishing services to meet those needs.Within British social welfare, health andsocial care needs are the responsibility ofdifferent agencies, each with its own systemsfor assessing and meeting those needs. Asthe government has indicated, it is believedthat this organisational separation leads to afragmented approach to services, a problemthat the emphasis on improved partnershipworking between health and social careagencies is intended to address. Certainly,there has been renewed interest in conceptsof partnership and collaboration since theaccession of the Labour government in 1997(Glendinning et al., 2002). As Hudson et al.,(1999) indicate, the terms ‘partnership’ and‘collaboration’ have been “conceptuallyelusive”. In this paper, ‘partnership’ is usedto describe the working together of agenciesat the organisational level, whereas‘collaboration’ refers to the workingrelationships of professionals within thoseagencies.The project was established on thehypothesis that locating qualified nurseswithin ACMTs would improve the quality ofsocial care assessments in respect of healthand nursing needs.There has beenconsiderable literature on the interfacebetween primary health care and socialservices (see Levin et al., 2002), butrelatively little that examines the role ofnurses within the context of assessment andcare management (but see Bergen, 1997;Weiner et al., 2003); more research has beenundertaken on the role of social workerswithin primary health care (see Lymbery andMillward, 2000). In general, the PINSSResearch Policy and Planning (2005) vol. 23 no. 287
Paper threeproject fitted within the priorities ofgovernment regarding the need for closerworking between health and social care, aswell as within a tradition of literature thatfocuses on the quality of inter-professionalpractice.The paper begins by outlining the contextwithin which the project was developed,moving on to consider issues concerning itsorigins, organisation, and purpose. It thenintroduces the evaluation approaches thatwere deployed before highlighting theproject’s key findings, focusing on two areas:88 The impact of the nurses on the teamswithin which they were located. The impact of the project on thenurses themselves.The paper concludes by suggesting thatunderstanding the mechanics of jointworking will assist in the development of thesingle assessment process for older people(DoH, 2001; 2002a; 2002b), both inillustrating how professionals can worktogether effectively and how organisationscan co-operate to facilitate joint working. Inconsidering the most effective way ofimplementingtheNationalServiceFramework for Older People (DoH, 2001),the paper suggests that full multi-disciplinaryteams would allow for the establishment ofintegrated assessment processes, a corerequirement of the single assessment processthat is a key feature of the Framework.The multi-disciplinary contextThis section identifies policy issues thatformed the background to the PINSS project,focusing particularly on partnership andassessment.It moves from a generalconsideration of the ‘new’ Labourgovernment’s attitudes to partnership andcollaboration to a discussion of the specificpolicy developments that are intended toencourage partnership working betweenhealth and social care organisations. Thesection then moves on to consider variousoptions for collaborative working to makeResearch Policy and Planning (2005) vol. 23 no. 2improved partnershipachievable goal.arealisticandIt has long been recognised thatorganisational differences between healthand social care agencies work against theinterests of people who require health andsocial care services (Lewis, 2001). Indeed,this has led the government to suggest thatthere is a ‘Berlin wall’ between health andsocial care agencies (DoH, 1998b). The wayin which the term is used implies that theresponsibility for this barrier rests in theorganisations themselves; this is an oversimplification of a complex structuralproblem (Lewis, 2001; Means et al., 2002).Means and Smith (1998) suggest that thebarriers between health and social careorganisations are long-standing, dating backto the National Assistance Act 1948. ThisAct created a category of people deemed inneed of ‘care and attention’ who became theresponsibility of social care agencies.However, the definition was ion of frail older people (who wouldhitherto have been the responsibility ofhealth services) to become defined as theresponsibility of social care services withoutsufficient resources being allocated to meettheir needs effectively.Much of the recent emphasis on partnershipworking has been on the need for improvedinter-professional collaboration as opposed toengaging with the structural problems thatcreated and perpetuated the ‘Berlin wall’(see, for example, DoH, 1998a).Thepublication of the NHS Plan appeared tochange this, declaring that there “will be anew relationship between health and socialcare”, which “will bring about a radicalredesign of the whole care system” (DoH,2000, p. 71). This has been seen as anattempt to introduce an element ofcompulsion into the previous exhortations toachieve improved partnerships (see Hudsonand Henwood, 2002). However, the coreweakness of this drive towards greaterstructural integration is simple: that in itself it
Paper threewill not be a guarantee of improved, betterco-ordinated services (Hudson and Henwood,2002).In an implicit recognition of this, theNational Service Framework for OlderPeople (DoH, 2001) contained severalfurther proposals for the development ofcollaborative working that would not dependupon structural change. It proposed theintroduction of a single assessment processfor older people, its purpose being “to ensurethat older people receive appropriate,effective and timely responses to their healthand social care needs, and that professionalresources are used effectively” (DoH, 2002a,p.1).The guidance emphasised thatassessments should be kept in proportion toolder people’s needs, that agencies shouldnot duplicate each other’s assessments andthat a range of professionals would need tocontribute according to the nature and extentof need (DoH, 2002a). In the view of theDepartment of Health – supported byconsiderable research evidence (Nolan andCaldock, 1996; Stewart et al., 1999) – goodquality holistic assessments of older peoplerequire the involvement of differentprofessional groups; in the absence of this,the overall quality of assessment practicewould suffer. Therefore, it is important toestablish effective arrangements for interagency, multi-disciplinary and interprofessional collaboration in order tofacilitate improved assessment practice; thePINSS project can be seen in this context.Origins, organisation and purpose of theprojectThe PINSS project can be seen ascomplementary to the Bridging the Gapproject that located social workers withinprimary health care settings within the samegeneral locality (Lymbery and Millward,2000). This project found that the placementof social workers in such settings “would bea move in line with government thinking onthe development of partnership betweenhealth and social care”, and also that “itenhances the level of professionalsatisfaction experienced by social workers,and that it provides an opportunity forexcellentmulti-disciplinarypractice”(Lymbery and Millward, 2000, p.39).Having pursued one direction for theenhancement of inter-professional working –which has resulted in the location of 6 socialworkers within primary health care settingsin one of the departments – the PINSSproject provided an opportunity to assesswhether alternative approaches to the sameproblem could have equally beneficialresults. At the same time, another projectwhich had an inter-professional focus wasalso under way. This focused on the locationof some Occupational Therapists withinACMTs, away from their normal location inspecialist teams; this project has not beensubjected to any external evaluation.This continuity with other related projectswas highly significant; the majority ofmiddle managers from both social servicesand health who were responsible for creatingand directing the project had worked togetheron previous projects, as had the evaluator.The original plan for PINSS was that threequalified District Nurses would be placed indifferent work settings across two SSDs, andwould be seconded to these posts from theirnormal roles within District Nursing teams.Two of these were full-time in ACMTs, onebased in a hospital with the other in an areabased team. The third worked on a half timebasis from a location in a different area-basedACMT.As originally defined, the nurses had twocore functions; 1) to be directly involved inthe assessment of need, and 2) to contributeto the process of quality control by takingpart in the panels that approvedrecommendations arising from completedassessments. The full-time placements wereinitially for 6 months, with the part-timeplacement being for 12 months. There wascontinued oversight of the project through aSteering Group, which met regularly toreview progress.Membership of thisResearch Policy and Planning (2005) vol. 23 no. 289
Paper threeSteering Group included middle managersfrom the various health and social servicesagencies along with the project’s evaluator.The project commenced in the autumn of1999; although the formal evaluation wascompleted in 2002, the project is ongoing,with nursing staff continuing to be deployedin social services teams.At the outset, the aims of the initiative weredefined as follows:1. To improve the quality of social servicesassessments, on the assumption that aqualified district nurse would add animportant dimension to the assessmentprocess.2. Byimprovingthequalityandappropriateness of assessment, toimprove the quality of service offered,and the appropriateness of serviceoutcomes.903. To improve links between social servicesand community health.4. To improve the quality of interprofessional working between socialservices and community health.5. To test out alternative models of serviceorganisation.The purpose of this paper is to explore theextent to which objectives 3-5 were met. Thereasons for this choice are discussed in thefollowing section.While the broad intentions of the projectremained unchanged, it went through severalchanges in its structure and organisation.Within a few months, the part-time DistrictNurse opted to return to a mainstream post.It proved difficult to replace her with anotherDistrict Nurse; at the same time,consideration was given to the viability of therole as it had been constructed. It wassubsequently decided to change the nature ofthe project by recruiting a community-basedRegistered General Nurse to replace theResearch Policy and Planning (2005) vol. 23 no. 2District Nurse. It was accepted that the rolethe District Nurse had been asked to fill wasproblematic, particularly given her part-timehours. It was therefore decided that theRegistered General Nurse would be full-timeand carry out a more limited and clearlydefined role within a single team (the DistrictNurse had been working across 3 differentteams). This carried the added advantage ofplacing the nurse in a team that was alreadyfamiliar with the concept of interprofessional working, an OccupationalTherapist having been based there for somemonths. This nurse was also seconded froman existing District Nursing team.Due to the perceived success of the project inits initial stages, the Steering Group decidedthat it should be increased in scope andduration to provide an opportunity toevaluate it over a longer period. Thisdecision had various knock-on effects. Forexample, the District Nurse placed at thehospital ACMT retired during 2001. Inaddition, it was decided to fund a similar postbased at the other large hospital within thelocality; here, an RGN started work in late2000.The final evaluation sought toencompass these changes.Evaluation criteria and approachThe topicality of the subject matteremphasised the importance of evaluation, as“the dual demands of collaboration andevidence are an integral part of manyhealth and social care programmes” (ElAnsari et al., 2001, p. 216). This section willoutline the evaluation strategy that wasadopted while also highlighting factors thatinformed and impeded its progress anddevelopment. The evaluation started fromthe location of the project in its policy andorganisational context (outlined above),gauging the extent to which these factorsinfluenced the project’s findings. Therefore,it focused both on the extent to which theproject fulfilled its objectives and on thecontext-specific issues that affected this.While the evaluation did attempt to link
Paper threedirectly to all the project’s objectives, itsmain focus was on inputs (the contribution ofcommunity nurses to assessments and to theteam setting) and processes.processes alone constitutes a relatively weakform of evidence of improved collaborativeworking. (This issue is explored in moredepth by Hughes and Traynor, 2000.)A number of specific problems wereencountered in the evaluation process. Oneof the critical limitations was in the fundingof the evaluation and the way in which thislimited the scope of what could realisticallybe attempted and achieved. For example, itwas not feasible to seek to engage withservices users or their carers, even thoughthis would have produced useful and relevantdetail. Another particular difficulty wasencountered in seeking to establish improvedassessment quality and better outcomes forservice users, which was more complex thanhad been envisaged at the start of the project.Although steps were taken to establish aquality baseline, through an examination of27 completed assessments, it became clearthat there was no necessary connectingrelationship between subsequent changes inassessment quality and the project. While allpractitioners and managers who wereinterviewed insisted both that that there hadbeen improvements, and that there was acausal link between these improvements andthe project, this belief could neither beconfirmed nor denied by the evidencegenerated through the evaluation. As aresult, this paper does not comment on theextent to which objectives 1 and 2 were met,other than reporting workers’ perceptions ofsuccess in this area.The role that evaluation played in themanagement and development of the PINSSproject was also of interest.Broadlyspeaking, evaluation can either bepredominantly ‘summative’ or ‘formative’(El Ansari et al., 2001). In the early stages,the ‘formative’ elements of evaluation wereparticularly strong, with a direct feedbackloop between the evaluation and themanagement of the project. The changes tothe project (noted above) were a product ofthis ‘formative’ element in the evaluation.Martin and Sanderson (1999) haveemphasised that public policy evaluationscan legitimately focus on either themeasurement of outcomes, the monitoring ofprocesses or the management of pilotprojects. In the case of the PINSS project,the evaluation became more concerned withthe monitoring of processes and themanagement of the pilot project than themeasurement of outcomes, for the reasonsoutlined above.Similarly, it was difficult to identify theextent to which any changes in the processesthat characterise collaborative practicehelped to bring about improved outcomes.This reflects an ongoing debate in theevaluation literature. There are a number ofstudies (see, for example, Lymbery andMillward, 2000; Ross et al., 2000) thatassume that improved outcomes will stemfrom improved processes. However, asBrown et al. (2003) have demonstrated, it isnot always easy to define the relationshipbetween process and outcome; a focus onTwo main areas of activity are emphasisedhere. The first concerns the impact of theproject on the ACMTs, particularly on socialwork staff. The second focuses on theimpact of the project on the communitynurses, where it was assumed that theunfamiliar role would present specificchallenges and problems. Evidence relatingto these areas of activity was accumulatedfrom a range of sources.Group andindividual interviews provided the basis forevidence regarding the impact of thecommunity nurses on ACMTs. Meetingswere held with each of these teams near thebeginning and again towards the end of theproject.There were also individualinterviews with Team Managers, whichallowed from some comparison between themanagerial and practitioner perspectives. Intotal, 6 group interviews with teams and 4Research Policy and Planning (2005) vol. 23 no. 291
Paper threeindividual interviews with managerscontributed to this part of the research.The impact of the project on the communitynurses was also a key variable. Since nursesare unaccustomed to working within theorganisational environment of SSDs, it wasinstructive to analyse how well they adaptedto different requirements. There were twomain ways of securing the nurses’perspectives.First and foremost, semistructured interviews were carried out withall the nurses at the start of theirsecondments; a second interview wasconvened with the original nurses once theywere well into their work. In total, 8individual interviews were held with nursingstaff. In addition, the nurses provided abreakdown of their work over a defined 6month period towards the end of the project,when it was working at its operational peak.This generated data on which the followingsection draws.92The themes that emerged through the processof interviews were confirmed by reference toan operational group – of nurses and theirsocial services managers – that met quarterlythroughout the project. This group fulfilled auseful function, particularly in the‘formative’ aspects of the evaluation, as wellas providing a useful means of support forthe staff. In addition, it was an invaluable aidto the smooth running of the project. Theevaluator made quarterly presentations of thedata to the Steering Group, with particularattention given to the generation ofinformationthatcouldaffectthedevelopment of the project.Impact on Social Services TeamsInterpersonal issuesThere was a pattern to the responses fromstaff and managers in relation to this theme.Early in the project, team members tended toreport that they felt some “resentment andsuspicion” about the presence of a nurse inthe team. As the projects progressed, moststaff saw this differently, wi
to describe the working together of agencies at the organisational level, whereas ‘collaboration’ refers to the working relationships of professionals within those agencies. The project was established on the hypothesis that locating qualified nurses within ACMTs would improve the quality of social care assessments in respect of health
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