5. What Works?
Similar barriers and proposed solutions to overcoming such barriers arise time and again in studies and discussions on integrated working (Cameron & Lart 2002, Integrated Care Network 2004, Park & Turnbull 2003, Johnson et al 2003). This section highlights these barriers and discusses the factors that have been identified as crucial for successful integration.
Financial uncertainty is one of the often cited barriers to integrated working (Sammons et al 2003, Cameron & Lart 2003, Wilkin et al 2003, van Eyk & Baum 2002, Johnson et al 2003, Tisdall, Wallace, McGregor, Atkinson et al 2001). This has certainly been an issue as the integrated community schooling approach has been rolled out to all schools in Scotland. Authorities and schools often claim that the funding is not sufficient to roll out the approach in a similar manner to the pilot projects and that uncertainty about future funding causes difficulties in appointing permanent staff. Johnson et al (2003) reported that the greatest barrier to joint working between social services and the NHS in England was concern over costs and whose budget would pay for what. Very few localities perceived collaborative working to be an efficient way to manage resources.
Cultural differences between different professionals is also frequently reported as a barrier to integrated service provision (Cameron & Lart 2003, Harbin 1996, Wilkin, White & Kinder 2003, Wasoff, MacIver, McGuckin, Morton, Cunningham-Burley, Hinds and Given 2004, van Eyk & Baum 2002, Johnson et al 2003, Coxon 2005). Crouch & Johnson (2003) report differences between health and social care in terminology, attitudes to information sharing and professional principles, issues that the authors consider need to be dealt with to enable integrated working. Process mapping was undertaken by West Surrey to overcome some of the cultural barriers, such as these, that often limit joint working. By analysing working practices and designing improved processes, health and social care professionals built up mutual trust and understanding of each other. In addition, joint training, joint protocols and joint working procedures helped break down cultural differences between the organisations.
Tension between professionals is an issue that has not been fully addressed in the public sector according to the report "Schools Out" (Craig, Huber & Lownsbrough 2004). While professional judgements are being seen as increasingly important, professionals are also being called to work in contexts outside their professional tradition. The resulting tension and conflict, according to this report, is not being directly addressed. Instead incremental approaches such as the appointment of "co-ordinators" or "integration managers" are preventing professional barriers being broken down and often arbitrate between professionals rather than confronting them head-on.
Clarity of roles and responsibilities
Blurred professional boundaries and lack of clarity around roles and responsibilities is also often mentioned as a barrier to integrated working. The importance of clear aims and objectives that are realistic, achievable and understood and accepted by all the partners emerged from Cameron & Lart's (2003) review of the factors that promote and hinder joint-working between the NHS and social services research. Similarly, clearly identified roles and responsibilities were identified as vital to avoid overlaps in work and gaps in provision. This is supported by Rushmer and Pallis's argument about the disaster of blurring professional boundaries, often an expected consequence of multi-disciplinary working. It is argued that each professional brings with them their own skills and expertise and for successful collaborative working, professionals should not be working beyond their area of competence. In fact, it is argued that successful collaborative working depends upon establishing clear boundaries between each party. McCulloch et al's (2004) findings from school staff working in an integrated community school cluster confirm this argument as collaborative working was found to be most successful from a school perspective when other partners were seen to have added value to the efforts of the school. Schools welcomed other partners in areas that were out with their expertise.
Rushmer & Pallis (2002) suggest that joint-working relies upon the merging of the skill, experience and knowledge of each partner with reliance upon team members for the outcome that only working together can achieve. The blurring of boundaries that can happen when integrated working takes place without clarity of task allocation and responsibility can lead to unsuccessful collaborative endeavours. Difficulties in defining boundaries between professional groups were also identified in the Scottish Centre for Social Research's study exploring the effectiveness of early years policies (Wasoff et al 2004). Consequences include disputes over responsibilities, feelings of inequity, stress and anxiety about what is being contributed from each party. Role ambiguity can result from such "blurred boundaries" and may have negative effects on job satisfaction, trust between parties and ultimately may lead to unsustainable relationships (Rushmer & Pallis 2002). Developing formal policies and procedures is one way to clarify the roles and responsibilities of partners involved in joint working (Rushmer & Pallis 2002) as well as allowing time and support for workers to achieve effective collaboration (Wasoff et al 2004).
Lack of clarity in roles has been identified as a key issue for the social work profession in the current review of its profession (21 st Century Social Work 2005). A literature review on the role of social workers found widespread views on the nature and role of social work. Language within the field was reported to be a contributing factor to confusion about what it is social workers do. The interim report of the Social Work Review recognises the diverse roles that social workers are now fulfilling and is responding to a variety of issues such as the distinctive contribution that social work can make to integrated team working.
Lack of shared understanding
A common theme within the literature is ambiguity resulting from integrated working. For instance, ambiguity around the purpose of a partnership, the different roles and responsibilities of the parties and the purpose of meetings and plans are common (Stewart et al 2003, Percy-Smith 2005). For instance, Webb & Vuillamy's (2001) evaluation of a 3-year project that placed home-school support workers within secondary schools to work closely with other agencies, reported that the strategic advisory group meetings were referred to as "sterile exercises" and "talk shops". Group participation included those from health, social work and the police but dwindled over time, limiting its potential to facilitate co-operation between the agencies and resulting in the project being "a bottom-up innovation" with its development shaped almost entirely by the ideas and working preferences of the support workers. Perhaps assisting with achieving clarity of roles and contributions to partnerships is the National Audit Office's (2001) guidance on accountability. Achieving a clear definition of the roles and responsibilities of each organisation involved in the partnership, setting out unambiguous targets for service delivery and setting out a party responsible for taking action if progress is unsatisfactory are suggested minimum requirements for sound accountability. Similarly reviewing and evaluating partnerships as they evolve can contribute to maintaining such clarity around purpose and roles (Percy-Smith 2005).
Key Success Factors
Unsurprisingly, much of what is cited to facilitate integrated working is the opposite of what is reported to hinder. For instance, clarity of aims and objectives that are understood by all parties, clearly identified roles and responsibilities, commitment from both senior management and front line staff, strong leadership, good systems of communication and information sharing and structures for joint planning (Sloper 2004, Integrated Care Network 2003, Coles, Britton & Hicks 2004, Sammons et al 2003, HMIe 2004, Cameron & Lart 2003, Rushmer & Pallis 2002, Dolan 1996, Harbin 1996, Stewart et al 2003, Atkinson et al 2001). Joint training, appropriate support for staff, recruitment of the right people with the right skills and shared resources as well as robust monitoring and evaluation of integrated working have also been identified as crucial to the implementation of such working (Sloper 2004, Percy-Smith 2005, Craig et al 2004).
Organisational climate has also been identified as a contributing factor to integrated working. Johnson et al (2003) report that organisations that support teamwork, flexibility, open flows of communication and promote a shared vision are better able to delivery positive outcomes for clients and provide more integrated services. Similarly, Gardner (2003) and Glisson & Hemmelgard (1998) highlight the important link between organisational climate and improved outcomes for clients. Organisational identity and staff confidence in the working practices within their own organisation is important in assisting integrating working practices with other organisations (Gardner 2003).
Strategic support and organisational commitment to joint working are also frequently identified as critical for success (Gardner 2003, Atkinson et al 2002). Strategic leadership and vision as well as sustainable infrastructure have been described as the "engine for joint service delivery". Simply bringing a group of professionals from different agencies together and calling them a "team" will not guarantee integrated working (Rushmore & Pallis 2002). Guidance, support, leadership and commitment to integrated working are essential and have already been identified as a characteristic of successful ICS approaches (Sammons et al 2003). Despite being an essential characteristic for ICS, leadership and commitment to integrated working has not been found to be consistent in developing the approach ( HMIe 2004). HMIe suggest it to be a key factor for success, confirming the Integrated Care Network's comment that "without strategic vision and support, collaboration at the front line of service delivery will be impossible to optimise, however well intentioned the professional practitioners".
It is also often claimed that co-terminosity contributes to successful integration of services (Park & Turnbull, Integrated Care Network 2004). However, in their review, Cameron & Lart (2003) conclude that the evidence in the literature is inconclusive around co-terminosity. This supports some of the anecdotal evidence around the integrated community school agenda where in some instances co-terminosity of staff from different agencies has improved working relationships whereas in other instances it has contributed to ICS being perceived as an "add-on" to the mainstream school business. The pros and cons of co-located working were also recognised in a study of early years policies in Scotland (Wasoff et al 2004).
There is a significant amount of material reporting barriers to integrated working and key factors for success. Perhaps the key area for development of the evidence base in this context would be in successfully feeding the learning from such work into future practice rather than continuing to augment the evidence around well established themes.