INTEGRITY AND INTEGRATION: PRODUCING BETTER OUTCOMES FOR SERVICE USERS AND CARERS

1
INTEGRITY AND INTEGRATION PRODUCING BETTER
OUTCOMES FOR SERVICE USERS AND CARERS
2

It is important to recognise that the way in
which the mentally ill sic are defined and
cared for is primarily a social response to a
very basic set of human problems How do we
define (Mental Health)? What forms of care
should the community provide? Who should be
responsible for administering them? What is
liberty, and how can it best be safeguarded? All
societies have these problems. How they answer
them depends on what they are, and the values
they hold. Kathleen Jones (1972) A History of
the Mental Health Services, London RKP. Quoted
in Peter Gilbert 2003, The Value of Everything
Social Work and its Importance in the Field of
Mental Health, Lyme Regis RHP. (My emphasis in
the quotes.)
3
MODERNISING MENTAL HEALTH SERVICES
The 1998 White Paper, Modernising Mental Health
Services, set out ten guiding principles. People
with mental health needs can expect services that
will

• Involve Users and their Carers in the planning
  and delivery of care.
• Deliver high quality treatment and care, which is
  known to be effective and acceptable.
• Be well suited to those who use them, and be
  non-discriminatory.
• Be accessible, so that help can be obtained when
  and where it is needed.

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MODERNISING MENTAL HEALTH SERVICESP.2

• Promote their safety and that of their carers,
  staff and the wider public.
• Offer choices which promote independence.
• Be well co-ordinated between all staff and
  agencies.
• Deliver continuity of care for as long as it is
  needed.
• Empower and support staff.
• Be properly accountable to the public, users and
  carers.
• Reduce suicides.

See also DoH (November 2001), The Journey to
Recovery, London DoH.
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LOOKING AT THEWHOLE PERSON
Understanding hopes, fears and aspirations
Cognitive Physical Emotional
Psychological Spiritual Creative
Understanding the past
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THE INDIVIDUAL IN SOCIETY
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BUYING A TICKET TO RIDE
Being joined up means recognising the
wholeness of peoples lives. Many people who use
Social Services rely heavily on other public
services Health, Housing, Employment Services
and Benefit Agencies. The problems that people
experience are connected .. Service delivery
needs to be integrated such that our services
move around the person, not the person around the
service. People should experience their services
as being well-co-ordinated as well as making a
difference to the quality of their lives. Social
Services Inspectorate (2000), Modern Social
Services - a Commitment to People, 9th Annual
Report of the Chief Inspector of Social Services,
London DoH. BUY A TICKET!
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WE ARE ALL IN THIS TOGETHERProfessional and
Organisational Synthesis
SOCIETY COMMUNITIES NEIGHBOURHOODS FAMILIES SERVIC
E USERS
PURPOSE PURPOSE-FULLNESS
VALUES
FRONTLINE STAFF FRONTLINE MANAGERS SENIOR
MANAGERS POLICY LEGISLATION
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1066 AND ALL THAT
King John was a bad thing. Robin Hood was a
good thing. Integration is what we make it.
10
WHY IS SOCIAL CARE IMPORTANT?

• It is where Users and Carers are at.
• Research demonstrates that Users primary
  concerns are around

- living conditions - work and occupation -
relationships - ethnicity, culture, gender and
sexual orientation, and societys acceptance or
non-acceptance - finances - inclusion and
citizenship - well-being - respect for them as
whole persons - access to mainstream services
education, health, leisure etc.
(See Macdonald Sheldon, 1997, and Mental Health
Foundation, 2000.)
11
THE SKILLED HELPER
Social work can make a particularly valuable
contribution to improving the quality and
delivery of services, given that the causes and
consequences of poor Mental Health are
significantly influenced by the environment of
which we are all a part. Social work is by
nature holistic in approach and views the
individual within a wider context of their
personal, familial, cultural and socio-economic
circumstances. Its ethos is on empowerment and
promoting independence through a focus on
working with rather than doing to which helps
to increase personal achievement,
self-fulfillment and create a much stronger sense
of citizenship. David Joannides, Director of
Social Services and recent Chair of the ADSS
Mental Health Strategy Group. Quoted in P.
Gilbert, 2003, page 36.
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SOCIAL WORK BOXED IN ?!
RESEARCH
CREATIVE
CARE MANAGEMENT
STATUTORY WORK AND MUST DOS
CASEWORK
COMMUNITY WORK
AND DEVELOPMENT
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WHAT USERS AND CARERS APPRECIATE ABOUT SOCIAL
WORKERS
Social Workers

• Look at the whole person.
• Consider the whole person in the context of their
  relationships, community and society as a whole.
• Are non-judgemental.
• Able to challenge the medical perspective.
• Consider the socio-economic effects on peoples
  lives, e.g. housing and employment.
• Working in partnership.
• Build helpful relationships with other
  professions and agencies.

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WHAT USERS AND CARERS APPRECIATE ABOUT SOCIAL
WORKERS p.2
In respect of Carers

• Appreciate the pressure on carers.
• Appropriate assessment and support under the
  Carers Act, 1995.
• Provide information and time to listen.

I find my social worker excellent, reliable,
reassuring, punctual, helpful and genuine. Always
friendly and reliable - always contacts me if
unable to see me on the day planned. Good
liaison between social worker and doctor. Living
alone, this service is more than important to me
having an understanding person to listen to me
and give advice in absolute confidence. Service
User in the Leeds Survey, 1997.
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WHAT USERS AND CARERS APPRECIATE ABOUT SOCIAL
WORKERS p.3
Some cautionary notes

• David Morris Social workers so tied to statutory
  duties that they are not engaging with the Social
  Inclusion agenda.
• Social workers have retreated from the Social
  Model, as they experience difficulties in finding
  a voice.

Consultant Psychiatrist with a strong emphasis on
social perspectives.
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THE ROLE OF THE APPROVED SOCIAL WORKER - THE
VITAL EQUILIBRIUM

• The role of the social worker in Mental Health
  is to operate on the margin . This unusual
  level of autonomy is pivotal to the role, which
  was intended to provide a fail safe against
  inappropriate use of the powers of detention. A
  counter balance to the draconian powers which can
  allow the removal of liberty without the scrutiny
  of the courts.
• Practising Approved Social Worker.
• The professional relationship between the doctor
  and the ASW is not a comfortable one, but it is
  precisely because of these different perspectives
  that the right outcomes for service users in
  crisis can be achieved. The ASW role is the grit
  in the oyster which produces the pearl.

Professor Peter Jones, Practising Psychiatrist
and Academic.
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THE ROLE OF THE APPROVED SOCIAL WORKER - THE
VITAL EQUILIBRIUM p.2

• ASW training is Gold Standard.
• Judy Foster, responsible for Mental Health
  issues with TOPPS.
• A lot has been written recently . about the
  extent to which social workers are undervalued.
  But in Mental Health work, their value is beyond
  doubt.
• Margaret Clayton, former Chair of the Mental
  Health Act Commission.
• Quoted in Gilbert, 2003, page 37 (my emphasis).

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A UNIQUE SYNTHESIS
The source of social works potential strength
. is the very fact that it does not separate the
world experienced by those in need of help into
component elements. Such experience is always a
complex, composite experience, it is always a
unique synthesis yet it cannot be impossible to
construct such a synthesis, because the client -
and everyone - does so all the time .. It is
only through such sharing that people sometimes
say to others you seem to understand - and
we know that to be understood by others is a
necessary and therapeutic experience. Hugh
England, Social Work as Art, London Allen and
Unwin, 1986.
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THE CENTRALITY OF VALUES (i)
Traditional values

• Intrinsic respect for individuals.
• Genuineness and integrity.
• Protecting the vulnerable.
• Allowing expression of feelings.
• Acceptance.
• Controlled emotional involvement.
• Competence.
• Self-determination.

He (the social worker) doesnt always agree
about my voices, and says No, its your
sickness. I can talk to him about it. I feel
quite comfortable discussing differences of
opinion with him. Service user.
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THE CENTRALITY OF VALUES (ii)
Emancipatory values

• Social justice.
• Citizenship.
• Partnership.
• Empowerment.

Note the changing emphasis in the BASW Code of
Ethics between 1975 and 2002.
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THE CENTRALITY OF VALUES (iii)
state
bureaucracy
laws
resources
social
worker
procedures
confidentiality
self-
determination
non judge- mentalism
societal norms
public welfare
Service User
acceptance
respect
user welfare
deterministic theories
technical approaches
efficiency
(Sarah Banks (1995)
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DR. BLACKS LIST - CAUSES OF MENTAL
ILLNESSCauses of insanity amongst patients
admitted to Bethlem in 1810.
23
USERS CONCERNS
Problem No. Mental State 64 25 Financial
difficulties/problems 41 16 Family
relationships 25 10 Housing/accommodation 24
9 Social isolation 24 9 Practical problems
22 8 Medical 16 6 Unemployment/boredom 13
5 Living circumstances 11 4 Other 20
8 Total 260 100
Macdonald and Sheldons 1997 Westminster Study.
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SELF-MANAGEMENT IN SCHIZOPHRENIA
Rethink Self-management Project.
See David Martyn, Running My Own Life,
Mental Health Today, June 2003.
Other users the user movement
Family friends
Exploring understanding your experience
Colleagues community
Personal qualities, attitudes beliefs
Relationships with other people
Reading
Mental health other practitioners
Maintaining morale, finding meaning
Religion spirituality
Self-management
Interpersonal self-management
Occupation
Recreation
Basic living skills
An ordinary life coping
An (extra)ordinary life thriving
Personal self-management
Healthy living
Social life
Information education
Relapse management
Talking therapies
Managing education
Managing having schizophrenia
Managing relationships with healthcare workers
Symptom management
Complementary therapies
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INTEGRATION - THE POLICY CONTEXT p.1

• Users and Carers wish to see improved access and
  integrated responses.
• People desire a Whole Persons and Whole
  Systems approach.
• The Audit Commissions Making Reality of
  Community Care (1986) proposed that services
  would be improved by clearer systems of
  accountability.
• Sir Roy Griffiths in his review of structures for
  the N.H.S. in the 1980s, came out with this
  caustic comment
• If Florence Nightingale were carrying her lamp
  through the corridors of the N.H.S. today, she
  would almost certainly be searching for the
  people in charge!

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INTEGRATION - THE POLICY CONTEXT p.2

• Flexible models of working were introduced under
  the 1999 Health Act, Section 31, which enabled
  the integration of services while ensuring sound
  governance arrangements with parent
  organisations.
• Care Trusts were proposed as a further step on
  the journey towards integration in the N.H.S.
  Plan, 2002.

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INTEGRATION - THE ADVANTAGES p.1
Integration is not an end in itself but a means
to achieve better outcomes and effective
services. Integration can help achieve this in
the following ways

• Management and service delivery are more cohesive
  and congruent.
• The organisation is easier for Users and Carers
  and potential referrers to understand - one door
  of entry to services.
• Specialist expertise - knowing the business.
• A co-ordinated approach to staff development,
  skill-mix and skill sharing.

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INTEGRATION - THE ADVANTAGES p.2

• The encouragement of appropriate specialisms
  within an overall framework.
• Economies of scale.
• A recognised centre of specialist expertise.
• The management clout to get things done.
• Social Care engaging in the culture of
  evidence-based learning so as to inform both
  practice and service development.

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INTEGRATION - THE CHALLENGES p.1
Because every structure has boundaries to it,
there will be some challenges as well as gains
through integration

• The new organisations could become divorced from
  the wider citizenship, social inclusion and
  regeneration agenda and specific services such
  as Housing, Environmental Health, Criminal
  Justice etc.
• Accountability for effective commissioning of
  services and delivery of the quality of life
  duty on Local Authorities remain important duties
  for elected members in the context of their
  scrutiny role.

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INTEGRATION - THE CHALLENGES p.2

• The Social Work/Social Care workforce could feel
  isolated as a relatively small component in a new
  organisation. Issues around value-base, style
  and culture are very important.
• The performance agenda on Local Authorities, and
  preoccupations with Child Care and hospital
  discharge may encourage Local Authorities to lose
  focus on and commitment to Mental Health.
• In some areas, significant groups of staff have
  spoken of being cut adrift or abandoned by
  their previous host organisation.
• Professional development may not be sufficiently
  addressed.

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INTEGRATION - THE CHALLENGES p.3

• Approved Social Workers may not feel sufficiently
  independent, and their ongoing independence and
  that of their possible successor, the AMHP, may
  not be safeguarded.
• Boundary issues with Children and Family Services
  and Education, and services for Older People
  require attention.
• Specialist services always face historical and
  sociological challenges in avoiding isolation.
• Services for people with learning difficulties,
  drug and alcohol problems and other areas of dual
  diagnosis need attention.

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OUTCOMES REQUIREDFROM INTEGRATION p.1

• An organisation which achieves effective outcomes
  for its stakeholders - in a way which maximises
  participation and partnership.
• Service Users and Carers at the heart of the
  service.
• Service models which focus on the whole person in
  the context in which they live, and which can
  bring an effective Whole Systems approach to
  bear.
• A value-driven organisation which has all staff
  and partner agencies working to common values and
  goals.
• A recognition of a valuing of diversity
  (diversity not sub-contracted out - see S. S.
  I. Report, June 2002).

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OUTCOMES REQUIREDFROM INTEGRATION p.2

• Sound governance arrangements which value
  openness, learning and innovation and links to
  the wider community governance.
• A workforce which has the right skill-mix to
  achieve its objectives, is supported, developed
  and empowered.
• Combining service effectiveness with cost
  effectiveness.
• Proper attention to dual diagnosis.
• Integration of Mental Health and Public Health -
  so that the service is not simply a mental
  illness service.

34
CONTINUING LOCAL AUTHORITY INVOLVEMENT
The Director of Social Services takes
responsibility for the quality of all Social
Services provided to local people, whether
directly or through delegation, contracting or
commissioning. Denise Platt, Chief Inspector,
SSI, Chief Inspector letter to Directors of
Social Services, July 2002 C.I. (2002), 9.
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SO WHOSE SERVICE IS IT ANYWAY?
? !
Abandon hope all ye who enter
Walk with us in hope
STRUCTURES WHICH SUPPORT OR THE TIES THAT BIND
36
VIEWS p.1
The system hasnt ever been designed around the
patient whereas almost every business these days
is having to design itself around whatever you
call them - customers or clients or
whatever. Derek Wanless, author of the Report on
the N.H.S., quoted in the Health Service Journal,
25th April 2002. When I think what he said on
Tuesday - leave the medication to me. Ill make
the decisions on that. Thats why you chose me
as your psychiatrist. off, Graham, it
should be a partnership, we have to arrive at
decisions with negotiation. He doesnt have to
take the drugs. If Im not in agreement when
this section is lifted, I wont co-operate. This
sounds very childish. Perhaps its just Grahams
attitude which makes me cross, but then he puts
me in a powerless position. Linda Hart, Phone at
Nine Just to Say Youre Alive, London PAN Books,
1997.
37
VIEWS p.2
We need to concentrate more on services and then
the right structures to deliver these services
will emerge organically. If we concentrate on
providing appropriate and high quality services,
rather than obsessing about structural
solutions then we will gain more credibility
with users and carers. An experienced Chief
Executive of a Mental Health Partnership Trust.
38
CHALLENGES FOR ORGANISATIONS

• Partnership is a relationship. You dont do
  partnership to somebody!
• Partnerships dont have to be absolutely equal,
  but they must be based on mutual respect.
• Do we lose interest in partnerships where we are
  not the dominant partner?!
• Relationships are long-term - and you need to
  keep working on them!
• Think global, act local.
• N.I.M.H.E. is mirroring a developmental and
  positive approach, balancing national strategy
  with local responsiveness.
• Values only give value if you live them.
• It is not enough to preach the doctrine, you
  must live the life - Victoria Woodhull.

39
AN EXAMPLE FROM A DIFFERENT CONTEXT
The merger between the Church of England and
the Methodists. Previous attempt in 1972 went
awry. The current approach is gradualist The
present step-by-step approach is sensible.
Relationship must come before structure. The
life of the spirit before organisational change.
Above all mission must set the agenda. Bishop
Cundy. As I look at the Church today I am
concerned because there is too much quarrelling
and not enough praying too much talk about God
and not enough talking too God too much talk
about love and not enough loving. Dr. George
Carey, former Archbishop of Canterbury.
40
STRUCTURAL CHANGE EXAMPLES AND ISSUES

• The evaluation of the Somerset Partnership by
  Peck, Gulliver and Towell.
• Evaluation of the national scene by Bob Hudson of
  the Nuffield Institute.
• Lessons from America and Europe - public and
  private sector.
• Commissioning Mental Health services - SCMH
  Paper, May 2003.
• Studies from the Netherlands find that far too
  much attention is given to issues of structure
  and too little to issues of power and culture.

41
THE NATIONAL PICTUREp.1
Bob Hudsons findings

• Attempts to address fragmentation have been
  frequent but generally ineffective - a dilemma
  which raises the issue of whether the problem is
  simply intractable or the policies inappropriate.
  An important distinction needs to be made
  between

- inter-organisational, and - professional
relationships.
There has been an implicit assumption that if
inter-agency arrangements are changed then better
inter-professional relationships will simply
follow.
42
THE NATIONAL PICTUREp.2

• The Nuffield Institutes study of the use of
  Section 31 flexibilities demonstrated that within
  eighteen months the flexibilities have had
  considerable impact

- Doing things differently move from a blame
culture to a whole systems perspective with
shared visions and objectives. High levels of
user consultation and involvement. - Partnership
framework including the potential for moving
partnerships from the margins to the
mainstream. - Resource and efficiency gains. -
Synergy and added value.

• The myth of Northern Ireland.

43
LESSONS FROM THE UNITED STATES AND EUROPE p.1

• Problems with the merger of the Beth Israel
  Hospital and the New England Deaconess Hospital
  of Boston. A basic lack of understanding of
  cultural change management (see Dana Beth
  Weinberg, Code Green Money-driven Hospitals and
  the Dismantling of Nursing, Cornell University,
  2003).
• Work by Peck and others, looking at studies in
  England and America show that mergers and
  acquisitions are much more complex than
  originally envisaged.
• The mid-Kent experience.

44
LESSONS FROM THE UNITED STATES AND EUROPE p.2

• Integrated budgets and commissioning, however,
  will not necessarily lead to enlightened Mental
  Health services, as is evident in most American
  managed care organisations (MCOs) ..
• The distinction between pernicious and
  beneficial competition is useful here.
• Donald W. Light and Alan Cohen, Commissioning
  Mental Health Services, SCMH Policy Paper, May
  2003.

45
THE CAFCASS EXAMPLE

• Should have produced a greater strategic process,
  more streamlined systems and a faster service.
• Major misunderstandings and under-estimate of
  cultural change.
• Demotivation of an expert staff group.
• Top-heavy management.

46
CONNECTIONS BETWEEN ASPIRATIONS AND PARTNERSHIP
ARRANGEMENTS (Cooney, 2002)
Mental Health Trusts (Health Social Care)
Integration
Partnership
Joint commissioning
Collaboration
Joint projects
Multi-disciplinary teams
Co-operation
Networking
Professional co-operation
Single agency/profession operation
Autonomy
47
EVALUATION OF THE SOMERSET PARTNERSHIPp.1

• Users found services better co-ordinated than
  previously and they felt supported.
• Choice, especially in relationship to
  alternatives to in-patient care was still
  limited.
• Carers felt the service was better co-ordinated,
  but service delivery had still some way to go.
• Impact on staff members - a dip in job
  satisfaction, role clarity and morale immediately
  after integration, now reported to have
  stabilised and improving.

48
EVALUATION OF THE SOMERSET PARTNERSHIPp.2

• Some staff members able to pick up new skills and
  knowledge from their colleagues.
• Many of the aspirations of participants were
  framed in terms of changes of culture, but
  questions remain about the nature of the changes
  required, and thus the extent to which they have
  been achieved.
• (See Peck, E., Gulliver, P., and Towell, D.
  (2002) Modernising Partnerships An Evaluation of
  Somersets Innovations in the Commissioning and
  Organisation of Mental Health Services, Final
  Report, London IAHSP, Kings College.)

49
ISSUES FOR PROFESSIONALS - AND CONSEQUENTLY FOR
USERS p.1

• Three sets of factors condition the views and
  responses of different groups of professionals

- Professional ideology the shared belief
systems which are created and maintained through
the development and consolidation of common
knowledge bases along with training processes to
which entry is circumscribed. - Cultural
allegiance associated with particular
organisations and their ways of doing things,
frequently based upon assumption, stereotype and
long-term unquestioned custom and practice.
50
ISSUES FOR PROFESSIONALS - AND CONSEQUENTLY FOR
USERS p.2
- Force of circumstance the conditions under
which professionals have to get on with the work
and do the best they can in difficult
circumstances. Dalley, G. (1991) Beliefs and
Behaviour Professionals and the Policy Process,
Journal of Aging Studies, 5, 2, pp. 163-80.
51
EVERY PROFESSION IS A CONSPIRACY AGAINST THE
LAITYGeorge Bernard Shaw

• User expectations users and carers demand the
  highest standards of professionalism in terms of
  knowledge, expertise and authority while at the
  same time desiring partnership and even
  friendship.
• I dont want to be empowered, I want to
  communicate with somebody who knows what they are
  talking about! - Clare Raynor.
• Issues of role definition and responsibility e.g.
  the experience of the Beth Israel and Deaconess
  Hospital nursing systems.
• At what point does the devolution of functions
  leave the consultant professional de-skilled?
• Issues of professional identity and professional
  partnership.

52
IDENTITY AND INTEGRATION

PERSONAL SELF
SELF-PROFESSIONAL CONFIDENCE leads to CONFIDENCE
IN PROFESSIONAL IDENTITY IN A MULTI-DISCIPLINARY
SETTING
53
TOWARDS A NEW PROFESSIONAL IDENTITY

• A strongly connected individual a sense of self
  in connection with others.
• Reflective application of knowledge blending
  knowledge and experience in a specific context.
• Engagement involvement of self and
  acknowledgement of emotions.
• Team practice welcoming and valuing the
  contributions of others.
• Specificity acknowledging unique expertise and
  experience of all.
• Multiple identities calling on the specificity
  of team members experience as a resource for
  clients.
• Celia Davies, Workers, Professions and
  Identity in J. Henderson and D. Atkinson (2003)
  Managing Care in Context, London The Open
  University/Routledge.

54
ELEMENTS OF ORGANISATION
55
LEADING FOR POSITIVE CHANGE

• If you do not know which port you are sailing
  to, no wind is favourable.
• The Roman Philosopher Lucius Annaeus Seneca.
• The love of liberty is the love of other people,
  the love of power is the love of ourselves.
• William Hazlitt, 19th Century philosopher and
  essayist.

56
LEADERSHIP
In essence, leadership is about

• Having and demonstrating a value-base.
• Setting and maintaining direction through
  formulating a vision of the future and setting
  out achievable steps to get there.
• Creating the right culture orientating and
  inspiring people.
• Delivering the agreed outcomes and maintaining
  focus.

With the extent and pace of change today,
individuals and organisations need a combination
of

• Leadership.
• Management.
• These must be combined and congruent but not
  necessarily in the same individual.

57
MANAGING CONGRUENCELEADING FROM CHRIS LAKE,
ROFFEY PARK
58
NHS LEADERSHIPQUALITIES FRAMEWORK
Setting Direction
Broad Scanning
Political astuteness
Intellectual flexibility
Personal Qualities
Drive for results
Seizing the future
Self belief Self awareness
Self management Drive for
improvement Personal integrity
Collaborative working
Leading change through people
Effective strategic influencing
Holding to account
Empowering others
Delivering the Service
59
MANAGEMENT AND LEADERSHIP COMBINED
MANAGEMENT CREATING SOUND SERVICES AND SYSTEMS
Creating a positive culture
LEADERSHIP
Taking services forward
VISIBLE LEADERSHIP ALIGNING CORPORATE AND SERVICE
OBJECTIVES
60
CREDIBILITY
Trust and credibility comes through everyones
observation of the managers symbolic integrity,
not his or her policy document. Tom Peters
(1987) Thriving on Chaos.
61
WHY TRANSFORMATION EFFORTS FAIL

• Not establishing a great enough sense of urgency.
• Not creating a powerful enough guiding coalition.
• Lacking a vision.
• Under-communicating the vision by factor of 10.
• Not removing obstacles to the new vision.
• Not systematically planning for an creating
  short-term wins.
• Declaring victory too soon.
• Not anchoring changes in the Corporations
  culture.

From J. P. Kotter, Leading Change Why
Transformation Efforts Fail, Harvard Business
Review, March - April 1995.
62
ORGANISATIONAL CULTURE p.1
Culture has been variously defined as

• The social glue that holds the organisation
  together, (Baker, 1980).
• How we do things around here, (Ouchi, 1981).
• A hidden yet unifying theme that provides
  meaning, direction and mobilisation, (Kilmann et
  al, 1985).
• The underlying values, beliefs, and principles
  that serve as a foundation for an organisations
  management system, (Denison, 1990).
• One image of culture is that it represents a web
  of understanding that we need in order to make
  sense of and copy with the complexity and
  confusion of organisational life. This web then
  gives shape to what we do and the ways in which
  we do it, (McLean Marshall, 1988).

63
ORGANISATIONAL CULTURE p.2
The only thing of real importance that leaders
do is to create and manage culture. Edgar H.
Schein, (1985) Organisational Culture and
Leadership.
64
READY, STEADY, COOK!THE CULTURAL RECIPE
Rituals and myths
Symbols
The RECIPE
Power structures
Routines
Organisa-tional structures
Control systems
From Gerry Johnson and Kevan Scholes, Exploring
Corporate Strategy, 1989.
65
THE NATIONAL INSTITUTE FOR MENTAL HEALTH IN
ENGLAND
N.I.M.H.E. is a relationship organisation. Profe
ssor Antony Sheehan, Chief Executive of
N.I.M.H.E., June 2003.
66
N.I.M.H.E. STRUCTURE
People, Teams, Services, LITs, Communities
North East/Yorks North West East Midlands
West Midlands Eastern London South West
South East
Development Centres
Acute Inpatient Service Substance
Suicide MH Research Equalities
Intelligence Workforce Care
Development Misuse Prevention Network
In Progress
National programmes
Communications Web site MH Times Supporting public
ations
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Standing groups Expert user Values Positive
practice and champions
67
STRUCTURES TO SUPPORT INTEGRATION p.1

• Cultural and behavioural change is probably a
  far more appropriate and important requirement
  for success than a centrally directed approach
  that emphasises the rearrangement of structural
  furniture, (Goodwin, 2002). (My emphasis.)
• Member scrutiny and commissioning from local
  authorities must remain robust.
• Governance arrangements within the Trust need to
  reflect the social inclusion and social care
  agendas.
• Social care/social work must be represented at
  executive board level, as are other professions.
• Does having a designated director of social
  care provide a clear champion for social
  work/social care or does it place it within a
  segregated box.

68
STRUCTURES TO SUPPORT INTEGRATION p.2

• What is the social care/social work influence at
  the crucial middle and frontline management
  levels?
• How is professional support and development
  delivered by the new host organisation.
• The social work supervision model is
  increasingly being appreciated by N.H.S. managers
  and staff.

69
POSITIVE APPROACHES TO INTEGRATION - SOME THEMES
p.1
1. What are we taking with us?

• Social Work values.
• Colleagues and the team approach. (There needs
  to be a critical mass of Social Work / Social
  Care staff to balance the other professions.)
• The Social Work approach to supervision - often
  very much appreciated by other professions.
• Social Services approach to Intake work has a lot
  to offer.
• The style of providing information.
• The ethos of empowerment and an holistic
  approach.
• Training and the budget for training.

70
POSITIVE APPROACHES TO INTEGRATION - SOME THEMES
p.2

• Care Management approaches in respect of using
  flexible budgets at the frontline to gain
  better-tailored packages of care for individuals.
• Sense of belonging.
• The rich diversity of backgrounds of people who
  come into Social Work and Social Care.
• Reviewing services for individuals, and also
  strategic reviews.
• Respect for the profession.

71
POSITIVE APPROACHES TO INTEGRATION - SOME THEMES
p.3
2. Things we would like to leave behind.

• The management style of the old and new host
  organisations is crucial to how
  staff feel about the move.
• The lack of clarity as to the balance between
  user empowerment and issues around Health and
  Safety, Risk, Management etc.
• Irrelevant paperwork and duplication.
• Inconsistencies between areas.
• The lack of attention local authorities give to
  Mental Health.
• Absence of a learning/research culture in some
  local authorities.

72
POSITIVE APPROACHES TO INTEGRATION - SOME THEMES
p.4
3. What kind of house do we want to move to and
what kind of relationship do we want with the
house we have moved from? a) The house we are
moving to needs to have

• A positive sense of direction.
• A Social Care/Social Work champion.
• Support, nurturing and educative supervision.
• A chance to have a fresh look at a range of
  issues.
• Proper facilities.
• A sound duty system.
• Dealing with systems of access.
• A learning culture - access to research.
  Integrating theory and practice.
• Parity in conditions.

73
POSITIVE APPROACHES TO INTEGRATION - SOME THEMES
p.5
b) Links with the Local Authority need to be
maintained especially in respect of the wider
social inclusion and regeneration agenda.

• Child Protection and Mental Health.
• Older Persons with Mental Health needs.
• Public Health.
• Social Inclusion and Citizenship.

LOCAL AUTHORITY
PARTNERSHIP TRUST
74
KNOWLEDGE TO PRACTICE BY p.1

• Accent on evidence-based practice.
• Need for practice-based evidence.
• Creation of a NIMHE/SCIE Social Care Fellow
  (Research and Practice) - Dr. Nick Gould,
  University of Bath.
• Truth lies in the quality of the users
  experience of the service, Jane Campbell, Chair,
  SCIE.
• To try and build a social work house on the
  shifting sands of social science theory is asking
  for trouble. Social work should probably
  concentrate on erecting strong, portable,
  flexible tents rather than houses, Professor
  Olive Stevenson, 1971.
• Integrity without knowledge is weak and useless,
  and knowledge without integrity is dangerous and
  dreadful, Dr. Johnson.

75
KNOWLEDGE TO PRACTICE BY p.2

• Knowing that a tomato is a fruit is knowledge.
  Not putting it into the fruit salad is wisdom,
  Miles Kington.
• First meeting of the Social Care (Mental Health)
  Research Forum held on the 5th June 2003.
  Participants suggested

- rediscovering what we already know -
assisting organisations become truly learning
organisations - investing in research in
specific issues which improve users lives.
76
SINGING THE SAME SONG BUT WITH A DIFFERENT TUNE?
p.1

• It is time for social work to recover its
  ambition as an organised and cohesive force for
  good in society, Bill Utting, former Chief
  Inspector, SSI, June 2002.
• Social work does not deal with some particular
  segment of the individual, but with the
  individual as a whole person, (my emphasis).
  Hugh England, Social Work as Art, 1986.
• Society is becoming more complex - social work
  has a wealth of experience in helping people to
  manage complexity.
• People want more of a say in how people work with
  them - social work has a record of empowerment.
• The social work degree, the new organisations,
  and the new approach to integrating theory and
  practice should increase both expertise and
  prestige.

77
SINGING THE SAME SONG BUT WITH A DIFFERENT TUNE?
p.2

• Social Work needs to rediscover the community,
  and take on board user concerns which we feel
  less comfortable with, e.g. Spirituality and
  Mental Health.
• Issues of ethnicity, culture and identity are
  increasingly important (see N.I.M.H.E., Inside,
  Outside, 2003), and social workers have a history
  of working with rather than doing to other people
  (Hari Sewell, Director of Social Care, Camden and
  Islington Care Trust).
• Social workers work with people to assist them in
  connecting their inner and outer realities.
• Social workers have the leadership and
  followership skills which organisations need in
  todays world.

78
SINGING THE SAME SONG BUT WITH A DIFFERENT TUNE?
p.3

• Care management has a great deal to offer in an
  N.H.S. which is having to face up to cash-limited
  budgets.
• We can be holders of peoples hope passing the
  torch back to the individual and keepers of
  each others stories, (Hoffman).

79
IDENTITY AND CONNECTION
THE BRICK WALL
PERSONAL IDENTITY PROFESSIONAL IDENTITY
MISTRUST AND ENERGY INTO RIVALRIES
INSECURITY SECURITY
THE LEYLANDII HEDGE
TEAM IDENTITY PLUS POSITIVE FOCUS ON USERS AND
CARERS LEADING TO INDIVIDUAL AND SERVICE
DEVELOPMENT
THE BRIDGE