Critical Analysis of Multi-Agency Team Working in Health and Social Care

Introduction

The modern health and social care is very complex, with numerous actors co-existing with the patients/ service users. However, these actors do not always have to work independently or in isolation. Collaboration among health and social care actors is essential to practice and team working is widespread (Whittington, 2013). Working with other disciplines, professions and agencies is a critical part of everyday health and social care practice and the concept of multi-agency team working in health and social care is one that has been emphasized as central to the quality of care provided. Multi-agency team work and collaboration have been presented as one of the most necessary and positive practice interventions, and which contribute to the achievement of successful, quality care provision. As a result of multi-agency working and collaboration, the service user is centred on multiple front-line professionals (Fejes and Dahlstedt, 2013). Atkinson et al. (2001) suggest that multi-agency team work and collaboration promotes the provision of care that is more holistic as well as the adoption of the person- or patient-centred approach to care provision by healthcare service providers. He adds that the concept further encourages the maximum and efficient use of available resources in the delivery of care. It has been evidenced that while it has been taking place for a long period, multi-agency team working has not always been effective or straightforward. This could likely be attributed to its complexity and the complex process through which it is achieved (Atkinson, Doherty and Kinder, 2005).

In order to analyze multi-agency team working and collaboration in health and social care, this essay will highlight the nursing profession, examine what is meant by multi-agency working in practice, its key drivers, the various theories and concepts (power, professionalism and identity) influence multi-agency working, as well as attempt to demonstrate how healthcare professionals should be supported to work collaboratively. Furthermore, the essay will also explore the ways in which multi-agenct working impacts on the provision and quality of care.

The Nursing profession

For the completion of this assignment, the professional role of choice is that of a nurse. Nursing is a profession whose primary mission is the identification and protection of the (physical, mental and psychological) needs of an individual in order to enhance their well-being and quality of life. The profession is highly specialized and is constantly evolving so as to effectively address the needs of individuals and the society. Professional nurses are tasked with assessing patients, ensuring the accuracy of diagnoses, educating the public on critical health issues, making critical health and care decisions, providing health promotion, counseling and education, administering medication and other healthcare interventions and coordinating care in collaboration with other healthcare professionals.

One can only be considered a professional nurse after earning the relevant academic qualifications at the degree, master’s or doctorate level, completing a specified minimum number of supervised fieldwork hours, and registering with the relevant professional body. The profession has, over the years undergone several changes that has seen to it being established as both an academic and practical profession, with registration with a professional body becoming mandatory requirement in the UK. This development resulted in the ability to hold accountable the registered professionals and ensure that the set standards were observed and that they act or conduct themselves within the acceptable limits of practice (Rogowski, 2010; Wiles, 2010). Before one can duly become a professional nurse, they must meet the requisite qualifications and proficiency standards for nurses as established by the Health Care Professionals Council (HCPC) (2018). In order to effectively perform their roles and responsibilities, nurses have to work in collaboration with other social and health care professionals including teachers, social workers, doctors, therapists, and so on (O’Laughlin and Bywater, 2008).

Defining Multi-Agency Working and Its Key Drivers

While the term multi-agency working simply describes the act of professionals working together, multiple other terms, such as multi-professional, inter-professional, inter-disciplinary, multi-disciplinary, inter-agency, partnership and collaborative working, have been used in the same breath and interchangeably. Leathard (2014) described this as a terminological quagmire given that the health and social care profession has experienced accelerated developments over the years, suggesting that the use of one time may not adequately describe or be applicable to the working together of some professional groups. However, all these terminologies have been acknowledged to represent the different forms of collaboration (Social Care Institute for Excellence (SCIE), 2020), which Cohen et al. (2015) describe as the act and process of healthcare professionals undertaking collection, sharing information within or among themselves and with other professionals, and cooperating to make decisions, solve problems and develop care plans for the service users.

McCray (2009) defined multi-agency working as the involvement of professionals (for example, nurses, pediatricians, dietitians, housing workers, social workers, teachers, and so on) drawn from a wide range of services (e.g. health, education, housing, social work, etc.) who undertake a multi-professional practice in teams to provide health care and services to an individual. Moreover, the patients’ and their caregivers’ involvement in the provision of care will make them part of the multi-agency practice, which could lead to it being referred to as partnership working.

There are various factors that act as the drivers for multi-agency working. Changes in the way health service funding is allocated, as set out by government policies and legislations, which have resulted in changes in the manner in which services are delivered thereby leading services to devise new methods of working with other professionals as a way of maintaining funding have been described as the ultimate and key driver in the shift towards multi-agency working (Johansson and Hvinden, 2007). The move from institutional care models to community level models of care or services for service users, especially those with mental health or learning disabilities and needs, has given rise to the need for healthcare professionals to establish different working relationships among themselves and with the service users (Cox, Adams and Loughran, 2014). The provision of community-based mental health care and services has meant that patients suffering from severe mental illnesses and living in the communities are exposed to increasing risk of developing physical health problems given their reliance on primary care services, which may not be readily accessible to them (Fejes and Dahlstedt, 2013). The Department of Health (DOH) (2006), in its document on supporting the physical needs of severe mental health illness patients, identified key issues that should be incorporated in the provision of services, and therefore care. It advocated a nurse-led assessment service as part of the multi-agency relationships that would improve the provision of services and care. Shift of the management of chronic illness patients to the community level, supported by community-based nursing teams in collaboration with GP practitioners has also driven multi-agency working. The successful management of the associated processes, including referral, assessment, through to treatment, which is usually led by community-based nursing teams requires a multi-agency approach and working that will involve primary and secondary healthcare services and professionals, social agencies, independent sector, among other services (McLaughlin, 2009, 2010). The introduction of individual budgets, through the UK Health and Social Care Act 2014, gave the service users increased power and autonomy, and made them the drivers of how they would like their health care services designed and delivered, and needs met (Glasby, 2017). This also increased the need among healthcare professionals to adopt and shift towards multi-agency working and collaboration.

Technological changes and developments which have transformed the way in which acute care is delivered have also been cited as a driver for multi-disciplinary working. Technological advancements have changed operating practices in acute medicine- for example through keyhole surgery and evidence-based post-operative conditions management- that have significantly shortened patients’ secondary healthcare journey. These new and enhanced practices and interventions have resulted in the aiding of accelerating patient recovery time leading to them being rapidly discharge from hospitals, which in turn creates additional and maximum availability of beds in acute care wards (Basse et al., 2002). This, however, leads to the patients and their caregivers significantly relying on primary care teams during the post-operative period. As a result there has been a growing need and consequent development of the crucial multi-agency relationships and working within primary healthcare teams, as well as between primary and secondary healthcare services and professionals post-discharge (Oliveira et al., 2017). Changes in the role of voluntary and independent sectors of the health care and services have also driven the shift toward multi-agency working. Transition of care for the elderly to the community has necessitated the local authorities to work with in official partnerships with third party or independent sector health care and service providers to deliver care and social support to the elderly within their homes (commonly referred to as home or residential care). Primary health care trusts may have also been faced with the need to partner with third/independent sector hospices and contracting them to provide day-care to service users in need of palliative care (Hudson et al., 2017). As such service user groups have become an important component of these teams and partnerships that facilitate the design, development and planning of care. By working in partnership and in teams, the various professionals create working relationships that can be either formal or informal, or both and enable the delivery of multi-agency healthcare practice (Odegard, 2007). This increases the frequency of multi-agency working in health and social care.

Theories and Concepts of Multi-Agency (Collaborative) Working

Various theories and concepts underlie nurses’ multi-agency working or collaboration with other professions in the sector. The most common of these are power, professions and professionalism.

Power is an extensive and multiplex health and social care theory that significantly influences the completion of duties, and achievement of satisfaction and set professional goals within the nursing profession. Huston (2014) defines power as something that enables a person or group (team) achieve goals, thus promoting their potential to change other people’s attitudes and behaviors, while Du Plat Jones (1999) and Chandler (1992) define it as an individual’s ability to act, control, influence and have autonomy. In health and social care, power revolves around a number of interpretations (Sambrook, Bradbury Jones and Irvine, 2008). For example a nurse could be a human resource specialist, strategic planning expert, a risk manager, quality manager and also have the understanding of clinical complexities (Trus et al., 2012). The possession of these various qualities gives nurses power, which enables them to maximize on the available opportunities to creatively use their knowledge and skills (D’Antonio et al., 2010), and also to give some of this power to their patients thereby giving them a sense of empowerment which contributes to the improvement of their health outcomes (Spence Laschinger et al., 2010). In relation to nursing and multi-agency working, power is a very important concept that facilitates the professionals’ knowledge to achieve autonomy and effectiveness (Oudshoorn, 2005). Power has been described as a purposeful concept that results in the promotion of health processes, attainment of professional status, privileges and development, and the achievement of various outcomes such as improved professionals’ and service users’ satisfaction, reduction of risk and complication incidences among patients, reduced hospital stay lengths and delivery of quality care and services to patients. However, Trus et al. (2012) described the improvement of patient care quality and professional development as the ultimate benefits of power in health and social care and multi-agency working. Nursing professionals working collaboratively, and as part of multi-agency teams, draw their power from various sources. These include knowledge, expertise, experience, position held, decision-making power, scientific power, financial power, skill power, implementation power, and so on (Anderson, Jones and Keltner, 2012). Power of nurses, in multi-agency collaboration, manifests in two forms- individual and professional. Individual power arises from the possession of certain resources and psychological qualities, including decisiveness, courage, self-esteem, communication capabilities, decision-making abilities, self-control and so on. Along with the possessed skills, academic and experience qualifications, individuals can attain power that enables them to influence others and achieve goals. The real individual power, however, enables one to gravitate toward the goal without having to apply various incentives such as encouragement or punishment, threats, rules, domination, pressure or intimidation, and their colleagues and subordinates demonstrate total satisfaction cooperating with them. This form of individual power establishes a link without the need to employ financial resources or force (Anderson, Jones and Keltner, 2012). Nurses can also achieve professional power, which arises from their professionalism, and the acknowledgement of the crucial positions they hold and the roles of their professions. This power also arises from the roles the practitioners are legally and professionally/scientifically able to undertake at various levels (D’Antonio et al., 2010). This type of power can only thrive when various conditions/concepts, such as concrete professional status, professional independence, professional development/growth, maximizing individual opportunities and potential, and leadership abilities, are present (Ponte et al., 2007).

Profession is the other theory/concept applicable to nurses involved in multi-agency working. Concerns were rife in the 19th Century England over the increasing competition from unqualified nurses and their rising numbers, leading to the establishment of the Medical Act of 1858 that outlined, for the first time, the minimum training and qualifications and a registration requirement that aimed at limiting practice to the ‘appropriately/sufficiently’ qualified. As a result, the General Medical Council (GMC) was created to regulate the nursing profession, oversee nurses’ training and maintain a register of qualified nursing professionals (Stepney and Ford, 2011). Subsequent developments led to the ascension of health practice (profession) to positions of power within the later-established state health care system, the National Health Service (NHS), with the profession establishing for itself the right to evaluate and determine patients’ health needs by virtue of their ‘gatekeeper’ positions within NHS. Arising from the establishment of a profession is a high level of clinical autonomy and status (Kieran et al., 2005). As a profession, nursing needs to conform to various ‘ideal’ structural and attitudinal characteristics: specialist knowledge; the presence of authority that patients defer to; self-policing and self-governing regulation, mostly through professional associations; presence of an ethical code; certification and licensing of practitioners; and protection of patients (Kieran et al., 2005; Parsons, 2010). These qualities have led to the rise of professional group identity, and shared values among nursing professionals. Therefore, in order to effectively form and work in multi-agency teams, the involved nursing professionals must possess the appropriate qualities and values that qualify them as members of the profession and recognized as being of professional status.

Consequent to the establishment of the nursing profession was the rise of professionalism, which is the other theory relevant to multi-agency working. Professionalism refers to the act of nurses providing high quality care while demonstrating respect for patients, advocacy and responsibility (Daniels et al., 2007). The concept also covers the nursing professionals’ ability to effectively communicate, self-reflect on actions, behaviors and attitudes, and to work toward their professional and personal growth (Kieran et al., 2005). Nursing professionalism components can be categorized as cognitive, attitudinal and psychomotor (Egener et al., 2017). Cognitive professionalism enables multi-agency working professionals to continuously learn about the evolving professional conduct and apply this knowledge to practice or in work environment. This will help nurses develop prioritization and effective decision making skills (Edwards et al., 2009). Attitudinal professionalism concerns the attitudes and ideas that guide health professionals in the performance of their duties and as they develop/advance professionally. Their attitudes should conform to the profession’s standards and their organizations’ goals (Kumar and Kumar, 2019). Examples include flexibility, courtesy, respect, compromising, adaptability, and so on. These will help them navigate any professional obstacles they encounter during practice. Psychomotor professionalism is concerned with the idea that nurses should strive to build on and improve their clinical/technical skills as they gain experience. Professionals in multi-agency teams could strive to improve their management skills or understanding of the inherent obligations or commitments their practice involves; this requires that they develop self-learning abilities and skills, and self-discipline (Edwards et al., 2009). Professionalism, and its above-mentioned principles, will enable nurses in multi-agency working to become effective leaders, use value judgments to make decisions and act, and create self-directed commitment to give the highest quality client service.

How Nursing professionals Undertake and Are Supported in Multi-Agency Working

The undertaking of a multi-agency working by nursing professionals requires and can only happen in a team work setting. A team, according to Mickan and Roger (2000), is a group (usually small) with the right skills and competencies required to complete a particular tasks and who- on the basis of agreed goals- work collectively to achieve the set goals. It is however, worth noting that there exists a variety of types of team (or multi-agency) working and the level or extent to which it occurs. Barr et al. (2005), Doherty (1995) and Odegard (2007) observe that the multi-agency working that occurs in health and social care involves multiple levels of health care and service, including service user, healthcare organizations, healthcare professionals, carers or caregivers, and communities. Each of these multi-agency working and team work types and levels demonstrate varying extents of innovation and innovative practice models.

Dehorty (1995) explored the scope of multi-agency working among healthcare professionals and ranked them from level 1 to level 5. In level 1, the different health care professionals are based in different spatial locations, handle different caseloads and demonstrate minimal levels of collaboration or multi-agency working. On the other end of the continuum is level 5, where the health and social care professionals are wholly integrated, share office spaces and caseloads, and have an enhanced understanding of their fellow team members’ roles, responsibilities, values and areas of expertise. At the fifth level of multi-agency working or collaboration, the team as well as its effective functioning is as important as the service users’ health problems and needs. Although Doherty (1995), in his research of the extent of multi-agency working, found that most health and social care multi-agency working happened at level 3; this is where the professionals comprising the care teams shared common systems and met face to face during which they shared information and discussed the service users and issues relating to their care. More recent and advanced care and practice models, including the introduction and rapid spread of integrated teams and integrated care in the provision and delivery of care and services to adults, have resulted in an increase in the adoption, implementation and frequency of the fifth level of multi-agency working.

Nursing professionals’ multi-agency working also takes place through teams based on their locality (Hudson, 2007). Hudson’s (2007) evaluation of five locality based teams revealed that the health and social care professionals collaborated and worked in teams that comprised three partner groups: the primary health care trusts, county council in charge of social care services and the borough council for housing. Professionals collaborating in this regard could create and incorporate service models that were locally based, as well as comprised integrated teams that operated at level 5 of collaboration based on Doherty’s (1995) classification of multi-agency collaboration levels. Based on the analysis of his findings, Hudson (2007) proposed two models of teamwork that described how health and social care professionals collaborated; the optimistic and pessimistic teamwork models, each of which presented varying sets of characteristics. The pessimistic teamwork model comprises distinct traits, accountabilities, knowledge, power and cultures of the various parties to the team, while the optimistic model involved the members sharing common values, accountability, location, learning, caseloads and culture (Hudson, 2007). In the same regard to the review of these teamwork models, contemporary and traditional are terminologies that are appropriate in the description of the different positions professionals comprising a team hold. The barriers created by professionals who collaborate by way of the pessimistic teamwork model, by virtue of these professionals’ distinct values, traits, knowledge, culture, status, power and accountability, straitjacket their traditional team working or multi-agency collaboration. This distinctiveness and the barriers they create could result in divisions and incongruence. Hudson (2007) suggests that the optimistic or contemporary multi-agency working characteristics prevent numerous common features among professionals that would outweigh any likely divisive factors.

Values are a core factor in the exploration of how nurses and other health professionals collaborate. McCray (2006) defines values as those things which an individual perceives as core and hold at the centre of their being. Values develop over time and as a result of experience, and could provide a reflection of a person’s lifestyle moral standing or culture. By collaborating and working in multi-agency teams, professionals are provided with the opportunity to share values on the basis of universalism- providing service to all and promoting benevolence in the delivery of service and care during practice (Hudson, 2007). Additionally, values are considered a significant influencer of multi-agency working as, if shared, they have a great potential of motivating professionals to collaborate and eliminating the barriers or differences arising from distinctive knowledge, traits, power or status that could impede this multi-agency working. This promotes a collaboration that provides an increased chance of benefiting the service user.

Communication is, perhaps, the most important factor that enables and facilitates effective multi-agency working among health care professionals. Healthcare professionals working in collaboration and in teams should possess effective communication skills and, given their numbers, they should develop appropriate methods of communication with each other and explicitly outline their specific roles (Batalden et al., 2006). Constantly communicating enables members of professional and inter-agency teams to share information and ideas relating to best practice that will enable them make them make decisions with regard to and adopt the best possible treatments and interventions that will contribute to promoting positive health outcomes among patients (Lyngso et al., 2014; Snelling, 2018; Social Care Institute for Excellence (SCIE), 2020). Additionally, working collaboratively and communicating within and among themselves enables healthcare professionals to brainstorm and collectively solve problems, as well as share accountability (Lyngso et al., 2014). Slusser (2019) further asserts that multi-agency working health care professionals should, besides within their teams, consistently and effectively communicate with their service users/patients and carers, whom McCray (2009) consider part of the multi-agency team. As a result of this type of communication, nursing professionals are enabled to furnish the service users and their caregivers with information that is crucial to their care and what they need to do in order to promote the ease of care and its delivery, and effectiveness (Slusser, 2019). This, in turn, promotes the service users’ involvement and empowers them to make decisions relating to their care process.

And just like any other team, nursing professionals undertaking multi-agency team work or collaboration will be guided by Tuckman’s (1965) stages of team development and behaviour theory if they are to form effective teams. The four stages suggested by Tuckman (1965) are: forming; storming; norming; and performing.

How Multi-Agency Working Influences the Provision of Care

Multi-agency working and collaboration among nurses and other health and social care professionals is core and very beneficial to professional practice as it influences the provision and delivery of health care and social service in various ways. However, for these benefits/influences to be achieved there is the need for certain conditions to be met by the multi-agency teams and the professionals comprising them. The practitioners from the various health professions should be available in the required numbers, well-trained, of high quality and sufficiently equipped to effectively respond to the needs of service users and deliver quality care. Increased multi-agency learning, training and development, and team working opportunities for practitioners from various healthcare fields/professions should be availed (Morris, 2008). Practitioners should also: have a clear understanding and appreciation of their and the other team members’ roles, expertise, knowledge, values, as well as an understanding of procedures and processes involved; share exemplification of best practice; demonstrate willingness to implement multi-agency working; and be supported in their multi-agency working efforts (Atkinson, Jones and Lamont, 2007).

By collaborating, practitioners are able to share information, ideas, best practice, brainstorm and collectively work in order to solve problems and determine the best and most appropriate interventions. This leads to the adoption of methods and processes that facilitate them to deliver the best-possible service and care to service users, resulting in the achievement of positive and improved outcomes for them (Abbott, Townsley and Watson, 2005; Moran et al., 2007; Townsley, Abbott and Watson, 2004). Multi-agency working improves team members’ understanding of each other’s’ roles thereby enabling them to focus on their own areas of expertise; this fosters the confidence that each member is adequately specialized in their specific area and can and will deliver as they should (Sloper, 2004). By working in teams, practitioners develop a cohesiveness that enables them to take greater responsibility and ownership that allows them to jointly address the patients’ needs. This contributes to the avoidance of duplication or overlap in the provision and delivery of care, thereby ensuring it is of the highest quality (Morris, 2008). Multi-agency working also enhances the fit between the service or care needs of patients and that offered to them thereby improving the potential of effectively meeting their needs. Multi-agency working additionally boosts the nursing professionals’ morale (since they do not work in isolation), facilitating the rapid and collective resolution of issues and challenges that may arise. This increases their confidence, enthusiasm and commitment to practice, enabling them to perform optimally thereby delivering the appropriate quality of care to patients.

However, concerns abound regarding various issues/challenges, such as: underfunding, funding differences within and between various agencies, overall lack of funding for multi-agency training, working and other related costs; availability of limited time; possible lack of clarity or understanding of roles, procedures and responsibilities; unclear or ineffective communication routes/channels; competing priorities; territorial issues and new environment adaptation challenges (Huston, 2014; Moran et al., 2007; Sloper, 2004; Trus et al., 2014); and so on. These issues, if not addressed adequately and in a timely manner will impede multi-agency working and therefore, negatively impact on the delivery of care.

Conclusion

Multi-agency working is a core concept in the delivery of health and social care and services. Nursing professionals need to work together in teams and with professionals drawn from different field of practice and specialties in order to collectively address the needs of a service user more holistically and effectively. A number of theories and concepts underlie multi-agency working: power, profession, and professionalism. These influence the manner in which multi-agency teams exist and how their members’ relate. Nursing professionals adopt and follow various teamwork models in their implementation of multi-agency working, such as locality-based teamwork models, optimistic and pessimistic models, and traditional and contemporary models. These models determine how and the extent to which multi-agency teams collaborate. Multi-agency working, if well implemented, also significantly impacts and contributes to the improvement of the provision and delivery of service and care.

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