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peech and language therapists are very skilled multi-disciplinary workers. In addition to being natural communicators, the nature of the job brings us into contact with a number of different teams and settings. Many of us function within teams built around a clients medical needs or place of education; these can be multi-disciplinary (within health) or multi-agency (health and education). Others particularly in the adult learning disability field are an integral part of multi-agency teams that cross health and social care. Most recently we have been involved in the transition to Childrens Trusts in England. This is seeing the removal of structural barriers between education, care, family support and health to enable formalised, fully integrated services for children. It is clear that the goal of redesigning the structure of childrens services is to improve life outcomes. As Pugh (2007, p.viii) says, Young children and their families do not see their needs for early education, health care, job or housing advice in separate silos, and neither should the professionals working with

Team talk
them. Multi-agency working was to be encouraged as the most effective way of responding to the needs of service users. But the practicalities and challenges of managing such transitions cannot be underestimated. How do we build in professional leadership and support so that the quality and standard of our individual contribution to a multi-agency service is assured? To find out how we might move forward, I asked eight speech and language therapists to share their experience of working with other professionals. Coming from a Language & Communication Resource, Helen Daly was used to working with education colleagues and parents. She feels fortunate to have been able to use that experience at a strategic level as principal speech and language therapist for paediatrics in Wakefield over a period of exciting change. Three years ago dissatisfaction among parents with the way speech and language therapy was provided to schools led health and education authorities to organise a multi-agency conference and strategy group along with parents and voluntary services. Helen says Research shows that barriers of

The advent of childrens centres in England heralds a massive change for public services, with all the ensuing hopes and fears. While speech and language therapists are already skilled multi-disciplinary operators, multiagency and fully integrated working require a further shift in attitude. Editor Avril Nicoll talks to Helen Daly, Christina Barnes, Judith Delve, Kate Evans, Karen Bonham, Gerry Walsh, Hayley Dench and Karen Davies about their experiences.
READ THIS IF YOU WANT TO MOVE CONFIDENTLY TO MULTI-AGENCY WORKING BREAK OUT OF TRADITIONAL WAYS OF WORKING INFLUENCE BUDGET HOLDERS AND COMMISSIONERS

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terminology, training and practice need to be overcome. We have gone from a fairly fragmented to a very collaborative service, with people really working together to benefit all children. Parents seem happier and as a clinician I feel more confident in my role. A Training Plan for teachers, outreach teams, the diversity service and educational psychology now covers speech / language and social communication / interaction. Through I CANs audit tool School Talk, (www.ican.org.uk) schools identify their training needs, while Bradfords Talking Partners project (www.bradfordschools.net) forms the basis of joint training to schools from speech and language therapy, educational psychology and the advisory service. An outreach advisory teacher in language and communication works alongside speech and language therapists. A Post Graduate Certificate of Education in collaborative practice for teachers and speech and language therapists has started at the University of Cumbria in Wakefield and Helen hopes this will spawn outcome evaluations. With strong leadership, training and a shared philosophy, expectations and responsibilities in Wakefield are shifting. Down in Wiltshire, Christina Barnes also works with education services. As a member of the South Wales and West Special Interest Group in deafness she took a lead role in developing care pathways for assessment and intervention with children who have a hearing impairment (Barnes, 2004). These continue to be amended to suit local circumstances such as availability of specialists. Parents and other professionals feel happier because they are clear about the levels of service delivery when, who, what to expect. This has been particularly helpful in relation to working with teachers of the deaf. Christina finds care pathways help parents and other professionals adjust to the realisation that once a week therapy with a specialist may not be the most appropriate input for the child. Instead, the specialist therapist is seen as one contributor to the creation of a 24/7 enabling environment. The care pathways have training built in, and the training offered to teaching assistants includes a piece of reflective writing about the impact of their learning on how they are able to support their named pupil. Christinas vision is for needs centred care pathways written alongside specialist teachers which would help identify the lead / responsible person at different times. She muses, Perhaps education could get management support and time to write their own care pathways first, then we could work on bringing them together? Care pathways have also been transformative for Judith Delves stroke team and consistency of provision across district general hospitals in Shropshire; although this is largely a multi-disciplinary rather than multi-agency service, the results suggest care pathways could be equally useful in a multi-agency context. Judith emphasises the value of face to face discussion to effective multi-disciplinary working, but adds that care pathway paperwork lends itself to audit to ensure standards are being met. The Royal College of Physicians Guidelines on Stroke and the National Sentinel Stroke Audit Programme (www.rcplondon. ac.uk) have been a really positive driving force. As

well as highlighting the need for improved clarity of note keeping, audit results have provided evidence for a bid to train nurses to screen for dysphagia within 24 hours of admission. Although team members at the coal face were already working well together, care pathways have raised the profile of the professions contribution with nurse managers and consultants.

Think positively

Judith reckons that, Local guidelines often reflect available staffing. The only way in the modern NHS to keep standards up is through a national organisation with a lot of power saying what we are expected to deliver. While targets may seem unattainable, you can think positively about the rationale behind them and how you can go some way towards meeting them perhaps through offering training or developing information leaflets. A settled staff with good leadership helps create a flexible approach to joint working. Judith finds joint assessments particularly useful, noticing clients can communicate differently for example during a physiotherapy session in the gym. In Gloucestershire, Kate Evans also shadows clients in different environments, and a calming sensory session with an occupational therapist can carry over to a communication session.

As communication specialists we are particularly good at 'opening up spaces'; together with what we know clients and families want, this should give us confidence to handle whatever challenges multiagency working presents.
Kate works in two 8 bedded in-patient units for adults with learning disabilities who have additional mental health, autism or challenging behaviour needs. Not only is multi-disciplinary and multi-agency working an aspiration, Its the only way we can work! Care pathways are again seen as crucial, to the extent that the Trust has a care pathway co-ordinator. Kate says, Care pathways put the client at the centre and stop us being in our little ivory towers. The team uses the East Kent Outcomes System model and the focus from the start is on agreeing a core aim enabling the person to be discharged. Each professional says what they will do to enable this to happen. Within the team the communication assessment is recognised as a priority so other professionals know how to communicate effectively with the person in terms of levels of understanding, expressive ability and whether additional strategies such as visual material are needed. More radically, a New Ways of Working conference has turned a nursing recruitment problem into

an opportunity for newly qualified professionals from other disciplines. Nursing money is funding a band 5 newly qualified speech and language therapist for two years to work a full shift system. The goal is to get effective communication at all times through modelling. Initially the nursing team felt threatened but they now feel more positive, and see it in terms of supporting clients. Kate is supervising the band 5 and the impact and challenges will be formally evaluated. Multi-agency working here with social workers, advocates and independent Mental Capacity Act advisors is at an advanced level but Kate wants it to extend to better outreach partnerships and so reduce the need for readmissions. Like Kate, Karen Bonham is passionate about spreading the benefits of multi-disciplinary working. She is also in a very specialised environment, in this case a regional neurorehabilitation unit for 16-65 year olds with acquired brain injury. Karens tightly knit team uses lean working. Borrowed from industry, this approach looks at the effectiveness and efficiency of service flow to identify care pathway constraints and bottlenecks. Solutions have included increasing the team presence and ward rounds on acute sites to facilitate timely referral. This has been successful in reducing length of patient stay in the acute sector and has indicated the need for developments at the pre-admission and discharge stage of the pathway. A clinical specialist across the acute and rehabilitation sectors has been funded and there are plans to appoint a discharge liaison nurse. The physiotherapists have also started flexible scheduling of shifts so they are there when clients are dressing or carers are visiting to maximise carry over of skills. Rehabilitation diaries, key workers, a client centred approach and discharge planning from the start set up realistic expectations. If a client is aiming to go home, they are encouraged to aim to go home safely. Goal mapping identifies the steps needed to achieve their goals, however unexpected. One client wanted hair extensions! When we tied it down, it meant she wanted to fit in physically with her group of friends and develop her social communication skills. Another client had a wedding planned, so the team had to consider issues from mobility, aids, equipment and car transfers to feeding requirements, medication and working with carers.

Cross-pollination

Karen likes the role blurring of multi-disciplinary work because You can work outside the box. Newly qualified therapist Gerry Walsh also says, I really enjoy working in this way. I may have found it limiting with speech and language therapists only I like the cross-pollination and being able to problem solve. There is an opportunity on a rolling basis to learn and to impart knowledge this builds confidence and respect. Working with adults with learning disabilities across two multi-agency teams in Kent, Gerry shares an office with a clinical psychologist, two care managers and a nurse. I see us as a set of people who can work holistically together. We see the whole picture and are a group of advocates rather than just one.

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Gerry finds the different teams function in different ways according to management style, average age or even a new member of staff. While team away days, shared notes and case presentations all help, she believes the most effective way to build relationships is through spending time together and talking. Hayley Dench agrees that - while it might sound clichd- The key to the whole thing is communication. We need to create a forum for discussion where people are open, honest, and prepared to be flexible and to compromise. Your vision might need to change and that adjustment can be hard. Working for an acute Trust in Birmingham, Hayley is involved in a partnership project with three Stroke Association Communication Support Coordinators and a community Trust. While speech and language therapists focus was for clients to get the most out of groups, the Stroke Association was pushing for client-led, functional goal setting. Working together they have developed an electronic resource to help the Communication Support Coordinators and their volunteers select appropriate activities for individuals when attending the groups. The project will be evaluated for its impact but Hayley already sees that the collaborative approach has led to a more useful resource than she envisaged. It is electronic rather than paper based and referrals are now supported by suggestions of activities and the level of cueing the client benefits the most from. The terms and language used in the documentation was guided by the Communication Support Coordinators. Hayley says all parties need to stop feeling that changing the way we have always done things is a threat, as in multi-agency working it is not necessary to compromise your integrity as a professional. Karen Davies is a speech and language therapy manager in Trafford. Her job as a professional manager for speech and language therapy is due to change as all childrens services are reorganised into an integrated Children and Young People Service. A long-time advocate for children and for the profession, Karen is facing the change with a mixture of optimism and trepidation. While accepting the transition will not be smooth she recognises a can do attitude is needed, with a focus on what is best for children and families. We need respect for the people we are working with, clarity about our roles and responsibilities and an attitude that doesnt view the new structure as an instant threat to the way we work. Karen believes the service in Trafford has many examples of successful multi-agency working which should provide a blue print for further integration of services. She is in no doubt that speech and language

10 steps to better multi-professional working

1. Take responsibility - be proactive 2. Spend time talking together 3. Focus on solutions and outcomes 4. Be flexible 5. Learn from colleagues and support their learning 6. Reflect, audit and evaluate 7. Build on strengths and professional networks 8. Offer joint assessment and agree roles and responsibilities 9. Cut out the jargon 10. Show what you can contribute
Join the multi-professional working discussion in the www.speechmag.com members area.
therapy is in a strong position to become an essential partner in newly established integrated teams. If integration is carefully designed, then the outcomes should be better for our users. Karen says we should achieve: 1. Quicker access to the right support 2. Prevention of significant secondary problems 3. More joined up targets 4. Quicker access to the right support in a crisis 5. Common standards and equity of provision 6. Reduced confusion of terminology and diagnosis. Karen hopes the process will be evaluated thoroughly, with speech and language therapy taking an active role. She suggests this is an area that the Royal College of Speech & Language Therapists could be involved in commissioning. Karen has found evidence that multi-agency working is successful in smaller teams who have

professional back-up, so her main reservation is around the weakening of professional support. Professional leadership within an integrated team can guarantee standards of practice, safety, effective recruitment, supervision and continuing professional development opportunities. She is unclear how this will continue when former heads of service take on multi-agency roles. Whilst speech and language therapists are very good at creating networks of support, she believes this cannot be left up to chance and needs to be carefully planned and monitored. Gerry Walsh agrees that in multi-agency working there is more personal responsibility to ensure supervision is adequate and appropriate. Her small speech and language therapy team makes time and space to get together and are always available by phone, text and e-mail. Gerrys line manager is a care manager who used to be a nurse but she also has her head of profession and another senior colleague as a clinical resource. Similarly, Kate Evans finds day to day management and supervision by a nurse is appropriate to her working context, and she can access more specific supervision from her professional lead or from the Mental Health Special Interest Group as required. French (2007) provides a helpful historical context for multi-agency working, where current structural changes can be seen as part of a continuum rather than experienced as an isolated upheaval. In the same text Whitmarsh (2007) addresses ethical anxieties around confidentiality, a major barrier to multiagency working. She argues, Considering ethical practice as relational opens up spaces in which we can discuss the issues while trying to weigh up which principle may, on this occasion, be of over-riding use to the specific situation (p.94). As communication specialists we are particularly good at opening up spaces; together with what we know clients and families want, this should give us confidence to handle whatever challenges multiagency working presents. As for where to start if you feel you are facing a brick wall, Helen Daly suggests the answer is to Get out and find people who share your philosophy, because they do exist. The key is talking to people, finding out their viewpoint and starting from there. SLTP

Acknowledgements

Many thanks to the speech and language therapists (names in bold) who gave me their time and the benefit of their experience.

References

Barnes, C. (2004) No borderline just a pathway, Speech & Language Therapy in Practice Autumn, pp. 14-17. French, J. (2007) Multi-agency working: the historical background, in Siraj-Blatchford, I., Clarke, K. & Needham, M. (eds.) The Team Around the Child. Stoke on Trent: Trentham Books, pp. 47-66. Pugh, G. (2007) Foreword, in Siraj-Blatchford, I., Clarke, K. & Needham, M. (eds.) The Team Around the Child. Stoke on Trent: Trentham Books, pp.vii-ix. Whitmarsh, J. (2007) Negotiating the moral maze: developing ethical literacy in multi-agency settings, in Siraj-Blatchford, I., Clarke, K. & Needham, M. (eds.) The Team Around the Child. Stoke on Trent: Trentham Books, pp. 87-103.

Resources

Karen Davies recommends: Rushmer, R. & Pallis, G. (2003) Inter professional working: the wisdom of integrated working and the disaster of blurred boundaries, Public Money and Management 23 (1), pp.59-66. Karen Bonham says there is more on lean working at www.dh.gov.uk/ahpbulletin (September 2007).

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