Horizontal Teamwork in a Vertical World

Exploring interagency collaboration and people empowerment

By Peter Limbrick

Verso
Horizontal Teamwork in a Vertical World: Exploring interagency collaboration and people empowerment
Copyright © 2012 Interconnections. All rights reserved. Published in the UK by Interconnections. No part of this publication can be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the Copyright owner. ISBN 978-0-9540976-6-0. Printed in the UK. Cover image © Martina Jirankova-Limbrick, 2012

This 2026 version of the book is true to the text but not to the design of the original publication

This essay is dedicated to all the people in the world who have needed help at some time and to all the people who have found opportunities to help them

About the author
Peter Limbrick established and directed a voluntary organisation called One Hundred Hours in the UK in the 1990s. Its purpose was to develop and validate keyworker support for families whose baby or young child had neurological impairment and consequent multifaceted disability. From this experience, Peter developed and published the TAC model (Team Around the Child) and has since promoted this approach in England, Scotland, Wales, Northern and Southern Ireland and Australia. From his home on the border between England and Wales he writes, publishes and continues his consultancy work to promote interagency collaboration in any country.

Contents
Introduction
Chapter 1: Horizontality
Chapter 2: Power in horizontality
Chapter 3: Where service user and horizontal structure meet
Chapter 4: The workforce in the horizontal landscape
Chapter 5: Planning the service user’s journey
Chapter 6: High standards in interagency collaboration
Chapter 7: A rich horizontal landscape for people in need
Appendix
References

Introduction

Focus, intended readership and aims of the essay

Some people who need support from public services experience problems of fragmentation and disorganisation when they are helped by more than one agency at the same time or in the same period of time. The agreed antidote is interagency collaboration or, to use another term, multiagency co-ordination in which separate agencies find a way of working together to minimise or eradicate the problems often caused to the service user by a number of separate, concurrent or consecutive interventions.

This essay is primarily concerned with service users who are shared between two or more agencies and it is written to promote and support efforts to create improved provision in any country. The intended readership includes:

• people who work in any of the public, voluntary & community or private agencies who are trying to develop or improve interagency collaboration for particular categories of service users

• service users, service user groups and people who represent, campaign or advocate for them

• policy makers in local or national government

• academics who might explore and develop these ideas in their institutes and universities

• staff members in agencies that provide professional training and qualifications

• staff members in public service training departments

• staff members in national professional colleges, e.g. Royal College of Nursing (RCN)

Though interagency collaboration is easy to define, it has not proved easy to achieve and good examples are a rarity. While service providers, whether concerned with education, health, social care, law enforcement, the courts, housing, etc struggle against the odds to comply with government regulations and guidance, and while the media have a field day each time the persistent fragmentation results in a high-profile tragedy, we seem to have made no progress in learning how separate agencies can work together effectively in systems – systems that are allowed to grow beyond pilot projects and are sustainable against persistent pressures to revert to fragmentation. In the UK we stumble forward, forever groping in the dark, always trying to make the best of a bad job without the benefit of accepted scientific or technological formulae about how to do it. Time and again we construct a more or less effective integrated system for this or that category of service users only to see it crumble in the face of stronger forces like a sandcastle before the incoming tide.

This essay is offered as an exploratory contribution to thinking about interagency collaboration and, seeking a fresh perspective in the hope that it will open up new solutions, will examine the issues in terms of verticality and horizontality.

Thus the subject matter of the essay comprises vertical organisations and the horizontal structures they must create between them in pursuit of interagency collaboration for particular service users or categories of service users. From this explorative viewpoint I intend to keep a close focus on the people who require simultaneous or consecutive support of some sort from two or more of their local agencies on the understanding that the effectiveness for them of interagency collaboration is the only criterion of success.

The essay will:

• draw clear distinctions between vertical organisations and horizontal structures

• demonstrate their interdependence

• inform the development of rich horizontal landscapes in which service users are more powerful and from which they receive effective joined-up support

• encourage and reassure practitioners and managers about the opportunities for improved working practices and job satisfaction in horizontal teamwork

• refresh debate and discussion about interagency collaboration for policy makers and academics

• add new insights and perspectives to training programmes

• suggest that national professional colleges help promote interagency collaboration and training for professionals in horizontal teamwork

Interagency collaboration, whether achieved at the grass-roots through the efforts of a keyworker (or ‘lead professional’) or the child’s small collaborative team in the TAC model, is elevated in this essay to life-saving status as an essential and imperative modernisation of service provision. I always wonder how many suicides and infanticides would have been prevented if agencies had been fully integrated around the particular service user. I wonder how much sheer misery and despair would be alleviated now amongst the multitudes that are given chaotic and piecemeal support in the UK but do not reach that tipping point – or have not done so yet.

It might be helpful at this point to indicate the range of people who might, at some point in their lives because of some condition or situation, need integrated support from two or more agencies. My list of examples includes:

• children of any age with a multifaceted condition

• children with special needs at school who, and whose family, have some formal involvement with social workers

• teenagers leaving local authority care with no home, qualifications or employment

• men and women with a history of drug addiction being released from prison

• elderly people who need continued support on discharge from a geriatric hospital ward

From these examples of what I am going to call categories of service users, it is clear that agencies can be providing support simultaneously or consecutively in response to a particular condition or situation. For instance, an infant can be helped by a health visitor and a social worker at the same time while an elderly person can move from a hospital ward with its medics to his own home with social work support. In both cases, interagency collaboration might be an imperative for the wellbeing or even survival of the service user.

It is impossible to treat the subject of improving service provision properly without also addressing empowerment of people who use public services. Everyone would agree now that the practitioner does not automatically know best, that the service user has views that must be heard and that the person being helped carries both rights and responsibilities to be an active participant. This enlightenment has not yet permeated through all of public service provision and many people complain of being a very junior partner or even of being subject to subtle processes of disempowerment at the hands of some agencies and the practitioners within them. Good practice in the UK shows that service users can be competent, equal partners and even help design local service provision for the category of service users to which they belong. The argument that this empowerment requires a horizontal landscape is a large part of this essay and I will take it a stage further and suggest that horizontality provides a space in which people can be proactive in finding local solutions to their shared problems.

Defining some terms

I have used the term service user to embrace all people who use some sort of agency or service whether as patients, pupils, parents, consumers, customers, citizens or community members. In some cases I have used person or child or parent instead.

I have grouped service users together when they share to some extent situations, conditions and needs as categories of service users and as groups of service users when people have come together for some sort of collective action.

The term agency encompasses all agencies, services and projects whether they are part of public services, the voluntary & community sector or private organisations. The term voluntary & community sector embraces traditional charities, public service mutuals, community interest companies and other social enterprises. It does not include private organisations and individuals working for profit. When agencies in a locality come together in a collective effort they are termed an agency collective.

Practitioners are people who work in an agency at the grassroots and are also sometimes referred to as people. I will distinguish between practitioners and managers but I am aware that this might be a dual role for some people. The terms members of staff, staff members, staff and workers are used as collective nouns for paid workers at all levels in any agency. When I use gender-specific terms they designate practitioners as female and service users as male.

One Hundred Hours (OHH), a voluntary organisation that pioneered keyworker-based family support during the 1990s in the UK, was a small organisation offering a free service for new parents of infants who had neurological impairment.

TAC is the acronym for Team Around the Child. In the original TAC model, designed by Interconnections, each child’s TAC is a small, service user-friendly, collaborative team that meets face to face to agree a multiagency action plan for a disabled baby or pre-school child. Both the TAC model and each child’s TAC within it are used in this essay as examples of horizontality. TAC, as an acronym, has a life of its own now in many countries and, if the reader wishes, can be given a much wider application as Team Around the Child, Customer, Client, Community member, Consumer, Citizen – or Service user.

I have included several numbered or bulleted lists in this essay and I am aware that in most cases I am representing blended and overlapping parts of a continuum. I am also aware that each list would be different if it were written two years ago or in two years’ time. Perhaps each list is best offered as an invitation for readers to compose their own to meet their particular situation.

A quick tour through the essay

Following this introduction, Chapter 1 gives an explanation of horizontality using TAC as a successful example and contrasting it with the verticality of public services in the UK. The horizontal landscape stretched between and created by public services is offered as the essential arena for inter-agency collaboration. While I suggest that horizontality should become a core function of public services, I acknowledge that its development can be a very great challenge to practitioners and their managers.

Chapters 2, 3 and 4 give greater detail about horizontal structures in terms of implications for service users and workers. Chapter 2 discusses the issue of disempowering and empowering service users on the understanding that service development initiatives in the 21st century must address partnership working. In the flattened power structure of the horizontal landscape, the voice of service users can be more clearly heard although I argue that the service user can never have an equal voice in how support is delivered. In chapter 3, the multiagency keyworker and TAC are described as essential models for the interface between service users and the horizontal structures that have been designed for their joined-up support. Lessons from the TAC model and from its predecessor, One Hundred Hours, are used to explain in part why keyworking has not flourished in the UK. I suggest that both children’s TACs and keyworking should be taken much more seriously and I offer suggestions for developing these roles. Chapter 4 focuses on practitioners and managers, showing clear advantages for them in developing and working in new initiatives for interagency collaboration but highlighting the need to offer them practical reassurance and protection in the horizontal landscape. The development of local initiatives for interagency collaboration requires time, resources and effort but should offer staff members new patterns of work rather than increased workload.

Chapter 5 offers a structure for radical service redesign, the purpose of which is to create multiagency integrated pathways for those categories of service users who are shared between two or more agencies. Discussions to agree a shared vision and a list of values are described as the essential starting point. One of the tasks for managers is to agree high standards for user empowerment and effective support with formal regulatory systems. Another key task is to agree how integrated support will be funded. Chapter 6 celebrates an example of very effective interagency collaboration in the commercial world and offers reflections on it. A key lesson from this example is the need for service contracts with enforceable criteria to prevent the horizontal landscape becoming an unregulated free-for-all. The provision of therapy for disabled infants is used to show how professional competence can be maintained in the face of very many new agencies providing interventions.

In Chapter 7, the final chapter, I argue for a radical shift of balance between the interdependent vertical organisations and horizontal structures that are needed to cater for the multitudes of people who require interagency collaboration. Three reports, all published early in 2012, are quoted to justify this argument. The experience of the new children’s trusts in England is used to demonstrate that this sort of expanded vertical organisation is not a viable way forward. I offer six key components of service redesign to counter the problems that have hindered horizontal teamwork to date in the UK. In the Appendix I acknowledge and applaud the brave efforts of the people in Argentina who, ten years ago, began a movement that became known as horizontalidad. I draw a distinction between their urgent efforts to provide essential schools, clinics, food, etc as a sub- or anti-political movement and the challenge of this essay to create horizontal landscapes between existing public services.

Chapter 1: Horizontality

Summary

In this chapter, clear distinctions are drawn between vertical organisations and horizontal structures and horizontality is offered as the necessary structure for interagency collaboration between service providers at both senior management and practitioner levels. The TAC model is described as an example of horizontality which can inform service development for all categories of service users that require support from two or more agencies. The chapter explores aspects of interagency collaboration and the need for it to be properly established as part of the strategic design and direction of local support services. Horizontality is presented as a great challenge to service providers now and, perhaps, increasingly in the next few years. The chapter has four sections as follows:

• Horizontality and verticality

• TAC as an example of horizontality

• Interagency collaboration and its foundation in horizontality

• The challenge of horizontality

Horizontality and verticality

So what do I mean by vertical organisations and horizontal structures? A vertical organisation is defined here as an agency of any size with a top-down, hierarchical management structure in which each and every employee can look up to the people who are more powerful than they are and down to the people who are less powerful and subject to their decisions and control. Vertical organisations are often presented diagrammatically as a pyramid in which each stratum has fewer people as the tip is approached. Horizontal structures on the other hand are characterised by people from two or more agencies collaborating with each other in a flattened power landscape in which no one has automatic authority over the others. While in vertical agencies, service users are typically positioned at the base of the pyramid, those in the latter might well be, or even should expect to be, part of the collaborative team that is the product of people working together in a more or less status-free forum.

I am using the word organisation for the vertical and structure for the horizontal to suggest a possible difference in the degree to which they are official or formally established bodies. In the context of this essay vertical organisations, be they public or voluntary & community services, can stand alone with their own funds for employing staff while horizontal structures are created by vertical organisations and more or less dependent on them for funds and practitioners. (As we will see in the Appendix, there can be horizontal initiatives that are independent of the established public services.)

Most of us recognise, use, are subject to or work in some version of vertical organisation, with the chief executive or director at the top overseeing the work of successive lower layers of staff and coming eventually down to grass-roots practitioners or fieldworkers – who are probably the ones doing most of the work with the service users or customers. Many people will be less familiar with horizontal structures and for them a brief description of the TAC model might be appropriate to explain the idea of horizontality.

TAC as an example of horizontality

The original TAC model was designed for infants with significant neurological impairment resulting in a multifaceted condition[1] in which several elements, for example cerebral palsy, sensory loss, cognitive impairment, challenging behaviour and social and communication difficulties, are intimately welded together in all of the child’s functioning. In traditional approaches in the UK these infants are often supported simultaneously by a number of discipline-specific practitioners in the mistaken assumption, in my view, that these disabilities can be treated separately from each other (as though they do not interact with each other in the neurological process of the child’s learning). The list can include: speech and language therapist, occupational therapist, physiotherapist, psychologist and separate specialist teachers for hearing, visual and cognitive impairment. There might also be additional people from local voluntary & community and private agencies offering their particular types of support and intervention.

Though not every child will have this whole set of interventionists, it is a wholly unplanned and additive approach in which a new worker is added to the present ones each time a new need is suspected or discovered. The outcome is a fragmented and disjointed set of separate services lacking any coherent planning and often, surprisingly when one considers limits on resources, too many practitioners with too many separate programmes. The child and family are at risk of duplication, contradiction, mismatches, overload and continuing unmet needs – needs of which no practitioners are aware because none of them see the whole picture of either needs or provision.

In the TAC model two or three key practitioners from two or more local agencies agree to hold regular face-to-face meetings, in which the parent is a full member, to share observations, discuss relevant issues, agree needs of child and family and construct a single, written, multiagency action plan. Successive TAC meetings modify and progress the plan as appropriate. The TAC model carries the option of joining separate education and therapy programmes into one integrated, whole-child programme and using the consultant model to reduce the number of practitioners required to work directly with the child and parent at any one time –perhaps agreeing a single primary interventionist for a period of time.[2]

Though I have described TAC as it is experienced by the family, the model cannot only involve grass-roots practitioners. For it to function effectively for children and families there must first be a collective effort by senior managers in the local agencies to create an integrated pathway[3] to give seamless and coherent support from the time when the child first enters one of the agency’s doors. This interagency collaborative effort at strategic level provides for each child a shared process for referral into the pathway, a joint on-going assessment of need, a unified action plan integrating interventions and programmes, and a joint review of progress.

Each child’s TAC is a horizontal structure because the practitioners are temporarily removed from their hierarchical relationships and work with each other and with parents as equals. Each TAC has a ‘facilitator’ to help the meeting run well and arrive at an agreed action plan, rather than a team ‘manager’ who exercises authority. This model works well with neurologically impaired infants in the UK and other countries and has been successfully modified for older children and young people with other needs.[4]

A strong appeal of the TAC model for both families and practitioners is that the phrase ‘team around the child’ itself seems to carry the solution to disorganisation and fragmenta tion and, in requiring people around the same child to talk to each other, accords with common sense. It is the model people who do not know better would naïvely assume to be the usual approach.

Interagency collaboration and its foundation in horizontality

From the example above we can take a wider look at horizontality. We can see that there can be no effective interagency collaboration unless multicomponent service provision shifts to a horizontal structure around a service user or category of service users – in a particular locality and for a fixed period of time. This shift towards horizontality is needed to bring directors, managers and practitioners from one agency into a place where they can integrate their work with directors, managers and practitioners from one or more other agencies in support of service users they share in that locality. (It is regrettable that agencies in the UK rarely share common boundaries so, for instance, one education agency might have to work horizontally with two or more health agencies or vice versa.)

If the phrase interagency collaboration is to have any meaning or relevance, it must require service providers to do something they would not otherwise be doing and service users to experience some valued elements of support they otherwise would have had to manage without. Starting at the grass-roots where practitioners offer direct support to service users, there are in my experience three increasing levels of interagency collaboration.[5] Readers are invited to consider how applicable this analysis is to the people they support. The three levels are as follows:

1. Liaison and networking
This is for children who at a particular time are in a more or less uncomplicated situation and with a single disability or need rather than a multifaceted condition. This simplest level of joint working keeps the family informed and in touch with relevant local agencies and keeps those agencies informed about the child and family – within the agreed limits of confidentiality. It is not an onerous task for a health visitor, children’s centre practitioner or school-based co-ordinator for children with special needs (SENCo). Such people might or might not be acknowledged more or less informally as the keyworker or ‘named person’ for the particular child and family. While this is offered as the least onerous level of interagency collaboration, it is not the least important. The links made here in the horizontal landscape might bring a shared awareness that a child is being neglected or abused when otherwise practitioners might have harboured suspicions but kept them to themselves.

2. Service co-ordination
This is for the child who has direct support from a number of people in two or more agencies. An effort is made by a keyworker or lead professional to support child and family in getting the best possible fit between all the appointments, clinics, assessments, reviews, meetings, etc in preservation of everyone’s time, money, energy and spirit. Service co-ordination supports the child in having the best possible experience of childhood and the family in achieving or reclaiming something like their version of normal family life.

3. Integration of interventions and programmes
This can be the core of close collaborative teamwork and becomes necessary when the child’s multifaceted condition requires a whole-child approach recognising the interconnectedness of the child’s various disabilities and needs. In the TAC model the key people agree to meet regularly in face-to-face meetings to share observations, agree needs and come to an agreed joint plan of action. Therapies, education programmes, activities of everyday living, socialising and play activity are integrated in response to the infant’s global functioning and in anticipation of his continuing neurological development – which will fuse together new skills in communication, posture, movement, dexterity, social behaviour, etc.

This is a cumulative hierarchy as each of the three levels encompasses the earlier level or levels: the keyworker who helps with service co-ordination also promotes necessary liaison and networking and the child’s TAC becomes an organisational nucleus promoting integration of programmes, service co-ordination and networking.

I would want to argue strongly that this tiered integration or joint working in the horizontal landscape is a professional responsibility for every person who works locally in some capacity with children. This ‘matrix of shared responsibility’,[6] as I have termed it, requires any worker who is offering or intends to offer some intervention to a child to ask herself:

• With whom should I be liaising?

• With whom should I be co-ordinating my interventions?

• With whom, if anyone, should I attempt to work in close collaboration to integrate programmes?

This means the practitioner must look out from her viewpoint in her vertical organisation to see who else is around the child and family in the horizontal landscape and then consider how she needs to link her work to theirs in the effort to reduce fragmentation and disorganisation and to create or contribute to a coherent whole approach.

There is no argument here that service users should have two or more agencies supporting them – if one does the job then so much the better for everyone concerned. But many service users do have two or more agencies supporting them and some sort of collective effort at one of the above three levels becomes an imperative. The particular tasks and activities that come within interagency collaboration will vary between categories of service users and between individual service users but it might be helpful if I offer here a list of activities at the service user-practitioner level. The list can also be read as the raison d’être of interagency collaboration. My list, again based on TAC experience, is as follows:

1. Observations are shared and notes compared to agree a whole and rounded picture of the service user, his situation and aspirations.

2. Once discussion has begun, people will almost certainly become aware they need to agree a common, jargon-free language about all aspects of need and provision to ensure clear and unambiguous communication.

3. There is an agreed process for assessment of needs leading to an integrated action plan that progresses along the particular integrated pathway for this category of service users.

4. Interventions are harmonised as far as possible to remove contradictions, duplications, gaps in provision and service user overload.

5. The people providing interventions support each other’s efforts whenever possible and work towards consistency in their approaches.

6. If appropriate, separate interventions are welded together and the number of people needed to provide them reduced, perhaps with a single practitioner becoming the primary interventionist.

7. There is a careful shared effort to maximise the service user’s involvement, empowerment and autonomy.

8. Within the workings of the integrated pathway there is a shared effort to minimise bureaucracy and waiting times in the support of the individual service user.

9. There is a shared intelligent anticipation of the longer-term situation and some effort to prepare for it.

Collaborative teamwork is not a new invention. Good practice has frequently brought together practitioners from two or more agencies around a particular service user in response to an agreed, perhaps urgent, need. While they form an ad hoc collaborative, horizontal team, this integration might not be available to other service users with similar needs in the locality and its good work might be compromised or discouraged by a number of factors including:

• a lack of officially allocated time and resources for this work

• unhelpful attitudes from management who might feel it takes their staff members beyond their job descriptions or takes the agency beyond its remit

• unhelpful attitudes from the practitioners’ colleagues who might feel their own workload is adversely affected

• a lack of training, support and supervision for this ‘extra-curricular’ work – resulting in practitioners feeling they have put themselves out on a limb without a safety net

From this exploration of interagency collaboration at the practitioner-service user level, it is appropriate to look at the contribution and activities of senior management. To make collaborative teamwork available at a consistently high standard to all service users in particular categories in each locality and for the periods of time that they need it, there have to be agreed horizontal strategies and structures in place. In broad terms, the tasks of interagency collaboration at the strategic level include:

• creating a culture of user empowerment

• establishing a favourable environment for liaison, co-ordination and collaborative teamwork

• designing and overseeing integrated pathways for particular categories of service users

• agreeing policies for sharing information and collecting data across the agencies

• providing training, supervision and resources for practitioners

• setting clear and enforceable standards for good practice

• disseminating clear, jargon-free information about the new local models of interagency collaboration across the locality to all concerned

As some service users require teamwork from a number of agencies (e.g. housing, probation, health, social care, police) in changing patterns and including public, voluntary & community and private agencies, effective integration requires a willingness and commitment in each agency to engender horizontal links at necessary levels. A variety of forces can drive this service development including professional concern for the wellbeing and rights of service users, a commitment to good practice, directives from elected officers or from government.

Experience since the middle of last century shows that an increasingly strong pressure for joint working can come from service users and service user groups who have suffered or seen others suffering under fragmented support, have developed a vision and a passion for an integrated whole approach and are campaigning for it for themselves and for others following in their footsteps. While public services can promote people empowerment by building the service user’s voice and influence into their strategic planning and daily operations, service users and service user groups can also be pro-active in not waiting for such invitations but instead making their own moves to improve provision by some sort of direct approaches and actions.

While each separate agency with its vertical hierarchy can cater effectively for those service users who are not using other agencies at the same time, or whose multiagency interventions can remain separate with no ill effects, they cannot cope effectively with other service users who require integrated support. This vertical-horizontal analysis does not tell us what proportion of people who are using public services need support from two or more agencies at the same time. I do believe though that the numbers are sufficiently large and the issues sufficiently serious to justify each vertical organisation treating horizontality as part of its core function rather than as an extra activity for a few atypical service users on the fringe of its normal work. The starting point would be up-to-date information within each agency about which of its service users are shared with other local agencies.

The challenge of horizontality

Interagency collaboration operates as a horizontal structure in as far as each director, manager or practitioner is willing to leave the confines of their particular vertical employing organisation to work in partnership with other people who are not part of their power pyramid. These new partners are neither their managers nor underlings and are probably on corresponding rungs of their particular vertical ladder. (Having said that, there will inevitably be instances of people jockeying for position and representatives of bigger agencies feeling more important than those from smaller ones – but the spirit of horizontality is equal partnership and the give and take that it brings at its best.) This analysis helps us to frame the discussion of interagency collaboration in terms of the question:

How can vertical organisations promote, design, fund, support and monitor horizontal structures in which agencies are successfully integrated in support of service users who require interventions from more than one of them at the same time?

This might also help us to appreciate the size and nature of the challenge. In the UK we take in verticality almost on our mother’s knee. We have political power narrowed upwards into a cabinet led by a prime minister. We have the bosses of multinationals at the top of international hierarchies reaching down to members of staff in factories and shops who deal with customers or consumers. In the armed forces and police we have generals and chief constables at the top managing squaddies and constables at the bottom who face extreme penalties for disobeying their superiors. Schools, hospitals, social service departments all have their own vertical structures. Verticality can appear to be the divine order for social organisation and thinking outside this construct can represent an almost insurmountable challenge.

It is valid to ask, given this cultural conditioning, if and how staff in vertical organisations can realistically promote horizontality. Is it a reasonable demand or is it tantamount to asking motoring clubs to organise cycling holidays or vegetarians to stage medieval banquets? My perception is that the requirement for interagency collaboration asks some of us to go against our nature and to deny our professional instincts. If this is so we should not be surprised to find that horizontality appeals to only a minority of people in our vertical public services and that workforce resistance is perhaps a large obstacle to interagency collaboration.

At the time of writing in England we have public services being eroded with some NHS hospitals being handed to new social enterprise agencies, schools being encouraged to break away from their local authorities, some elements of social support becoming a new responsibility of the voluntary & community sector and with the powerful and greedy private sector always ready to take over any agencies from which it can make a profit. Without doubt the landscape around the traditional public services is becoming more varied and potentially even more fragmented and piecemeal. In my view, it is the public services that carry the prime responsibility when creating horizontal structures to prevent a chaotic and damaging free-for-all.

[1] For an explanation of this term see Limbrick, P. (2010) pp 30-32, (2009a) and (2011a)

[2] For more information about the integrated programme, the consultant model and the primary interventionist see Limbrick, P. (2009b) pp 62-64

[3] The concept of the integrated pathway is explained in Limbrick, P. (2003)

[4] For an example of the TAC model for school-aged children at risk see Middleton, N. W. G. (2009) pp 7-15

[5] See Limbrick, P. (2009b) pp 46-47

[6] See Limbrick, P. (2009b) pp 41-42

Chapter 2: Power in horizontality

Summary

This chapter explores service user power in vertical organisations and horizontal structures and suggests that all agencies should, before addressing how they might empower users, be watchful for any existing culture of disempowerment. While service users have a right and a responsibility to be fully involved in decisions about what support they will receive and how it will be provided, the argument here is that an equal voice is not possible. Negotiation is offered as an essential element of partnership and empowerment and necessary conditions are offered for a culture of empowerment in any agency or agency collective. Horizontality provides new opportunities for agencies that want to enhance their users’ empowerment and for service users who want to be proactive in getting their voice heard. The three sections in the chapter are:

• Preamble

• Negotiating skills

• The culture of service user empowerment

Preamble

I have offered so far quite a generalised view of horizontality and an account of why it is the base structure for interagency collaboration. In this and the following two chapters I want to look more closely at some main features of horizontal structures as a prelude to describing, in Chapter 5, the steps necessary to create horizontal and integrative structures from two or more vertical organisations. Service users must be the first consideration in any discussion about service development and we have to believe, or if necessary fight to re-establish, that public and voluntary & community support services hold their work with people they support as the purpose of their existence – whereas private enterprises function primarily to make profits.

The last decade or so has seen a gradual movement in the UK towards the empowering of service users of public services so that they get more of what they need or want and less of the ‘This is what we are going to give you’ attitude from service providers. Now service users expect to have more information, more of a voice, more influence and more control over all aspects of the support they receive.

Before looking at service user power in terms of horizontality and verticality, it is worth noting that some agencies and practitioners are actively disempowering in how they approach their service users. It follows from this that some service users need even more empowering because of some degree of earlier disempowering. Disempowering approaches and attitudes seem to be built into some public services: using words the service user is not familiar with; being the expert who knows best and therefore does not need to listen; always meeting the service user in the practitioner’s environment; making bureaucratic tasks dictate the agenda and the pace; allowing the practitioner’s superior education (and often class) to flavour the conversation; and always being about to dash to the next appointment in an important hurry. Any sincere attempt to empower service users must be preceded by deep reflection on any disempowering attitudes and habits inherent in the work of practitioners or in the culture of their agency.

TAC and very many other support systems advocate a partnership model that is watchful for any disempowering behaviours and supports the service user in having a more equal voice in how support is offered. There are, though, limits to how far an equal voice is possible. Firstly, partnership working is characterised in part by mutual honesty, trust and respect and needs a willingness to participate from both sides. If the service user feels or demonstrates that this is not appropriate for him at that time then there is neither partnership nor the co-operative effort that could come from it. This does not mean work has to stop, just that another approach is required, perhaps for a limited time, which conforms to the service user’s position. There is a particular challenge here for those practitioners whose service users have to come to them on a non-voluntary basis.

Secondly, service user power, even in a partnership model, must be limited by the fact that one partner is a provider and the other is a receiver and that all service providers operate within an established structure with inevitable constraints. No service user can have a genuinely equal voice or free rein in deciding what will happen because each agency and agency collective has rules of engagement and limitations on resources to which it must conform regardless of the wishes of the service user.

We can explore this second point further, again using the experience from the TAC model whose service users actively choose to receive the service rather than being required to by some higher authority. In the process of agreeing an action plan there are six stages as follows:

1. The decision is made after one or more conversations or meetings that the service user and the agency will work together.

2. The service user describes their situation with an account of what has happened to get to this point.

3. The service user describes the better place and situation they would like to move into, i.e. their aspirations.

4. The service user indicates what they feel they need in order to move towards their aspirations.

5. There is an agreement between the service provider and the service user about which needs will be addressed and in what priority order.

6. A plan of action is agreed to address those needs.

These stages are only an approximation and there is no way of predicting how long each process takes, what level of detail it goes into or how clearly it is articulated. Stages 1 to 4 hold the service user in the driving seat, perhaps with the keyworker in a facilitating as well as listening role. (Good practice requires that such conversations go beyond mere information gathering and are structured as a positive and helpful experience for the service user.) But in stages 5 and 6 control moves towards the practitioner who is acting as the representative of the service provider and who does not have absolute freedom within her agency. The mode will now shift from listening and supporting to some level of negotiation which, as Dale[1] has shown, is the antidote to the expert model in which service users are told what is best for them and given little or no choice. The next section discusses negotiation as an integral part of partnership.

Negotiating skills

People with some basic negotiating skills are better able to avoid, in their personal and professional lives, disagreements that lead to falling out and even parting company. In the absence of these skills, parents and paediatricians, for instance, might stop working with each other when they fail to agree about a particular drug or a surgical procedure for the child. In the same way, practitioners can fall out with each other about the appropriateness of a particular procedure or intervention for a child they share. Negotiation is an approach that can bring a better outcome for children and for relationships among the people supporting them. The effort is to discuss the issues, air the different points of view and agree to explore a mutually acceptable way forward for the time being. This can mean, in the examples above, that the operation is postponed for re-appraisal when the child reaches his next birthday or that the suggested therapeutic intervention is offered in a less concentrated form while the child’s reaction and progress is observed.

In a successful negotiation neither party bullies the other and both work to come to an agreement about how to proceed. Both might feel they would have liked more of their own way but have the reassurance that the issue will be discussed again. Of course, the agreement to negotiate and the listening that comes with it, can result in both understanding the other better, and with one seeing it in a new light and moving a long way to the other point of view. Some negotiations happen with a glance (Can I pick the baby up? Where shall I sit?). Others might need one or a series of conversations and some might need to bring in a more skilled person to assist.

In my experience, few agencies are explicit with their service users or their workers about limits to the support that can be offered and about what is negotiable – and very few practitioners are trained in negotiation skills. The following list might be helpful in deciding what is fixed and what is negotiable in how any agency supports its service users. It suggests a spectrum of actions and interventions in any agency that can be fitted into five categories as follows:

1. In most public services there are some actions that must be performed come what may – some elements of the service that are imperatives for some reason.

2. Then there are actions and interventions that are almost always done, but could be omitted for a valid reason.

3. In the middle of this spectrum are actions that are neutral in that whether they are done or not done is not a big issue.

4. Then there are actions and interventions that are almost always not done, but could be included for a valid reason.

5. Lastly, there are some actions that must not be performed come what may – some actions that are not permissible for some reason.

In this analysis, the room to move to accommodate a service user, the zone of flexibility and negotiation, lies in items 2, 3 and 4. Items 1 and 5 are non-negotiable. This suggests service users can never have an equal voice in how support is provided to them but, on a positive note, the analysis clearly shows that there is always room for flexibility and negotiation if there is true partnership working. (The analysis is also an answer to those who argue that parent of disabled infants should have the lead voice in TAC meetings. Though this can happen at the meeting, any action plan agreed will then be subject to the above constraints in one or more of the vertical organisations.)

The culture of service user empowerment

It is interesting to speculate whether the potential for service user power is essentially different between vertical organisations and horizontal structures. It is tempting to suggest that service users of the former are automatically disempowered, finding themselves too often at the base of the pyramid, at the end of the pecking order, of very small voice and with little influence in how they are dealt with – and then to compare that with the service user enjoying partnership as a member of a horizontal collaborative team as in the TAC model. A more constructive way forward might be to look at the conditions in any agency or agency collective that promote the voice of the service user. My list is as follows:

1. The culture of the agency or agency collective advocates service users having as much influence and control as possible.

2. There is a proactive effort at all levels in the agency to empower service users.

3. There is an established forum or mechanism for hearing the voice of the service user.

4. Practitioners have necessary skills in partnership work including listening[2] and basic negotiation.

5. The decisions that result from discussions with the service user are written and broadcast to relevant people.

6. There is a mechanism for checking that the actions that should follow from these decisions are happening – and happening in the agreed timescale.

7. There is a mechanism involving the service user to review progress and, if necessary, refresh the action plan.

8. As a matter of course service users are invited to give feedback on to what extent they felt informed, involved and empowered in how support was provided.

In my experience, horizontality does typically do better at service user empowerment in the UK at the present time, with the flattened power landscape of horizontal teams offering increased opportunities for the service user’s voice to be meaningfully heard. This might also be because such models as TAC are more recent creations following up-to-date thinking about empowerment while the vertical public services have been around for decades and might be mired in the authoritative attitudes and values of former times.

We can look at this from another perspective in which community members and service users can proactively empower themselves by enriching the horizontal landscapes around themselves and nurturing purposeful links within them.

This is the subject matter of horizontalism[3] in which horizontality becomes a people-empowering antidote to or a bulwark against any of us, whether as service users, customers, community members, consumers or citizens, being subject to unwelcome, inappropriate or harmful authority and control coming down from above – from the verticality of government departments, local councils, health authorities, multinationals, religious institutions, security forces or whatever. In this dynamic of proactive service users, new horizontal structures arise as the initiative of local groups: whether dissatisfied hospital patients, unemployed teenagers, or community members wanting to rid their streets of drug dealers. When this happens managers of vertical organisations can find themselves invited into a horizontal landscape to sit round the table with a group of people offering their own agenda for local service development.

We can think of patients who want better care from their local hospital as an example of this. In this case, horizontality becomes a strategy for a patient group to take the discussion about their concerns beyond the relatively private and enclosed confines of the vertical organisation. The logic here is that patients are likely to get more attention and find more holistic solutions if they invite social services, relevant voluntary & community agencies and other local patient groups into the process with them. Horizontality will make them stronger and better equipped for their discussions with hospital managers.

While this discussion has not come to a firm conclusion about comparative potentials for vertical organisations and horizontal structures to empower service users, it does suggest that horizontality offers a way forward both for public services that are genuine about giving their service users more power and for people who are dissatisfied with their vertical public services and want change.

1] See Dale, N. (1996) and Edelman, J. & Crain, M. B. (1993)

[2] For an account of listening skills see Davis, H. & Day, C. (2010) pp 127-130

[3] See the Appendix for a brief introduction to horizontalism

Chapter 3: Where service user and horizontal structure meet

Summary

In this chapter I suggest that interagency collaboration, as a collective effort by two or more agencies, requires new professional roles at the interface between service user and the agency collective. The multiagency keyworker and individualised TACs are the roles that have been developed for this interface. To help highlight some important issues about both of these roles, a brief account is given of how the TAC model evolved out of a voluntary organisation called One Hundred Hours – an organisation that pioneered keyworker-based support for families with a disabled baby or young child. A critique is offered of why keyworking has not become a popular role and why very many keyworking projects have failed in England during the last decade or so. Both keyworking and TAC are described as highly successful approaches that empower service users and are greatly valued by them. The chapter has three sections as follows:

• How TAC evolved from One Hundred Hours

• Why multiagency keyworking has not become widespread

• Lessons from One Hundred Hours and TAC

How TAC evolved from One Hundred Hours

In vertically organised agencies the place where the agency meets the service user is usually at the base of the hierarchical pyramid involving two people; the service user and, for instance, shop assistant, service engineer or practitioner. This interface between service user and agency is straightforward and uncomplicated with a single person representing the whole agency.

When support agencies are integrated together there has to be a new way of representing the agency collective to the service user because it can no longer be solely the responsibility of a single agency operating on its own. The relatively new models that have been developed for this interface are the multiagency keyworker (which I am using in this essay to mean the same as lead professional) and the individual service user’s TAC. In this section I want to give a brief history of both models from my own experience over recent decades, describe how the two models fit together and list some key lessons from them to inform future planning of horizontal structures.

One Hundred Hours (OHH)[1] was established as a UK registered charity in the early 1990s in Yorkshire for families who had a baby or pre-school child with neurological impairment. It began with the intent of focusing on early intervention for the infant and, in response to the needs we found, became a support system for the parents and other family members – while keeping its central interest in the infant’s wellbeing and development. Having set up the organisation, I became its director and one of its handful of keyworkers. OHH was an attempt to explore both the validity of giving these infants and their families more support in the pre-school years and the role of the keyworker in providing that support.

The keyworkers we employed were ‘dedicated’ or ‘single-role’ in that this was the only work they did for the families they supported. This is in contrast to ‘non-dedicated’ or ‘dual-role’ keyworkers who support one or more families as keyworker alongside their main professional role as a therapist, social worker, health visitor, etc (often having both roles with the same child and family). Each family that opted for this free OHH support was given a keyworker who would stay involved with infant and parents during the first couple of years while the family were adjusting to the new family member, learning what they needed to learn at the beginning of this unexpected journey and getting other relevant pre-school support in place. Keyworkers in OHH each had a professional qualification, e.g. as a teacher, social worker, health visitor and nurse. We met together regularly to share experiences, discuss dilemmas, agree the major needs we felt we were meeting and, in the light of our experiences, formulate OHH policy. The keyworker definition we arrived at was:

The keyworker is both a source of support for the family of children with disabilities and a conduit by which other services are accessed and used effectively.[2]

The main features of the keyworker role as it evolved in OHH were as follows:

1. To befriend the parent or parents, offering a listening ear and emotional support and becoming a ‘special person’ who was there just for them.

2. Helping the parents get all known information about their child’s condition, strengths, needs and prospects.

3. Helping them find out what relevant support was available locally, helping them access it and, when access was made difficult, helping them struggle to get it.

4. Helping parents learn how to promote their child’s wellbeing and development day by day.

5. Helping parents co-ordinate all the appointments, clinics, meetings, etc so the whole package was as well organised as possible and considerate of the child and family’s time, energy and spirit and of the parents’ finances. (This is an example of the second level of interagency collaboration as described on page 25.)

6. Helping to integrate all therapy and education programmes towards a whole approach to the whole child. (This is an example of the third level of interagency collaboration as described on page 26.)

Families valued their keyworker, not just for what they could help the parents achieve in practical terms, but as a person they could rely on and relate to. OHH keyworkers were expected to be skilled in developing warm and trusting relationships with parents and to work with them in the spirit of genuine partnership. Later in the decade we were pleased to encounter Professor Hilton Davis whose work in developing the Family Partnership Model[3] reinforced our approach and gave us added confidence in what we were doing.

It was considered extremely important for OHH keyworkers to limit their role to that for which they had both competence and time. Though we expected keyworkers to be good listeners and sometimes provide a shoulder to cry on, they were not offering formal counselling. Similarly, while keyworkers could help families get the support they need from local services, they would not become formal advocates in any confrontations between families and authorities. In these cases the keyworker would be a signpost to any relevant support available locally. We established a rule that keyworkers would not offer advice on the level of ‘If I were you…’ or ‘What you should do is…’ but would help parents get good information about any current issue and then help them, if requested, to think it through to come to a decision.

With some infants, in pursuit of the integrated whole-child approach in item 6 in the list above, the OHH keyworker could try to bring the child’s key practitioners together with the parent and keyworker for a sharing and joint-planning meeting. This was the forerunner of what would later be called TAC meetings. This effort succeeded wonderfully with many children but with others it took many months of repeated invitations to achieve – or even failed completely because particular practitioners from the public services felt they could not justify this use of their time. (In years to come, when we evaluated the first TAC projects we learned that TAC meetings were highly valued by both parents and practitioners – even when limited time meant there had to be a choice between the meeting and a session with the child.)

When a shared planning meeting could not be organised or while waiting for one to be arranged, the keyworker could learn from each practitioner separately about their approach and goals and about what part of this work could be integrated into a whole programme. We recognised that good practice would require some practitioners to keep some parts of their interventions as special to themselves while other parts could be handed to another worker – just as some parts of a child’s programme were commonly handed to parents as ‘co-therapists’. In OHH experience, keyworkers can function as go-betweens in this way to arrive at a whole-child programme but for some children this is clearly less effective and less professionally responsible than the collective effort of the TAC model.

During this time, managers in UK education, health and social services, seeing from our newsletters the potential value of the OHH approach for some of their children and families, were wondering how they could provide this successful joint working between practitioners from different agencies supporting the same child and family. Setting up new teams of dedicated keyworkers was beyond their budgets so instead they opted for the TAC model (as it was eventually named in 2001[4]) in which joint working would be achieved by a child’s key practitioners and parent(s) all meeting together regularly to share observations and agree a plan of action. In this approach, one member of each child’s horizontal TAC would become the TAC facilitator (rather than manager) and would be recognised by all relevant local services as the child’s multiagency keyworker. TAC’s appeal for these health, education or social care managers was that it was a straightforward and uncomplicated approach, was immediately understandable in its intent by workers and by parents and seemingly required no recruitment of additional practitioners. It appeared to be affordable within the existing budgets.

When the TAC model was developed and written about, the child’s TAC was defined as:

…an individualised and evolving team of the few practitioners who see the child and family on a regular basis to provide practical support in education, therapy and treatment[5]

Individualised TACs were recognised from the first as teams in the real sense of the word (rather than mere groups) that represented a collective effort with shared concern and wisdom and that was supportive to all of its members – parents and practitioners.

Why multiagency keyworking has not become widespread

During the first decade of this century there was a blossoming of keyworker and TAC projects in the UK and other countries especially in early childhood intervention (ECI). This has left us with many valuable lessons, the first of which is that these models of support are greatly valued by families. But there are also strong lessons about what does not work and what is not sustainable. In 2004, with a deep sense of frustration, I wrote a short article questioning why the majority of families of disabled infants still did not have a keyworker.[6] My analysis of the reasons why so many keyworking projects failed included the following:

1. Most local authorities, for very understandable economic reasons, had opted for shared-role keyworkers recruited from within health, education and social services. The dual effects of this was that keyworkers, struggling to manage two roles, soon became overloaded and consequently there could never be enough keyworkers for all the infants, children and young people that needed one.

2. There was a common and inappropriate assumption in the UK that a lone keyworker could achieve interagency collaboration on their own by pulling the services together around each child. In fact, multi-agency keyworkers can only function effectively when they are positioned as the interface between each child and the local collective effort in the horizontal landscape. Without an integrated, multiagency pathway for each category of service users, the keyworker can easily become impotent and disempowered in the empty spaces between the vertical silos. Examples of joint working that the lone keyworker cannot achieve include shared referral processes with a single door, joint assessments of need and unified, multiagency action plans. These processes require interagency planning at the strategic level. Nor can we assume a keyworker can organise TAC meetings in the absence of multiagency strategic support.

3. The majority of keyworking projects were fairly informal arrangements lacking proper management structures. Often there were no new contracts or job descriptions for keyworkers, no training, support or supervision, no administrative or clerical support and no funding beyond an initial two- or three-year grant.

It is easy to see with hindsight why very many keyworking projects were doomed to fail and I take my hat off to all the brave people who strove valiantly against the odds to provide this support for children and families when they were not properly supported themselves. Of course, there is no way of knowing how many projects failed to get established in the first place because of apprehension by staff members about the implications for workload, standards, accountability, etc.

Lessons from One Hundred Hours and TAC

What have we learned from OHH-type multiagency keyworking and the TAC model to help us promote interagency collaboration for disabled infants and for other categories of service users? My list includes the following major points:

• Both multiagency keyworking and TAC are successful models for supporting service users who require interventions from two or more agencies in the same time period. They are highly valued by service users and are the effective interfaces between the service user and the local horizontal structure.

• At this interface, both models are effective in empowering service users.

• The planning of local horizontality by senior managers must include very careful preparation and provision for the practitioners who are going to take on new roles as keyworkers, TAC facilitators or TAC members. There should be no easy assumptions that existing practitioners will take the new work in their stride and that the workforce will manage the new work patterns within existing staff numbers and resources.

• There is a balance to be found between the time and effort necessary for the new work patterns in both models and the time and effort saved when agencies collaborate to reduce duplication, bureaucracy and waste.

• The least preferred option for multiagency keyworkers is to recruit them from within our traditional public services and to require them to manage keyworking alongside their main professional role. Single-role keyworkers coming from the voluntary & community sector will have more room to move and fewer critical dilemmas about time management.

• Keyworkers can be effective service co-ordinators for some service users, while for others it might be necessary to get key people around the table. The advantage of meeting face to face is that the service user and practitioners can see who is involved and get to know each other if they have not met before. This co-ordination and planning meeting can be valuable at the start of integrated support for a new service user but care must be taken to keep such a meeting sufficiently small to be service user-friendly; judicious and firm decisions about who should attend might be necessary.

• If there is a requirement to integrate interventions into a whole approach and at the same time, perhaps, to reduce the number of practitioners working directly with the service user, then individualised TACs are effective forums. The small face-to-face meeting involving and empowering the service user brings

  • a collective perception of the service user’s situation, condition, strengths, needs and aspirations

  • collective concern about the wellbeing of the service user

  • collective competence[7] as people present share relevant skills with each other – knowing that no single practitioner has all the skills needed to support someone with a multifaceted condition

  • collective wisdom on the basis that three or four heads are better than one for considering complex issues

  • mutual support for its members.

• In the design of the horizontal structure for the particular category of service users, multiagency keyworkers and service users’ TACs must be invested with authority to represent the interests of their service user within local agencies.

• To facilitate keyworkers and individual TACs becoming agents for effective information-sharing in the local networks around the service user, there must be explicit policies and rules of confidentiality agreed at strategic level. There must also be electronic communication systems shared across the agency collective.

• An essential requirement for keyworkers, TAC members and other workers in horizontal structures is an up-to-date online directory of all local support services.

So far in England, keyworking seems not to have been taken sufficiently seriously by the generality of managers in public services who could allocate the necessary resources. It is entirely understandable, especially now as cuts in public finances bite deep, that keyworking and the TAC model have to compete for management attention and funds with the ‘harder’ issues of getting nurses on wards and teachers in classrooms. Without a shift in attitudes and work patterns, this new category of practitioners will remain a very low priority. In pursuit of improved interagency collaboration and enhanced service user power, we must first acknowledge the need for horizontal structures and then recognise the essential role keyworkers and service users’ TACs play within them.

[1] See Limbrick-Spencer, G. (2001) for a full account of One Hundred Hours and West, S. (1994) for an evaluation of it

[2] See Limbrick-Spencer, G. (2001) p 7

[3] See Davis, H. & Day, C. (2010)

[4] See Limbrick, P. (2001)

[5] See Limbrick, P. (2009b) p 21

[6] See Limbrick, P. (2004)

[7] For an explanation of collective competence see Limbrick, P. (2009b) pp 69-70

Chapter 4: The workforce in the horizontal landscape

Summary

In this chapter we look at interagency collaboration from the perspective, first of practitioners in support services and then of their managers. Horizontal teamwork, with the TAC model as an example, is described in terms of the significant advantages it brings to workers while acknowledging that not every worker is suited to it. There are apprehensions and real risks involved when practitioners step outside their vertical organisation to work in the horizontal landscape and this chapter offers suggestions for reducing and managing those risks for the protection of workers. Interagency collaboration requires an investment of time and effort at all levels in the agency collective to get new work patterns established and then to support service users in their particular integrated pathways. This effort is offered here as changed work patterns rather than additional tasks. There are four sections as follows:

• The advantages horizontality brings to practitioners

• Protecting workers in the horizontal landscape

• Tasks for managers

• Making the best use of resources

The advantages horizontality brings to practitioners

Partnerships will not function effectively if one partner is expected to sacrifice themselves to the other. Horizontality invites people to meet each other on a more level playing field and, while acknowledging that the wellbeing of the service user is paramount and support for him is the purpose of the encounter, will also acknowledge that practitioners and managers are people too – and can have reasonable expectations for their own wellbeing and fulfilment in the work they have taken on. When members of staff feel valued and fulfilled in their work they are likely to be more effective – and happier.

This section and the next explore some issues of horizontality for practitioners and the third section focuses on management. I shall refer to senior management, meaning chief executives, directors and heads of major sections or departments and middle management meaning managers in closer day-to-day, functional contact with workers at the grass-roots. I appreciate that some small agencies might not have people in these clear and distinctive roles, and that many managers are also practitioners.

Keeping to my own experience of OHH and the TAC model, working within one or more horizontal teams will be a very positive experience for practitioners who have seen the need in their service user for an integrated approach, want to respond to it – and have sufficient confidence in their professional standing and in their work with this service user or category of service users to be able to share it openly with others. There are tangible benefits for practitioners in the TAC model and readers are invited to check my list against their own experience. My list is as follows:

1. Each individual TAC is a supportive team, not only for the service user, but also for each of the practitioners in it. TAC members do not have to experience challenging situations with or dilemmas about the support for the service user on their own and they have a small familiar group for celebrating successes and sharing disappointments.

2. Each TAC meeting can be a learning experience as practitioners come to understand the approach of those from other disciplines and see first-hand how they treat a child with this or that condition or need. As practitioners gradually clock up the number of service users for whom they have been a TAC member, they become ever more competent in perceiving the wholeness of each child and family. Horizontal teamwork brings an awareness of the interconnectedness of all elements of the child’s or service user’s situation and needs enabling practitioners, in time, to contribute naturally and almost instinctively to a whole approach.

3. While working with the child and family, practitioners have the reassurance that their work and the multiagency action plan of which their work is part has been discussed and agreed collectively in the child’s TAC.

4. The TAC model provides an excellent training ground for practitioners who have not worked before with children with a multifaceted condition. (Managers and practitioners will need to consider how far it is appropriate for newly qualified practitioners to work in horizontal teams before they have become confident in their practice and have developed a solid foundation for their work.)

A relevant question is whether vertical organisations and horizontal structures suit different sorts of workers. In my experience the answer is ‘probably’.

On one level there are certainly practitioners who are quite content doing their job on their own, in their own way without entering into partnerships with others but with more or less support from their colleagues in their vertical organisation. For these practitioners there can be great security in having a hierarchical management providing a single-agency job description against which performance can be measured. It seems fair to suggest that these practitioners are not suited for collaborative work in horizontal teams and should not be asked to undertake it until and unless some future change of heart and willingness to train in horizontal teamwork. It also seems fair to suggest that these preferences should be fully explored in the selection of new workers.

In my work in the field of childhood disability, I am surprised when I meet therapists or teachers who have no desire to integrate their interventions with others when they work with a child who has a multifaceted condition. Perhaps my surprise is because this feels like bad practice, is counter to current thinking and denies the significant advantages to the practitioner of collaborative teamwork. This is not to suggest that such practitioners are not competent, do not form effective relationships with service users, or do not listen and empower. It does suggest though that under their care some service users who require coherent multiagency support will be left wanting.

Protecting workers in the horizontal landscape

While the practitioner who is part of a number of individual TACs will gradually increase her capacity to support her service users and will enjoy the benefits already discussed (which to me represent a significantly enhanced professional role) she might also feel she is spending more and more time away from ‘home’ and away from the certainties, securities, comforts and colleagues of her vertical organisation.

The antidote to this lies in the original design of the integrated service and in the continued efforts of middle management in the agency collective to provide training, support, supervision and oversight. A brief account of some conditions necessary for supporting a practitioner operating within a local horizontal structure is as follows:

1. Local practitioners are involved at all stages in the development of the new interagency collaboration for the particular category of service users.

2. There is a clearly described multiagency integrated pathway along which the service user travels after entering the horizontal structure. This is sufficiently logical and clear for each practitioner to see their part in it.

3. Each practitioner is involved in agreeing a refreshed contract and/or job description reflecting her role in this new work and confirming that it is a radical change in how time is managed rather than additional work.

4. Strong reassurance is offered that horizontal teamwork is not going to ask any practitioner to do anything that her professional body would consider inappropriate.

5. An effective communication system is designed to link workers across local agencies. Depending on the nature of the work and the resources available, some sort of shared accommodation or meeting place might be made available.

6. A distinction is made between professional or clinical work and clerical work so that practitioners can be relieved of as much of the latter as possible.

7. The middle managers of the agency collective have agreed a process in which each practitioner has supervision, oversight, support and evaluation – and which reduces any confusion between the practitioner’s responsibility to her line manager in the vertical organisation and to leadership in the horizontal structure.

8. Initial multidisciplinary, in-service training for work in the horizontal structure is provided followed by opportunities for further learning and professional development. Because each practitioner will have their own professional qualification(s), this on-going training matches training to individual needs and so is different for each practitioner. This opportunity to train alongside practitioners from other agencies is an excellent opportunity for everyone to get to know each other and develop mutual trust and respect.

9. There is access to a comprehensive directory of all local support so that practitioners can guide and signpost service users. To stay up to date this is provided as an online resource.

10. Because of the gradual blossoming of new types of agency in the voluntary & community sector and of social businesses, private enterprises and private individuals, the local directory distinguishes between those agencies and individuals who have demonstrated that they work in a professional manner and those who have not. This vetting is probably the responsibility of the relevant vertical organisation if the information is not coming from elsewhere and is an essential support for practitioners in their signposting role.

If there is reluctance and resistance in the public service workforce to horizontal teamwork, which would help explain why verticality remains the dominant style, it could lie in some practitioners’ entirely valid nervousness, uncertainty and apprehension about entering a space which might not be properly organised, might compromise their professional standards, might increase their workload and might expose them to dangers from which they are protected in their vertical organisation.

This obstacle to interagency collaboration has to be respected and addressed in careful design of the horizontal structure, fastidious attention to the maintenance of high professional standards, and the provision of initial and on-going training and proper supervision. Experience shows that practitioners are not going to become comfortable and competent in horizontal teamwork overnight just because a new system has been imposed.

Tasks for managers

Horizontality requires significant management initiative, creativity and support at all levels in the agency collective, firstly to get new integrated systems off the ground then to keep them running and developing. Managers might share with practitioners a largely negative view of horizontality and imagine it will bring only added effort, extra expense, new and unwelcome responsibilities and loss of control at all levels in each vertical agency. I would not promote horizontality and the people empowerment and effective joint working it brings on the false premise that it comes without the need for particular effort and resources, but it brings clear advantages too.

The elected officers, chief executives, directors, and senior managers at the top of the vertical hierarchies (whether public, voluntary & community or private) will be reassured to know that they have agreed common strategies and structures for particular categories of service users under their care. This collective effort and shared responsibility is the antidote for managers to being accountable while standing alone. Joint work at this level supports senior managers in keeping in mind a wider perspective of their various tasks and a more comprehensive picture of their service users’ strengths, circumstances and needs.

Middle managers find themselves with a new group of colleagues who work in corresponding levels of local agencies and, perhaps, with roughly similar tasks to perform. For some, this could pose a threat while for others it brings a wider perspective, an opportunity to expand one’s influence in local provision and a new group of mutually supporting colleagues. Their collective effort will begin in helping design the integrated pathway for the particular category of service users and then continue with:

• promoting the new culture of interagency collaboration and people empowerment within which the service user’s voice is heard

• translating horizontal principles into effective and viable practice

• supporting practitioners in time management

• organising in-service, multidisciplinary initial and on-going training

• making resources available

• agreeing enforceable standards

• providing interagency support, supervision and evaluation

• keeping bureaucracy and waiting times to a minimum

• anticipating threats to sustainability of the horizontal structure

• planning for future resource needs in the horizontal landscape

For many managers and practitioners there can be an increase in confidence, accountability and authority as they hold the reassurance that the plan they are working to with a single service user or a category of service users has been devised in a collective effort with their colleagues from the relevant local agencies and is not the invention of just one of them working from a single perspective. In this harmonising of interventions the likelihood of contradictions, mismatches, gaps and overlap is reduced and the best use is made of limited resources.

Making the best use of resources

We can now look at the time and effort horizontality needs, acknowledging from the start that the majority of practitioners and managers in all support services are already busy enough. Many speak of being overloaded with too many service users, too much bureaucracy and not enough time. This is worsening at the time of writing in the UK as the first phase of cuts in public services bites hard. If horizontality asks busy workers at any level to add to their task list and increase their efforts it will fail.

I hope I have shown in this essay that the effort towards horizontality brings significant rewards to service users and workers and offers itself, when we consider the harm that can come from fragmented support, as an urgent organisational imperative rather than a choice. But the issue of time has to be addressed to prevent worker overload and then a failed joint initiative. The collective effort of horizontality, when two or more vertical organisations look closely at their work with the same category of service users, will show how many repetitions, duplications and pointless procedures there are at all levels. The necessary radical rethink of how agencies use their resources and how workers spend their time and energy can include the following:

1. At senior management level including directors, boards and elected officers of local support services there are often parallel committees or panels addressing the same issues but from the limited perspective of the single agency. Integrating and harmonising these can save much time and lay the foundation for integration at all lower levels.

2. Similarly, when senior managers get together to create integrated support many examples will come to light of processes that would be better integrated than dealt with separately in each agency. Examples are referral processes and assessment of needs.

3. Executive multiagency decisions can focus on eliminating unnecessary bureaucracy, reducing report writing and eliminating all but essential meetings.

4. At middle management levels training resources can be pooled, made available to larger numbers and therefore become more cost-effective. This might make some expensive training more affordable and of wider local impact.

5. Each user’s TAC brings action planning into a sharp focus at grass-roots level around the individual service user. Because TAC members take a whole view, not only of service user’s situation, strengths and needs, but also of all interventions being provided, the TAC meeting can:

   • quickly identify any gaps and duplications in provision

   • regulate and often reduce the numbers of people becoming involved

   • reduce the number of meetings about or with the child and family to just those required for the effective functioning of the TAC model

In this collective effort to develop and enrich the horizontal landscape, the key resource question becomes not ‘How much time will interagency collaboration cost?’ but, ‘How much time and effort are we wasting now in separate, fragmented and piecemeal provision?’

Chapter 5: Planning the service user’s journey

Summary

Providing support to a person in need can be thought of as accompanying them on a journey between two places. The journey created by an agency collective must be essentially different from that within a single agency. This chapter describes five phases that must be built into the journey or ‘integrated pathway’ and describes how the shared process of designing it can begin. I suggest that before any group of people can embark on building something together, they must first create a shared vision of what it is intended to look like and agree the values it must embrace and reflect. It is the same when designing a new integrated pathway. This service redesign provides an opportunity to set higher standards for service user empowerment and professional performance. Managers from the separate public services have a lead role in this service redesign and in securing the necessary funds to set it up and sustain it in the long term. Nine stages are offered for this management task. The three sections of the chapter are as follows:

• The integrated pathway and how to get started on creating it

• Vision and values

• Management and funding for the redesign

The integrated pathway and how to get started on creating it

There will be different pressures, drivers, commitments and interests in any locality leading to a collective effort to engender interagency collaboration, but the practical starting point for planning must be senior managers (sufficiently senior to allocate resources) from two or more local agencies agreeing to work together in partnership. Their task is to design integrated support in the form of a clear staged pathway for a particular category of service users who require simultaneous or consecutive support from those agencies – and are known to be suffering ill effects from fragmentation and disorganisation. These ill effects can include the addition of entirely new stresses and strains as the service user struggles to make sense of chaotic and piecemeal interventions that might pose real threats to his wellbeing and survival.

In the absence of specific government directives, new agency collectives must be self-generating and it is not possible to be directive about who should start the ball rolling. The decision can happen spontaneously in a similar way to a group of friends deciding to go on holiday together. But it may be that once a local category of service users comes to the fore as needing integrated support there is one local agency that has a prominent role and can take the initiative.

We should not assume the impetus has to come from the upper management levels in the public services. It is just as likely to come from the local community, from a service user or group of service users, from a pressure group or from local practitioners around a category of service users. Again, there are many possible routes for activists to translate this grass-roots concern into a first meeting of multiagency managers committed to developing a new horizontal structure including:

• broadcasting service users’ experiences of harmful fragmentation

• identifying key practitioners who want joint working and seeking their support in approaches to relevant managers

• contacting relevant managers to ask them to form an agency collective to start planning joint working

• staging a service users’ interagency planning meeting and inviting relevant managers to it.

An important part of this process is to explore the horizontal landscape around the particular category of service users to see who has some interest, concern and weight to add to the cause. As with any pressure group activity this initiative can be supported and publicised by local press and media.

This initial effort, once managers have entered into a horizontal partnership, must sooner or later clearly define the category of service users that are going to be catered for and the starting group of agencies who are signing up to a new integrated pathway. It is possible one or more relevant agencies do not want to be part of the interagency collaboration and might, or might not, join later.

Clearly, there will be reduced potential benefit for service users when a particular agency delays or declines joining the collaborative effort but fresh approaches can be made when the new interagency collaboration is seen to produce better outcomes for service users. Once senior managers are sitting round the table they can agree the locality within which the pathway will operate – that is, the geographical and administrative boundaries beyond which people cannot be supported in this system.

The purpose of the multiagency integrated pathway is to weld processes and interventions seamlessly together so that the service user experiences a single coherent support system that lasts as long as it is needed. Pathways will be different for each service user category in terms of the agencies involved and the elements of support in them but will probably share the following overlapping phases:[1]

1. The Meeting Phase – in which the service user and agency collective (or one of the agencies) first meet each other.

2. The Learning Phase – in which the service user and practitioner(s) start learning about each other and in which some first support is provided.

3. The Planning Phase – in which needs are agreed and a joint action plan is created to address some or all of the identified needs.

4. The Support Phase – in which support is provided according to the action plan. This phase is the whole point of the pathway and of interagency collaboration.

5. The Review Phase – in which progress is reviewed and a fresh action plan created if support is still needed.

In the original TAC model, because each disabled infant has on-going needs, the Review Phase loops back repeatedly to the Planning Phase – the process of refreshing action plans being part of the function of each TAC meeting. With other service users, successful shorter-term interventions will end with the first Review Phase.

This horizontal effort by senior managers to create an integrated pathway (ideally including representative service users) brings an excellent opportunity to see from a wider than usual perspective what this category of service users typically experiences under the existing fragmented arrangements. The discussion will expose any gaps, duplications and service user overload in the totality of provision and will highlight bottlenecks where service users have to wait too long for some element of support. As a creative and shared exercise by people committed to improving support, the discussions will surely find some immediate solutions even before the pathway is finished and running.

Vision and values

In a group effort to create something new, for instance a boat for a youth club or a community hall, there has to be an agreed vision of what the outcome should look like and an agreement about which values it must enshrine (e.g. that the boat is to be built of sustainable materials and the appearance of the community hall will blend with its surroundings). So must the integrated pathway start with an agreed vision and a set of values – the vision encapsulating the type and standard of support to which the agency collective aspires for that category of service users. Values and vision for each integrated pathway are, and can only be, the products of horizontality.

The agreed list of values will be an amalgam of those of service users and the vertical organisations. It will also be informed by current thinking in the fields of ethics, morality, rights, responsibilities, etc and one of the values might be horizontalism itself. It might be helpful to offer here the values and philosophy built into the original TAC model as promoted by Interconnections. (I am using values as the principles and standards the people involved are prepared to stand up and fight for and philosophy as the thinking and actions that follow from those values.)

TAC values, as offered in the Interconnections TAC training programme, are as follows:

The TAC model values and respects children

a. The child is a child first and foremost and is not defined by any disability.

b. The disabled child has the same needs as other children for love, maternal bond, nutrition, warmth, clean environment, play, experiment, exploration, development, learning, success, praise, self-esteem, confidence and celebration.

c. Children with life-limited conditions are helped to enjoy the richest possible experience of life.

d. All children are helped so that pain, stress and anxiety are reduced as much as possible.

e. Each baby and child’s ‘voice’ is carefully listened to.

The TAC model values and respects families

a. Families are an important structure in our civilisation and deserve support at times of need for their own sake.

b. Families are likely to be the child’s main support for a long time into the future and so the child benefits when the family is supported.

c. Most families are strong enough to get through the bad times – and grow as a result. Support can be essential for this, but too much support might take away the opportunity for growth.

d. Families are supported and helped to stay together at vulnerable times.

e. Each family’s drive to get back to their version of normal family life is supported.

f. Family members are helped so that stress and anxiety are reduced as much as possible.

g. Family members are listened to.

The TAC model values and respects practitioners

a. Practitioners have clear terms of employment, good conditions at work and opportunities for fulfilment, growth and development.

b. Practitioners do not have to be left alone in situations that are particularly challenging.

c. Practitioners have peer support and supervision which addresses emotional needs.

d. Practitioners have relevant support when stress and anxiety are mounting up at work.

e. Practitioners are listened to by families and by their managers.

The TAC model values and respects partnership

a. When parents and practitioners work in horizontal partnership in the small collaborative TACs they will add to each other’s efforts and find creative solutions to challenges.

The TAC model values and respects language and communication

a. Information is shared in clear language(s), in a variety of formats, without jargon, and repeated as necessary.

The TAC model values and respects knowledge

a. All interventions with children and families are ideally supported by research, surveys, audits, etc.

b. All available information is made available to families and practitioners to support their decisions.

The principle of horizontality as promoted in this essay not only brings vertical organisations together to create integrated support but also, as a fresh collective effort, provides an opportunity to eradicate outdated practice, raise standards and rethink values. In the interests of best possible practice, the following questions can be explored in the design of each of the five phases of the integrated pathway:

1. What do we know from service users about how the phase should be designed?

2. What are the limits to flexibility in how support is provided to the service user?

3. What is the mechanism for the service user having a voice, making choices and generally exerting influence?

4. What is the actual process or mechanism for the phase and which workers should be involved in it?

5. What are the minimum paperwork, recording and report writing requirements?

6. 6. Is there good administrative and clerical support? Could office workers take more of the workload from practitioners and managers and drive the process?

7. How is performance to be measured?

8. What are the on-going opportunities for service users and workers to give feedback to management?

Management and funding for the redesign

Interagency collaboration in support of a particular category of service users is, in effect, a service redesign in a collective effort by agency managers acting in the horizontal landscape from their position in their vertical hierarchies. These managers can become or can appoint an interagency overseeing panel and/or a leader for the new integrated service. ‘TAC co-ordinators’ are now quite common in England. The leadership task is to oversee the working of the integrated pathway and the workers in it and ensure service users have influence at all stages.

This overseeing function can be termed quasi-management because it is an overseeing role that is qualitatively different from management in a vertical organisation. Linear authority, under which workers carry a contractual obligation to do as they are told, is replaced here by leadership characterised by influence, trust, respect, resourcefulness and creativity and which employs skills in operating effectively across agency boundaries, working from an evidence base and managing change. The marker of success in this is the ability to engage, innovate and negotiate without the aid of direct power over others.

The wide range of horizontal collaborations between local support services will be matched by a spectrum of funding arrangements. At one end of the spectrum will be new teamworking that requires no new funding arrangements or in which one of the agencies agrees to cover costs. In the middle will be some agreement about how to make different use of the separate agencies’ budgets, then an actual pooling of budgets and, at the end of the spectrum, joint commissioning. It might be felt that some new funding arrangements require a legal contract.

Some finance managers might be apprehensive about being nudged out of their verticality into horizontal ventures that seem to represent risk, uncertainty and some loss of control about how money is being used. There are hearts and minds to be won here as these managers, who carry a clear and inescapable duty to be responsible about their agency’s incomings and outgoings, are invited into the collective effort to better serve local people in need. Finance managers are asked to bring all of their knowledge and skills to bear on this different, but still responsible and legal, use of the money they hold.

Success in this will depend on how well the people controlling finance can work horizontally with each other in the agency collective once they have been asked to do so by their own management. When it is a matter of agreeing use of parallel budgets, pooling budgets or establishing joint commissioning, finance managers will have the reassurance that they are not making decisions on their own, that they have a shared responsibility in the new arrangements and that they have a crucial role in bringing about change that their agency’s service users want.

I would suggest that the redesign towards ever more effective interagency collaboration from the perspective of its management and funding can have the following stages:

1. Once the agency collective has brought itself into being, there is a decision about which senior managers will be involved in the design of the new integrated pathway.

2. Each agency confirms that it has up-to-date information about what its service users want in the new integrated support system – or that it is in the process of collecting the information. Service user representatives are invited to sit around the table with the managers involved.

3. Quite early in the process there can be a decision about agreeing a common jargon-free language coming out of detailed discussions about how workers from different agencies use the same word to mean very different things. This must also take account of the language of government acts and guidance.

4. When the pathway has been designed and agreed, there is careful consideration of what new resources it will need in terms of senior members of staff to oversee its workings, administrative and clerical support, new accommodation, etc.

5. This consideration of resources also looks at any present resources that become redundant in the new plan.

6. If there is a need for new financial arrangements, relevant staff members are consulted or brought into the discussions. There is consideration here about any need for legal contracts.

7. In the interests of sustainability, there must be consideration of long-term finance.

8. There needs to be consideration of which existing workers need new job descriptions or new contract of employment.

9. A plan can be agreed now about the timescale for the redesign, about how progress towards it will be measured and about the interagency system for evaluating the new work.

Although this service redesign is focused on a new horizontal structure for a particular category of service users, it represents a local collective effort to agree high professional standards and enhanced user empowerment. It is a collective effort in which managers will inspire each other and share good practice that can be fed back into each vertical organisation for the benefit of all service users and practitioners.

[1] Limbrick, P. (2003) pp 7-9

Chapter 6: High standards in interagency collaboration

Summary

The way support is provided to people in need in England is changing dramatically – as it is in some other countries. We are in a state of flux not yet knowing how, for example, education and health services will be structured by the end of our coalition government’s (first?) five years in office. As service provision is increasingly opened up to new social enterprises and private agencies, there is valid concern about how standards will be set, to what extent service providers will be regulated and whether interagency collaboration will become even harder to achieve. International air travel is offered as an example of effective interagency collaboration (but not of horizontality) from which we could learn valuable lessons. I offer some optimistic speculations and suggestions for establishing standards and promoting joint working in the horizontal landscape and then refer to the field of therapy for disabled infants, firstly to highlight the potential for an unregulated free-for-all in support for all service users and then to offer a helpful approach to achieve and maintain competency in interventions. The four sections in this chapter are:

• Preamble

• A successful example of interagency collaboration

• Some optimistic speculations and suggestions to help prevent a fragmented free-for-all

• Therapy for disabled infants: maintaining collaboration and competency in the horizontal landscape

Preamble

The beginning of the 21st century has brought great changes to support services in the UK, paralleled by changes in some other countries, with the accelerating growth of social enterprises including:

• co-operatives

• public service mutuals

• community interest companies that reinvest profits for the social good

• social businesses that are self-sustaining but have an explicit social benefit

There is also a blossoming of private agencies and individuals. This whole trend has been encapsulated by the coalition government in England in their ideology of localism which presages a reduction of the role of national and local government agencies in providing direct support to people in need. An additional factor in this rapidly changing pattern is the continuing trend to resource some categories of service users with a budget to purchase for themselves the support they feel they need. To prevent a chaotic free-for-all with no checks on standards and with an acceptance of chaotic and disorganised fragmentation there must be some forms of regulation and sanction built into the new pattern of organisations and into new horizontal landscapes.

A successful example of interagency collaboration

In pursuit of a positive approach, it might be a good idea to look at successful collaboration in the world of commerce on the basis that, if private companies can do it, then the rest of us can. My example here is international air travel. I am always impressed when I fly to another country that so many separate elements have been brought together to make it possible: ticket purchase, passport control, security checks, fuelling the plane, safety checks on the tarmac, luggage handling, air traffic control – and even my vegetarian meal. I know I have missed out a list of other functions I am not even aware of, but I am aware that getting me across a few countries and then safely down again has required professional conversations in several languages, conformity to many national and international regulations and adherence to very strict timetables. Thousands of flights every day around the world evidence extremely successful interagency collaboration and bring to an end all defeatist protestations from national and local government officers and public service executives that it is all too complicated, difficult and ultimately unachievable.

Any failure in integration in the aviation industry can result in a lost landing slot, stranded passengers, a missing plane or even lost lives – and that in turn can bring loss of reputation and profits, severe penalties for workers found to have failed in their duties and prosecution of one or more whole companies. Negative and condemnatory coverage in the inter-national press and media will play a large part in holding companies to account and alerting potential customers to their shortcomings.

In contrast to this, my perception is that support in the world of public services is allowed to remain disorganised and fragmented because it is not such a big issue for most of us. Nobody, except those intimately involved, cares that much. The obvious exceptions are the short-lived clamours of outrage when a service user dies in sufficiently tragic circumstances for the media to notice – clamours that are always followed by a government promise to take all necessary steps so that it could never happen again. Then we all forget. Then it happens again.

There would have to be a great change in society in general and in the culture of public services for the severe penalties that can apply in the commercial world to follow a lack of interagency collaboration in support of service users.

It is worth speculating on how the aviation industry achieves its high level of efficiency in joint working. It goes without saying that the industry is not organised horizontally in a flattened power landscape. My assumption is rather that this successful and enviable interagency collaboration comes from two factors:

1. Absolute clarity about what each task entails, how it should be performed and what qualifications and training are required to perform it.

2. The establishment of very strict criteria when contracts are put out to tender followed by heavy penalties when those criteria are not met. These criteria will comprise international and national regulations coupled with logistic and financial imperatives – and will filter down as companies that win contracts in turn put some of the new work out to tender, e.g. a company contracted to provide the fuel for a company’s fleet of planes might contract another company to deliver it to the planes on the tarmac.

By this thinking, these commercial agencies collaborate effectively, not just because lives are at stake – they are very much at stake too in the world of public services – but because each agency and worker knows exactly what their task is and what standard is expected of them. They know too that world-wide exposure and severe penalties can follow mistakes, shortcuts, errors of judgement and cheating. This requirement for tight organisation, high standards, strict regulation and heavy sanctions is not routine in the world of public services and it would come as a very rude shock to many of its workers if it were.

While I am arguing for high standards and regulation in horizontal teamwork, I am not equating a service contract for fuelling planes with one for offering psychotherapy to an addicted teenager in care or education to a blind baby who has cerebral palsy. Life is simpler and more certain when dealing with machines and there can be boxes to be ticked or left blank with great confidence. Not so when working closely with fellow human beings in need. But there certainly should be service contracts when an agency or a practitioner is offered work and these contracts should be informed by solid local agreements about what constitutes good practice – good practice as agreed by the agency collective and its users. Regulation and sanctions are essential because a service contract is meaningless in the absence of thorough checks on performance with penalties for failure.

Some optimistic speculations and suggestions to help prevent a fragmented free-for-all

In England we are in a state of flux with, at the time of writing, a lack of certainty about how public services – health and education are major examples – are going to be organised in the next few years. While full service user empowerment and effective interagency collaboration have been very far from the norm (an understatement), it is easy to imagine that the emerging unplanned mix of service providers will demolish our few examples of successful interagency collaboration. England’s coalition government might well be creating a culture with no enforceable standards and in which fragmentation is inevitable – leaving service users even more powerless and vulnerable in a swamp of confusion and bewilderment.

Keeping a focus on interagency collaboration and people empowerment in the horizontal landscape, the following paragraphs in this section are my speculations and optimistic expectations. Readers are invited to match these to their own intentions, predictions, hopes and fears.

Vertically organised public services will, for the foreseeable future, continue to be key players in the creation of new integrated pathways and the horizontal teamwork generated between them. From this central position, albeit with gradually diminishing influence, they can evaluate the competence of relevant local or national voluntary & community and private agencies before inviting them to help design or have an on-going role in their integrated pathways for particular categories of service users.

The government is encouraging the formation of public service mutuals and would like to see one million public service members of staff decanted into them by 2015.[1] I am given to understand that when a public service mutual is generated there are explicit standards and regulation built into the new arrangements. Whether this is the case or not, I suggest that on principle the handing over of any aspect of a public service to a voluntary & community or private agency should be accompanied by a set of enforceable professional standards.

In the interests of service user empowerment, service users and service user groups will list, as many have done already in the UK, elements of good practice they require in their support. Such lists can be offered when service users are invited into consultations and planning meetings. In a more proactive stance, service users will make these standards known to the agencies supporting them and will press for the necessary service development. Service user groups who have developed local horizontal links with and support from related agencies, campaigns, press and media will have more influence in getting agreement to and compliance with their standards.

Effective partnerships in the horizontal landscape require public service practitioners to be willing to collaborate with private agencies that are working primarily for profit. In my experience with disabled children and young people, members of staff in public services can be ambivalent about this. On the one hand they can feel that selling a treatment or therapy to the family of a disabled child – families who are typically impoverished by the extra expense this family member brings – is in some way immoral or exploitative. On the other hand they can be entirely happy to work with a technician from a private company in fitting a new wheelchair for a child or hoist for a teenager. Horizontality in the new environment requires us to consign any such negative attitudes and prejudices, well-meant and protective as they might be, to the great bin of times past.

There is a need for clear and authoritative distinctions to be drawn between professional, evidence-based support systems and interventions and those which lack a professional approach and have no evidence base. I would argue that an agency collective concerned for a particular category of service users should publish online information for service users and relevant local agencies about all local public, voluntary & community and private agencies and individuals working in that area of need. The information would have two strands:

1. It would establish the professional standing of the agency and the interventions it offers in relation to particular categories of need.

2. It would state whether the agency is willing to use its practitioners’ time to establish necessary partnerships in the horizontal landscape to prevent fragmentation.

This directory would offer general, helpful advice to service providers about what needs to be done to demonstrate this competence.

The next section expands on this approach for establishing competence of agencies and practitioners in the horizontal landscape using support for disabled infants as an example.

Therapy for disabled infants: maintaining competence in the horizontal landscape

For some years now there has been a gradual blossoming of new treatments, therapies and programmes for children with disabilities and their families provided by the voluntary & community and private sectors. My perception is that this growth is accelerating and my expectation is that public service practitioners will increasingly find themselves being asked to join with these ‘new’ practitioners in horizontal teamwork. While good practice requires that team members be competent, there is an increasing danger of new interventions being offered to children and families (and other categories of service users) by someone without any proper qualifications and in the absence of any evidence base for the effectiveness of the intervention for the particular category of need. The fault here can be that of an individual practitioner or of a whole agency or company.

The suggestion on page 90 for clear distinctions between interventions that are professional and those that are not is offered as part of the solution and is more fully discussed in an article in PMLD-Link[2] which raised the question of criteria for professional therapy. Three paediatric NHS therapists collectively answered the question, ‘So what criteria can we use to distinguish between therapy that is thoroughly professional and that which is not?’ as follows:

This is an important question for everyone working in ECI, partly because some therapies might do more harm than good – the last thing any of us want for disabled infants and vulnerable families. It comes down to what is known about the therapy, how the therapist is trained and supported and how he or she operates.

The first question must be about the clinical evidence base for the particular therapy as applied to a particular category of need whether in skill development, improved wellbeing or enhanced environments. If there is no valid information then we should not support it. Training is critical and we must never equate professional training over a number of years, perhaps at graduate level, with skills learned over a few weekends or at a summer school! In the UK, all NHS therapists are registered with the Health Professionals Council and must make a declaration every two years that they are up to date with innovations in professional practice.

A professional therapist will begin with an appropriate assessment, discuss the results with the parent to agree a course of action, integrate her work with any other interventions being offered and measure outcomes. She is accountable to the child, the parent and the agency that employs her. When she has uncertainties, these are acknowledged and dealt with in supervision.

Agreeing the dangers inherent in unprofessional therapy, the writers made the following recommendations:

1. 1. To help protect children and families, the paediatric world should promote awareness of two categories of therapy:

   • Professional therapy with an evidence base, properly qualified therapists and accountable and responsible delivery.

   • Other therapies which do not meet these criteria.

2. This distinction does not necessarily conform to statutory and non-statutory (whether 3rd sector, i.e. charities and voluntary organisations, or private agencies).

3. Paediatric NHS therapists should support parents in learning about and making judgements on any additional therapy interventions and be willing to work with, when appropriate, additional professional therapists.

4. Therapists, other paediatric practitioners and parents would be greatly helped in the above by an official register of professional therapy and therapists or the promotion of existing registers.

5. Authorities that allocate budgets to parents should restrict their use to professional therapies on the register.

6. Local councils and NHS trusts should strive to agree contracts with local registered therapists, whether 3rd sector or private, to ensure they will, as appropriate, work in partnership with others around the same child in pursuit of an integrated whole-child and whole-family support system. Turning for additional support to the 3rd sector or private agencies should not automatically lead to fragmented and disjointed support.

The verticality of our traditional public services is giving way to a mix of new organisational models in the middle layer between service user and the public authorities. In the spirit of horizontality, this must be celebrated as a very welcome opportunity for smaller, locally based agencies that can represent communities that are trying to create the sort of support they want for their people in need. As suggested above, to avoid an unprofessional free-for-all there must be standards, regulation and sanctions built in to the new arrangements. Whether or not these will come from national government in any meaningful detail we will have to wait and see. The greater likelihood is that standards and regulation will have to be set locally – initially by traditional public services on their own or in collaboration with other agencies.

[1] See TAC Interconnections online news page at http://www.teamaroundthechild.com/allnews/commentopinion/479-public-service-mutuals.html

[2] See Limbrick, P. et al (2011b) pp 3-5

Chapter 7: A rich horizontal landscape for people in need

Summary

This final chapter offers vertical organisations and horizontal structures as contrasting but interdependent modes of service provision. There needs to be a shift of balance towards the latter in consideration of the great numbers of people shared between agencies whose needs are not being met. Using England’s new children’s trusts as an example, I argue that expanding the functions of vertical organisations is a less satisfactory solution than enhancing horizontal teamwork and a vision is offered for a vastly richer horizontal landscape. Six elements are listed that must be built into new initiatives for interagency collaboration to counter the main problems that have held back joint working to date. Three current reports are quoted to demonstrate firstly that many categories of service users urgently require interagency collaboration and secondly that these service users, taken as a whole, constitute vast numbers of people. There are four sections as follows:

• Horizontality, verticality and their interdependence

• Developing the horizontal landscape

• The imperative of horizontality

• In conclusion

Horizontality, verticality and their interdependence

Sunlight enters the eye with vertical, horizontal and diagonal waves unless Polaroid sunglasses are worn to allow only the vertical – the others being filtered out to reduce glare from water and other flat surfaces. This essay has intended to act in a similar filtering capacity with UK public services but allowing us to see the horizontal more clearly, though, in fact, these agencies are complex and cannot be divided so neatly into vertical and horizontal configurations. Nevertheless, this focus on the horizontality of interagency collaboration has enabled us to perceive a contrast between vertical public services and the horizontal structures that are created in the spaces between them. With this perception we can look afresh at the persistent problems encountered in interagency collaboration that prevent it flourishing and identify some remedies that must be built into future attempts to give them better chances of effectiveness and sustainability.

This essay has attempted to isolate horizontal structures from vertical organisations in pursuit of seeing more clearly how they differ and how they fit together. Public services in the UK have been characterised here as traditional vertical agencies that are well established, carry funds to employ staff, have top-down management structures and, by and large, use their own ‘in-house’ services to deliver their version of support to service users. In contrast, horizontal structures are described as:

• the result of interagency collaboration

• belonging more to the modern world than the traditional

• not yet commonplace and well established

• holding practitioners in partnerships in a more or less flat power landscape

• operating a quasi-management style in which leadership relies much more on personality and people skills than on hierarchical authority

• succeeding in their efforts to support service users only in as far as they join multiagency managers, practitioners and interventions together

While I have not argued that service users are automatically disempowered and voiceless in the UK’s vertical public services, I have suggested that horizontal teamwork, as exemplified by the TAC model, provides an ideal forum for listening to service users and involving them fully in decisions about how they are to be supported. The flattened power landscape of horizontality holds service users on a more equal footing and affords them maximum rights and responsibilities as receivers of support.

There is no argument here that we should promote horizontality at the expense of our vertically organised public services. We need both. Interagency collaboration is essential for effective multiagency support for service users who are helped by other agencies at the same time and this horizontal teamwork in the UK depends for its creation and sustenance on our traditional public services. But I am arguing for a new understanding of and respect for the structures that must be nurtured in the horizontal landscape if support agencies are going to work together for the wellbeing and empowerment of all their service users. So I see verticality and horizontality as being both essential and mutually supportive while recognising that horizontality is still novel and quite rare.

The key message of this essay is that horizontality should be acknowledged, taken seriously and provided for in an ever-improving balance between the two modes.

With this need for balance in mind, it is worth taking a look at the idea of children’s trusts which were tried in England in the first decade of this century. These were an attempt to create reliable and sustainable child-centred interagency collaboration by welding together local education, children’s social care and relevant parts of health agencies to form a new vertical organisation under a single director. Despite the 2007 report on the official children’s trust pathfinders[1] giving a generally positive message, the incoming coalition government has made no commitment to them. In fact, the government’s strategies for encouraging schools to move away from local authority control and handing to GPs responsibility for commissioning local health services are likely to result in dissolution of the very structures that were needed to prop up children’s trusts. We can only wait and see what becomes of them.

Moving away from England’s politics to get back to our subject of horizontality, the University of East Anglia report on children’s trusts found (4,2):

More needs to be done to involve police authorities, youth offending teams and local learning and skills councils in joint planning.

While applauding any attempt to create interagency collaboration, it seems obvious that no vertical organisation can ever be broad enough to cope on its own in support of people whose condition and situation are multifaceted and requiring connections to multiple parts of local service provision. A children’s trust, in pursuit of comprehensive joined-up support for children, would need to involve, in addition to the services in the above quote, local housing, relationship counselling, benefits advice and many other agencies that are involved in some way with children and families. The options would be to bring these additional agencies into the new trust under the management of the single director or to develop links with them in the horizontal landscape. It seems clear that these brand-new 21st century children’s trusts were immediately limited by the boundaries of their verticality and would need, if they were allowed to survive, fresh horizontal thinking in order to serve their children effectively. I wonder what the result would have been if the same amount of time, money and creativity had been invested in research and development of horizontality.

Developing the horizontal landscape

The essay has established that verticality and horizontality are valid labels for two contrasting, but interdependent, modes in how support is offered to people in need in any locality. The development of interagency collaboration for the multitude of service users who require support from two or more agencies in the same time period, exemplified by the list on page 12 in the Introduction, requires extensive development of horizontal structures in the landscape between the vertical public services – service development that has to be the responsibility of the public services themselves even if the impetus for it comes from service users and pressure groups.

In my vision, the few treasured strands that already connect the vertical and largely insular silos will multiply dramatically to become a rich and complex pattern of interconnections that holds service users in respectful partnerships, harmonises support for them, nurtures practitioners and establishes higher standards of performance (that then feed back into each vertical public service for the benefit of all their users). This flourishing horizontality will value service users, workers and the partnerships they create together across agency boundaries.

An essential starting point in pursuing this vision, with or without pressure from service user groups, is for vertical agencies to find out the proportion of their users that receive support from other agencies at the same time or in close sequence. The next survey question would be to ask to what extent this proportion of users suffers ill effects from fragmented and piecemeal provision from their agencies. This is not a campaign to get more agencies around each service user; it is merely asking, ‘Are you helped by other agencies as well?’ and ‘Are we all joined up enough?’

My assumption is that the proportions will differ between local agencies. My strong assertion is that those agencies that find they share a significant proportion of their users with one or more other local agencies and get reports from those service users of unhelpful fragmentation must give an appropriate proportion of their efforts to develop the horizontal landscape – aspiring to the high standards of interagency collaboration set by British Airways, Qantas, Virgin Atlantic, etc. The clear implications are that the pattern of work for many staff members will change and resources will be used in different ways. The process of change and reformation will be a sufficiently large task in some vertical organisations to justify a new post of director of horizontal working.

Following the logic of this essay, there can be advantages in two or more local agencies joining together horizontally to survey and involve local service users and then to allocate resources within their agencies for the shift of balance between verticality and horizontality. These large-scale structural changes will pave the way for developing integrated pathways for particular categories of service users.

In the interests of clarity and emphasis, I am advocating here a new mindset in public service provision to embrace horizontal thinking at all levels. I am also advocating that this altered mindset embraces ambitions to create the highest levels of user empowerment and professional competence. Any new horizontal structures that operate to low standards and are unregulated will probably do more harm than good leaving service users exposed and vulnerable in a no-man’s-land that holds no one accountable. I have described benefits to practitioners and managers of horizontal teamwork so my essay is not intended to confront anyone with impossible hurdles and unsatisfactory work patterns.

Summarising earlier parts of the essay, the major elements that must be built into local interagency collaboration, allowing for variation in work with different categories of service users, are as follows:

1. Full user empowerment in interagency collaboration requires that local public services have up-to-date information about which categories of their users are suffering ill effects from fragmentation and lack of co-ordination in their support. This body of information must also include detail about what is failing, the impact of these failings on users and what users feel should be done to improve the situation. Users can be invited to give information individually and in groups and in whatever medium best suits them.

   Where users have collected and provided feedback proactively without waiting to be invited, their efforts should be acknowledged, valued and fed into service development with their representative being invited into the process.

2. Very careful consideration must be given to the multiagency keyworkers and individual TACs at the interface where the service users meet their integrated support in the horizontal landscape. Keyworkers, TAC facilitators and practitioners who are potentially TAC members need appropriate contracts and job descriptions, training, supervision and administrative support. These are important professional roles on which interagency collaboration will stand or fall. Asking busy public service practitioners to take on additional keyworking roles is an unsatisfactory half-way measure that would be better replaced by positioning the work in the voluntary & community sector and with a move toward multiagency keyworkers having just a single role. Local interagency collaboration must invest authority in its keyworkers and individual TACs so that they can properly represent service users’ best interests.

3. The collective effort to promote horizontal teamwork will need to balance the time it requires against time saved by eradicating duplicate processes, unnecessary meetings, reports that no one reads and by no longer requiring practitioners to do mountains of clerical work. This long-awaited modernisation of support services represents a radical change in how practitioners and their managers use their time and, while being necessitated by interagency collaboration, is also catalysed by it.

4. I have suggested a very significant barrier to horizontal teamwork in the UK is staff members’ apprehension about increased workload, anxiety about lowered professional standards, nervousness about being vulnerable and unsupported outside the vertical organisation, and perhaps a reluctance to change that we all experience sometimes. On the other hand, there are enough successful examples to show that such negativity proves to be unfounded when the redesign is done properly. The necessary antidotes to valid staff concern, listed on pages 61 to 63 include involving workers in the redesign and fully addressing their anxieties one by one as new systems are constructed. Going back a stage, when practitioners are interviewed for their jobs, evidence of positive attitudes to horizontal teamwork should be a requirement for getting onto short lists.

5. In support of practical grass-roots work with service users there need to be interagency agreements at senior level about sharing information (with a jargon-free common language that everyone can understand), rules of confidentiality that are clearly explained to service users and everyone else involved and realistic efforts to ease the flow of electronic information between agencies at all levels. In this effort to keep everyone informed there needs to be an up-to-date directory of local support services.

6. Clear and measurable professional standards and strict regulation of them are absolutely essential for two reasons: firstly so that the horizontal landscape does not become a rule-free zone; secondly to maintain a professional and responsible perspective on all new treatments, therapies and educational programmes as they emerge. I have suggested five approaches to this:

   • High professional standards and regulation are built into the integrated pathways for each category of service users.

   • Each local directory of support lists which local services are fully professional (with an evidence base and properly qualified staff members) and which are signed up to horizontal teamworking.

   • Agencies and practitioners who have not demonstrated that they are professional are not invited into horizontal teamwork.

   • Agencies that allocate personal budgets to service users should specify that the money cannot be used to purchase work from agencies and practitioners that have not demonstrated that they are professional.

   • When any support work is handed over from public services to another local agency in the voluntary & community or private sector, there must be strict and enforceable performance criteria.

The imperative of horizontality

In the introduction I offered a sample list of people with various needs who would, in my view, benefit from new or improved interagency collaboration. It is worth reminding ourselves that we are all subject to history. In the UK we have inherited, keeping in mind for the moment children who have a multifaceted condition and their families, separate health, education and social care agencies – all with clearly differentiated remits (and all with substantial achievements even if now badly in need of modernising) that must in some way be brought together in support of the whole child and family. If we started afresh to design services for these children we might first be tempted to think of whole new agencies and practitioners equipped to deliver completely seamless care-education-health packages without any agency or professional boundaries to get in the way.

Children’s trusts were an attempt to move in this direction as is, to an extent, Conductive Education[2]. I would not want to detract from either initiative (and I have very great respect for Conductive Education) but each is only a partial solution to fragmentation and we would need, should we follow the logic of these examples, similar fixed constructions for every conceivable category of service users that needs multiagency support. We would need new ‘poly-agencies’ to bring together police, social work, schools, hospitals, GPs, children’s centres, drug rehabilitation, prisons, old people’s homes, children’s homes, benefit agencies, etc in every possible configuration to meet the particular needs of every category of service users. And there lies madness.

Interagency collaboration in the horizontal landscape is not a half-way measure or a second-best option; it is presented here as a universally applicable service design that offers itself as the first choice for supporting people shared by two or more agencies. Horizontal teamwork between practitioners from separate vertical organisations would still be essential even if we could build support services from scratch. There is still need, nonetheless, for ‘poly-centres’ and ‘poly-clinics’ catering for particular categories of service users, but I see these as the products of interagency collaboration rather than replacements for it – valued joined-up foci in the ever richer horizontal landscape.

My invitation to readers at this point is that they consider support for their own service users from this horizontal perspective – support as it is now and as they would like it to become. My view is that very many service users in the UK would benefit from support in a new or enhanced horizontal landscape. I have already given information about how horizontal teamwork can operate for infants with a multifaceted condition and it might now be pertinent and helpful to point to the applicability of horizontal teamwork to three other categories of service users. I have chosen these three categories merely because their unmet needs have come to public notice (but not for the first time) in reports published as I have been writing this essay during the first two months of 2012. The three reports are as follows:

Child Neglect in 2011: A report published in January 2012 by Action for Children in conjunction with the University of Stirling entitled, Child Neglect in 2011[3] says on page 4:

Although much good work takes place in pockets across the country, there is an urgent need for a far more concerted and consistent approach to helping neglected children… The critical challenge across the UK now is to galvanise an effective, integrated and early response to neglected children.

My reading of the report suggests that enhanced interagency collaboration is needed to:

• collect data at the strategic level across local agencies about how many children are suffering neglect

• create effective liaison and networking in the horizontal landscape between practitioners and managers in social care, health visiting, schools, police, housing, etc in order that people can compare notes and raise joint concern about particular children

• establish individualised horizontal teams to co-ordinate interventions and to collaborate on an integrated response to each child’s needs once their plight has been discovered

(The second and third points above reflect the levels of interagency collaboration described on pages 24 to 26 of this essay.)

The UK-wide Square Table programme: The report, The UK-wide Square Table programme[4] published in February 2012 by the organisation, Together for Short Lives, is concerned with children’s palliative care and calls, inevitably, for improved awareness of need and enhanced provision for children and families. It is sufficient for the purposes of this essay to quote from the executive summary on page 3:

ii. Professionals and families recognise that greater coordination of services and partnerships at all levels is needed.

Many parents and professionals said that health, education and social care agencies work independently of each other, creating difficulties for families in navigating the patchwork of services available. There was universal agreement that the best outcomes for children and families are achieved when parents, professionals and volunteers work together in partnership.

The Interconnections TAC model of horizontal teamwork holds a large part of the solution to this problem.

Report into Social Care: My third example concerns older people. Launching the report of a recent inquiry into Social Care (HC 1583, Fourteenth Report of Session 2010-12)[5], Stephen Dorrell MP, Chair of the Health Committee said in February 2012:

This report is latest in a long line of reports which have stressed the importance of joined-up services. It is impossible to deliver either high quality or efficient services when the patient is passed like a parcel from one part of the system to another, without any serious attempt to look at their needs in the round. This obvious truth has often been repeated, but seldom acted upon. The funding for NHS care, social care and social housing comes from different sources. Apart from a few exceptions like Torbay Care Trust in Devon, attempts to join up these funds and to integrate services have been disappointing. We welcome the government’s stated determination to tackle this long-standing issue; the key is to move beyond restating the aspiration to addressing the question of 'how'.

With this third report in mind, I want to explore the potential benefits of horizontality for elderly people whose last years include some mix of social services provision and one or more stays on hospital geriatric wards. We have repeated press and media reports (and again at the time of writing) about patients on geriatric wards lying in their own urine and faeces and being left unattended with drinks and meals they can neither reach nor feed to themselves. Public services, no matter what official reasons are given out when the situation is exposed, can hardly be much worse than this.

Taking the vertical-horizontal perspective, these patients, who might or might not have been under the care of local social services – but who certainly have a GP – and who probably had some links to their local community, when they go into hospital are entering a typically vertical and relatively enclosed domain which, at worst, can hold them disempowered and voiceless at the base of its highly structured power pyramid.

While having only limited experience of this category of service users, I do feel that some modified version of the TAC model could offer a bridge between the two relatively unconnected environments the elderly person switches between – at home with more or less community support and in hospital under the NHS. The TAC model demonstrates the value of key people from both worlds linking together in some way in the horizontal landscape in pursuit of less fragmented regimes for treatment and care. Whatever form the linkage takes, its effects, following TAC principles, would be to:

• bring a shared view of each elderly person’s situation, aspirations, strengths and needs

• gather direct information from and indirect information about the elderly person to ascertain their under-standing of their situation, preferences and wishes

• share knowledge, wisdom and concern in making a plan of action for the place where they are now and the transition to what might come next

• maintain a close watching brief over the treatment and care that is provided in any setting

• assume continuing responsibility for the elderly person’s autonomy, health, comfort and wellbeing

I am sure that some elderly people, with or without the benefit of family involvement, have received such compassionate and joined-up care. My plea is that it should not be left to chance – because we can see what can happen when it is. Such a strategy as I have described above must be the product of discussions in the horizontal landscape between hospital, social care, voluntary & community and private agencies and community members. It is the antidote to the ‘pass the parcel’ approach under which elderly people can so easily disappear from view.

In conclusion

These three reports surely bolster my argument that there are vast numbers of people needing interagency collaboration in pursuit of their effective support and that public services in the UK, stuck in an outdated mindset, are falling very far short of their duties. I have argued for a shift in the balance in the UK between the verticality and horizontality of provision coming out of radical, top-down redesign of local agencies. This must be a collective effort and represents a fight against the odds to bring all agencies that support people in need up to date and relevant to the 21st century. The local horizontal teamwork I have described and advocated for at senior management, middle management and practitioners levels has a triple function:

1. The creation of a culture of service user empowerment: inviting representative service users into the redesign process from the first stages and being prepared to engage with service user groups who are proactively campaigning for effective and coherent support.

2. The facilitation of joint working at the three levels:

   • liaison and networking

   • service co-ordination

   • collaborative teamwork to integrate interventions into a whole person approach

3. The setting of high professional standards and regulatory systems that:

   • ensure the effectiveness of interventions in the horizontal landscape

   • reflect back into each vertical organisation for the benefit of all of their service users

My focus on the horizontality of interagency collaboration has shown the scope and nature of the changes required to properly support people who need help from two or more agencies at the same time. I have not suggested these changes come without a determined and committed effort. Nor am I pretending that I have provided all the answers. Senior managers in the public services face the tremendous challenge of radically reshaping their vertical organisations so that practitioners have the necessary training, support, leadership and time to be effective in their local enriched horizontal landscape. My educated guess is that time is by far the greatest of these challenges.

So, where should we look for answers to this so far intractable problem? I have suggested that parts of the commercial world seem to manage their version of interagency collaboration very effectively and without the ‘it’s all too complex and difficult’ protests we get from many of our public services. There are certainly answers here and it would seem to be a rich field for the academic world to explore. Then there are the national professional colleges who have the authority and resources to promote research into interagency collaboration and to include horizontality in their training courses. These professional colleges could even link with each other in their own high-level horizontal landscape for a collective effort to crack this persistent problem of fragmentation and disorganisation between professional groups.

While we are desperate for a constructive technological and scientific approach, we also need a new mindset in which each practitioner automatically surveys the horizontal landscape around each service user and in which applicants for managerial positions in support services are required to demonstrate that they are completely at ease with horizontality. We do need to pay attention to all of the reports that emerge from government departments and public services that have direct bearing on this subject, but perhaps we should also be prepared to survey our own horizontal landscape for inspiration, initiatives and ideas that can help us – even though at first they may seem unconnected. In this spirit of exploring off the beaten track I offer three books: Us Mob[6], General System Theory[7] and Mutual Causality in Buddhism and General Systems Theory[8]. I am sure readers will have their own sources of inspiration to share with others in pursuit of effective interagency collaboration.

Appendix

Horizontalidad

I first wrote about horizontality in October 2011 in an ed- itorial for the TAC Interconnections Bulletin[9] entitled The ‘Big Society’, secular horizontality and, of course, Team Around the Child[10]. I saw the English coalition government’s plan to reduce the power of the state to make room for ‘localism’ as a policy to be hijacked on the basis that I welcomed the space it might create for people empowerment but had no faith in what the government would actually produce or in their motives for doing it. The following are extracts:

I want a move away from verticality and towards horizontality. We are conditioned from toddlerhood to vertical and hierarchical power structures...Verticality is characterised by power, control and influence extending relentlessly down while money and privilege flow ever upwards. There is no intent in these hierarchies for people like you and me to lead rich and rewarding lives in which we are genuinely free to grow ever more human.

Could the ‘Big Society’, whether the coalition government approves or not, create a space in which the people in the bottom layers of these power pyramids work together to create secular and horizontal structures of co-operation and mutual helpfulness – building new organisations that promote human-scale groups, communities and societies? Here we would be less subject to and less reliant on those above and strong enough to welcome, embrace and support the most vulnerable and deprived members of this true society.

There is no suggestion here that we can eliminate verticality. I am merely advocating that we gently and determinedly hijack the coalition’s Big Society in order to shift the balance towards horizontality as far as we can. An element of this for us in the field of childhood disability…is…to do what we can to enrich and strengthen the horizontal structures – horizontal structures that empower children and families, reduce prejudice, make a fairer distribution of resources and help make life worth living.

Since then I have been taken up with the idea of these horizontal structures, of which the TAC model is an example, being the necessary addition to and link between our traditional public services – and with the inspiring thought that the horizontal-vertical analysis might usefully inform our thinking and planning to help us achieve the interagency collaboration that has proved so elusive during the last half century. Thus began this essay.

Having brought horizontality into my consciousness, I then came across horizontalism as a social movement begun in Argentina ten years ago. I strongly recommend Horizontalism: voices of popular power in Argentina[11]. In the Introduction, speaking of the emergence of autonomous social movements around the world, Marina Sitrin tells us:

In Argentina, these active movements are now communicating, assisting, and learning from one another, and thus constructing new types of networks that reject the hierarchical template bequeathed to them by established politics. A core part of this rejection includes a break with the idea of “power-over”. People are attempting, instead, to organize on a flatter plane, with the goal of creating “power-with” one another. Embedded in these efforts is a commitment to value both the individual and the collective. Simultaneously, separately and together, these groups are organizing in the direction of more meaningful and deeper freedom, using the tools of direct democracy and direct action. They are constructing a new form of popular power.

Horizontalidad is a word that has come to embody the new social arrangements and principles of organization of these movements in Argentina. As its name suggests, horizontalidad implies democratic communication on a level plane and involves – or at least intentionally strives towards – non-hierarchical and anti-authorit-arian creation rather than reaction. It is a break with vertical ways of organizing and relating.

It is an inspiring book in which people tell their own stories. I have chosen two extracts, the first from Nicolás and the second from Claudia:

Nicolás: Power is seen as more of a daily practice now. For example, in my neighborhood there’s a very bureaucratic health center that, until recently, has been the place that gives out milk. The problem was that the milk never arrived, or no one knew how much milk was coming, or if it was going to be bad when they got it. … my neighborhood assembly saw that the health center wasn’t functioning, or that it only worked for its own employees, who didn’t even do anything. That took away people’s motivation to go to the health center. So they began to peacefully take it over, pressuring the doctors and managers to do their jobs. They spoke of power, meaning the power of the neighborhood – not government, but everyday power.

(p 166)

Claudia: We can’t try to understand how the movements are organized by thinking in terms of models of domination or other concepts of power. It isn’t a question of massive numbers either. We can’t let ourselves enter the mindframe of who has more or who can do more. It’s this very logic that needs to be changed; the logic of how the system of power organizes people. We’re doing something else.

I believe that if people are left to their own devices and we pay attention, we’ll find that people naturally organize horizontally, and the rest is a process of unlearning hierarchy. Children are a good example of this. We can observe how they socialize naturally, how they come to agreements, divide roles, and generally come together as a group. It’s not that they immediately elect a leader and other children have to get permission from him to play in the group. This sort of natural coming-together appeared in Argentina when everything else disappeared. Money disappeared, the institutions disappeared, and trust in leaders and government disappeared. The system had been becoming increasingly decadent, and then it was finally left naked. And it was a natural response, for people to begin to organize horizontally.

(p 52)

For readers who would like to learn more about horizontalism and its reordering of power and state I recommend the work of John Holloway.[12]

While I do not imagine any western government really wants to give the power held by the state to its citizens, I do see the value and the possibility of people making their own decisions to become less passive and more directly involved in what is happening in their communities, not because government is telling us we can but because we realise our wellbeing and welfare, now and in the future, is not best served by officials in the upper reaches of the vertical power hierarchies.

Perhaps the crisis of national debt and the subsequent loss of funding for the public services is a hefty nudge for all of us in this rethinking of whom we trust to act in our best interests.

[1] University of East Anglia in association with the National Children’s Bureau (2007)

[2] For more information about Conductive Education see Baker, W. & Sutton, A. (2008) and Sutton, A. & Maguire, G. (2004)

[3] See Action for Children in partnership with the University of Stirling (2012)

[4] See Together for Short Lives (2012)

[5] See UK Parliament (2012)

[6] See Mudrooroo (1995)

[7] See Bertalanffy, L. von, (1969)

[8] See Macy, J. (1991)

[9] See http://www.teamaroundthechild.com/about-the-bulletin.html

[10] Limbrick, P. (2011c)

[11] Sitrin, M. (ed) (2006)

[12] See Holloway, J. (2002)

References

Action for Children in partnership with the University of Stirling (2012) Child neglect in 2011: Summary of recommendations for the UK government. London: Action for Children. http://www.actionforchildren.org.uk/media/2760605/childneglectin2011summary.pdf

Baker, W. & Sutton, A. (2008) ‘Parent-child interaction as a focus for early intervention: experience from early-age Conductive Education’ in Interconnections Quarterly Journal, Vol. 1, No. 2, pp 14-22

Bertalanffy, L. von, (1969) General System Theory: Foundations, development, applications. New York: George Braziller

Dale, N. (1996) Working with families of children with special needs: Partnership and practice. London: Routledge

Davis, H. & Day, C. (2010) Working in Partnership: The Family Partnership Model. London: Pearson

Edelman, J. & Crain, M. B. (1993) The Tao of Negotiation: How to resolve conflict in all areas of your life. New York: Harper Collins

Holloway, J. (2002) Change the world without taking power. New York: Pluto Press

Limbrick, P. (2001) The Team Around the Child: Multi-agency service co-ordination for children with complex needs and their families. Worcester, UK: Interconnections

Limbrick, P. (2003) An integrated pathway for assessment and support: For children with complex needs and their families. UK: Interconnections

Limbrick, P. (2004) Keyworkers are an essential part of a quality service for families. So why do most families not have one? Is the “Team around the child” part of the solution? in PMLD-Link, Vol. 16, No. 2, Issue 48

Limbrick, P. (2009a) ‘TAC for the 21st Century: A unifying theory about children who have multifaceted disabilities’ in Interconnections Quarterly Journal, Vol. 2, No. 5

Limbrick, P. (2009b) TAC for the 21st Century: Nine essays on Team Around the Child. UK: Interconnections

Limbrick, P. (2010) ‘The multifaceted condition and collective competence’ in PMLD-Link, Vol. 22, No. 1, Issue 65

Limbrick, P. (2011a) ‘Holistic interventions in complex care: A multifaceted support system is needed for children with neurological impairments’ in Nursing Children and Young People, Vol. 32, No. 10, p 13

Limbrick, P. with Boulter, L., Wassall, L. & Rimmer S. (2011b) ‘What do the terms ‘therapy’ and ‘therapist’ really mean in early childhood intervention for children who need on-going interventions?’ in PMLD-Link, Vol. 23, No. 3, Issue 70

Limbrick, P. (2011c) ‘The “Big Society”, secular horizontality and, of course, Team Around the Child’ in TAC Interconnections News Bulletin. http://www.teamaroundthechild.com/allnews/commentopinion/448-the-big-society-secular-horizontality-and-of-course-team-around-the-child.html

Limbrick-Spencer, G. (2001) The Keyworker: a practical guide. Birmingham, UK: WordWorks with Handsel Trust

Macy, J. (1991) Mutual Causality in Buddhism and General Systems Theory; The dharma of natural systems. New York: State University of New York Press

Middleton, N, W, G. (2009) ‘Early intervention: Children at risk’ in Interconnections Quarterly Journal, Vol. 2, No. 4

Mudrooroo (1995) Us Mob - History, culture, struggle: An introduction to Indigenous Australia. Australia: Angus & Robertson

Sitrin, M. (ed) (2006) Horizontalism: Voices of popular power in Argentina. Oakland, USA: AK Press

Sutton, A. & Maguire, G. (2004) Maria Hari on Conductive Pedagogy: An Introduction to the Philosophy of Conductive Education. Birmingham, UK: Foundation for Conductive Education

Together for Short Lives (2012) The UK-wide Square Table Programme: Overall learning and evaluation report. Together for Short Lives, 4th Floor, Bridge House, 48-52 Baldwin Street, Bristol, UK, BS1 1QB. www.act.org.uk/core/core_picker/download.asp?id=969

UK Parliament (2012) Health Committee - Fourteenth Report on Social Care. http://www.publications.parliament.uk/pa/cm201012/cmselect/cmhealth/1583/158302.htm

University of East Anglia in association with the National Children’s Bureau (2007) Children’s Trust Pathfinders: innovative partnerships for improving children and young people’s well-being. Centre for Applied Research in Education, School of Education and Lifelong Learning, University of East Anglia, Norwich NR4 7TJ. http://www.uea.ac.uk/polopoly_fs/1.73459!nect2007.pdf

West, S. (1994) When the bough breaks: An independent survey into families’ perceptions of the One Hundred Hours model of service. Addingham: One Hundred Hours