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Therapy without frontiers, families without tears

Placing children at the centre of care brings benefits for families and professionals alike, says Denise Roberts

'Imagine the scene in early 2002,' says Suzanne Rimmer, superintendent paediatric physiotherapist at Walsall primary care trust. 'Our child development centre in Walsall followed the well-established medical standardised model of service. When children were referred to the centre, they were usually required to attend a medical appointment before they could be referred to other members of the team. This often resulted in unnecessary delays in receiving appropriate provision.

'In many instances,' Suzanne adds, 'it was considered appropriate for the child, accompanied by an adult carer, to attend the centre for a two-week block of assessment followed by a formal case conference. Feedback from carers indicated they often found this assessment time- consuming, stressful and very daunting.'

This process, with all its problems, has now disappeared in Walsall and other areas; thanks to a new way of working - the team around the child approach — that places children with complex disabilities and their families at the centre of a multi-agency team. In doing so, the model crosses professional boundaries, encouraging collaboration and communication. Regular reviews, joint targets and a joint physical management programme mean the families do not have multiple professionals all asking the parents to try and follow different pathways. It fits with the government's focus on placing patients at the centre of healthcare.

In the approach, when a referral is received, a panel consisting of a representative of each of the agencies involved, discuss and decide who is the most appropriate agency to take the lead and complete an initial assessment. Health, education and social care workers can all be present, as well as other appropriate services.

At Medway trust, meetings have involved MPs and the housing department as well as therapists. 'We do not run services prescriptively but ask families who they might like to come to meetings,' says children's disability lead Carole Campbell. 'If the family wants to make a point about something like housing we organise someone to be there so they get a chance to hear their needs. Medway introduced the approach four years ago and had so much success we introduced the model to all children under five needing multiple disciplinary care. We now cater for over 200 children.'

Working collaboratively has many advantages. At Walsall, copies of a client's initial assessment are given to each team member. This is, says Suzanne, 'so that the family do not have to repeat their story to countless professionals. Parents are also given a copy of all the paperwork to take to any other appointments at the hospital.'

Following this assessment, an initial coordinator is appointed, charged with the task of establishing the team around the child. Initial coordinators also provide support to team members in establishing the relationship with the parent or carer and in gaining an understanding of the particular needs of the child and family. Plus, in consultation with the family, they prepare a family service plan identifying the needs of the child and their family, and discuss how the team intend to met them.

The family service plan is critical in ensuring care is truly patient-centred. A family service plan is owned by the family and contains personal thoughts and feelings, as well as information they may require. Plans are also used to outline how the multi-agency team aim to work together with the child and family. 'It puts them at the centre of planning and delivery of services,' comments Suzanne.

Families are involved in establishing the targets and aspirations for their child, with practitioners working at a pace acceptable to the family. The family can also choose the venue for case reviews: whether in the family home or elsewhere, as long as privacy can be ensured.

'The opportunity to provide one plan for the family' is one of the key aspects, says physio Linda Fisher, early support and paediatric coordinator for Southend Hospitals trust, who works across Essex. 'For us, implementing “team around the child” was about raising awareness of the need to rethink and change how we work; to have a more effective mechanism to plan a more coordinated service... The team around the child model is very family-centred,

so we were able to plan services around families rather than the family fitting into our services.'

Linda says: 'As soon as we did a few, people realised it reduces repetition, confusion and service fragmentation. It maximises resources, and practitioners say anecdotally that it saves time, improves communication and shares responsibilities.' In Walsall, one result was shorter waiting lists, due to fewer inappropriate referrals.

A crucial role in the model is the key worker, who 'can be drawn from any of the disciplines involved with the family, but must, stresses Suzanne, 'be someone with whom the family feel comfortable'. The role is twofold: involving befriending and coordinating. With befriending, staff use active listening skills and basic counselling ones. As coordinators, they are responsible for bringing together professionals and integrating interventions in the best interests of the child. In addition, they provide advice, information and guidance to families.

Parents say having a key worker assigned to the family is very helpful and, as a result, report feeling more confident.

The physio team in Walsall, assistants through to senior clinicians, work at all the different stages of responsibility. As initial assessors, physios use extended skills and knowledge of child development, family dynamics and local service provisions to determine a comprehensive picture of the family's needs. 'The person completing the assessment must have the skills to be able to inform and advise parents of the choices and opportunities, as well as reassuring and supporting the family in an often stressful situation. They must facilitate the involvement of the family from the beginning in the decision-making process, agreeing an appropriate timeline of intervention,' Suzanne says.

Training and working as key workers has enhanced physios' skills, as well as benefiting the service. 'It has given our team the confidence to chair a meeting and to promote our profession in front of consultants, strategic managers and managers from outside agencies.' She adds: 'Taking

on a key worker role recognises the work we have traditionally done, but have not had specifically identified.'

Suzanne also points out benefits of joint visits and regular inter-agency training days. 'We have been able to multi-skill the other professionals so that even if we are not present, a child may be indirectly receiving physiotherapy when another professional is working with them, as that professional will know the correct way to handle the child and the targets we are aiming for.' For example, the physiotherapy department hosted a basic handling training session highlighting the commonly used handling and facilitation techniques. 'All staff found this particularly helpful as it gave them an insight into they way they could help a child move from one activity to another while helping them to maximise their physical potential.'

The benefits of inter-agency working flow in both directions. 'Our team has become multi-skilled and has increased its depth of knowledge of other professions' working practices. This gives us a more holistic view and a deeper insight into the challenges our families and clients face. We can also reinforce the work of the other agencies by using some of their activities during our sessions.'

Suzanne, Carole and Linda are part of a national team around the child development group, led by the initiator of the model, Peter Limbrick (see box below). They aim to bring projects together to share experiences, establish core principles, develop an evidence base and the model

further, and produce guidance for others.

Despite the challenges that implementing the model brings — the temporary upheaval to services, paperwork, marketing to the different practitioners, and coordinating meetings — there are good reasons for adapting services in this way. Peter observes: 'It is widely accepted now that fragmented services can damage these vulnerable children and families. “Team around the child” is an effective solution based on accepted good practice.'

'Embracing this approach has meant a lot of hard work and commitment from all the staff,' acknowledges Suzanne. However, she concludes, it 'has resulted in a well-trained cohesive workforce who gain satisfaction from knowing they have made a difference to the difficult lives of the families we serve.' Who could ask for more than that?

Listening to children

While working in special education needs teaching in the 1990s, 'team around the child' innovator Peter Limbrick set up the voluntary organisation One Hundred Hours to develop and validate the key worker model of family-centred support for young children with significant neurological impairment. 'I realised very many years ago that I could not work successfully with children with multiple disabilities without very close collaboration with the therapists who were also supporting those children,' Peter told Frontline.

'Finding that the standard approach for these children was for their practitioners to all work separately from each other, we did what we could as key workers to get people together in small individualised teams around each child, to share information with each other and with parents, and to generate shared plans of action.

'Mostly [services] were fragmented, but I did see good examples of physios and occupational therapists working together. Less often I saw physios and speech and language therapies working together, and even less often I saw therapists and pre-school teachers working together across the agencies. But even if there was some joined-up working, it was never officially recognised or resourced.'

'Team around the child' gradually evolved as the best way to create a joined-up approach within existing resources. Peter now works as an independent consultant to services in their development of multi-agency integrated support for children and families who require multiple interventions. He chairs the Handsel Trust, which is also about promoting effective support for children with disabilities.


There will be a team around the child conference on 14 November, 2006 in London.



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