Integration and relational practice

Integration can be a tricky concept to pin down and is used by different people to mean different things. Through integration, we seek to improve the connections between professionals, providers and services to improve outcomes for children and their families. We can think of these connections as on a continuum toward integration. The continuum starts with agencies operating in isolation, moving to increasing levels of communication, coordination and collaboration, and finally achieving integration.   

We might also think about integration as multi-professional care pathways intended to enable effective, focused services where additional needs are identified and supported through the latest evidence in practice. 

Integration may take place between professionals, providers and services operating at the same level, often referred to as horizontal integration (the engagement of several services related to different areas e.g., health, youth and early years). Integration may also take place between professionals, providers and services working at different levels, known as vertical integration (for example, ranging from early intervention to the involvement of children’s social care, or acute and primary care in a health setting). 

Each local authority area will have examples of integrated multi-professional services that have been designed and sustained. Those developing family hubs can learn from what has worked well, and what has been learnt in partnership, in the design of these existing services. Integration is also a key part of children’s strategic partnerships and integrated care system (ICS) transformation.  

Children’s strategic partnerships are multi-agency partnerships that provide strategic leadership to improve outcomes for children and young people within a local authority. The partnerships oversee the development and implementation of local children and young people’s plans, which set out the collaborative work programme across all partners responsible for providing services to children, young people and families. The partnerships routinely have direct strategic reporting to health and wellbeing boards. In some local areas, they hold delegated responsibility for progressing the 0-25 strategic transformation agenda. 

ICSs are geographical partnerships that bring together providers and commissioners of NHS services with local authorities and other local partners to plan health and care services in 42 areas across the country. They have a larger footprint and include more than one local authority area. ICSs offer an important opportunity to improve population health through genuine partnership working between the NHS, local government, the voluntary and community sector (VCS) and local communities. 

As with the ICSs, developing family hubs involves significant transformation and systems change, requiring collaboration and commitment from across the children’s early help system and the local community. Effective, integrated early help governance is therefore an important starting point. It begins the process of partners collaborating in building a vision and committing to a shared approach and outcomes, which can be recorded in a co-produced early help strategy. As mentioned above, many partners will have had experience of similar arrangements through safeguarding, Sure Start local programmes etc.

An overarching Early Help Partnership Board can provide a framework for family hub governance and will ensure that learning from all the government’s early intervention initiatives is pulled together into this integrated delivery approach.  

Governance structures must enable different agencies to take collective responsibility, share risks and jointly invest in family hubs as well as representing the views of parents, carers and young people. 

Relational practice is an approach to working both with individual and across systems that is built on trust. Successful implementation of a family hubs approach requires the behaviours and relationships that support collaboration to be developed, nurtured and modelled right across the family services system. A relational frame can support you to think about the people who make up a system and how those people relate to one another. 

Adaptive Mentalization Based Integrative Treatment (AMBIT) is a relational framework developed by the Anna Freud Centre. It provides tools for using mentalization within teams, wider inter-agency networks, and with individuals. Mentalizing is the human capacity for making sense of oneself and others by imagining what might be going on for someone underneath the behaviours we see on the surface. It is being able to understand our own mental state and that of other people, and how this understanding affects our behaviour. It is sometimes described as ‘understanding misunderstanding’.  

Trust is a core component of the AMBIT framework and will facilitate effective integration. It recognises that cultivating trust and reflection within the workforce will enable individuals to work more effectively within complex and sometime stressful systems through a ‘team around the worker’ model. This model gives the family a manageable network of relationships which are most likely to bring about change, and enables those professionals seeking to help the family to work most effectively to achieve that aim.  The model was orginally designed to be used in higher-tier services, but can be applied at a universal and early help level. 

This approach can be used in conjunction with your chosen relational practice approach for example: restorative practice or systemic practice, You can even apply a relational approach to commissioning. 

An important lesson from over 30 years of policy initiatives is that achieving integration is hard to do. Integration takes time and it is important to acknowledge that it is not possible to integrate all services for everyone. Integration should be seen as a journey along a continuum. For some elements of your family hub approach, simply improving coordination between professionals in different agencies may bring significant benefits for families. 

Differences in language, assumptions, and expectations of what good looks like means that working together in a fully integrated way can be challenging. Gaps in understanding about how the ‘other side’ works and the policy drivers that underpin the practice and priorities of different agencies can add to this challenge.  

Current provision relating to family hubs which includes our health and care system, is complex and can mean families receive fragmented care from services that are not effectively co-ordinated around their needs. This can negatively impact their experiences, lead to poorer outcomes, and create duplication and inefficiency. The fragmented nature of provision leaves families vulnerable to ‘falling through the gaps’, particularly when accessing support during transitional periods (e.g., moving from perinatal support services to early years support). 

The involvement of multiple services and practitioners can be particularly overwhelming for children and families who have previous experiences of trauma, abuse or marginalisation. Artificial service boundaries and thresholds of individual services mean the cumulative burden of multiple needs is not recognised and go unmet. 

EIF has highlighted a lack of evidence on the effectiveness of multi-agency service integration in improving outcomes for children at risk of poor / poorer outcomes and the need for robust evaluation. However, there is a strong practice consensus that greater service integration can benefit families through reduced duplication and greater efficiency. Research suggests that integrated family support services can improve the experience of families when they only need to tell their story once. This is because integration helps services and professionals work together to make the right decisions and give families the right help. Better connected professionals reduce the burden on families of managing multiple relationships and appointments and means they should not have to continually retell their story.  

The recent Public Services Committee report – Children in crisis: the role of public services in overcoming child vulnerability highlights the significant increase in the number vulnerable children “invisible” to social services, the NHS and the education system during the coronavirus pandemic, and the important role that family hubs can play in supporting this cohort of children by improving service integration at the local level. Learning from case reviews highlights the most serious consequences of poorly integrated services and poor coordination between services, including insufficient joined-up leadership and inadequate information sharing practices. 

The needs and experiences of babies, children, young people and families must be at the at the heart of any family hub. It is imperative to consider what integration means from the perspective of families, recognising that families will not take a linear journey through the system, often accessing multiple forms of support at the same time. An approach based on needs rather than service boundaries and threshold, can help families navigate the support system.  

The THRIVE Framework for system change is an integrated, person-centred and needs-led approach to delivering services for children, young people and their families. It has been developed by a collaboration of authors from the Tavistock and Portman NHS Foundation Trust and the Anna Freud Centre, and is now being embedded to facilitate service transformation across the UK. Though initially designed as an approach to delivering mental health services specifically, it is a helpful framework for thinking about the whole family help system.

Co-production describes a way of working together in which both support providers and service users are recognised as stakeholders and are part of the same decision-making process.  

Within the context of integrated services, listening to families and communities is key to improving services and understanding how efforts to join up services are progressing to meet people’s needs. The King’s Fund has developed a useful guide, Understanding integration: how to listen to and learn from people and communities. It includes practical steps to help partners and carers come together and work with communities to identify what people need, what is working and what could be improved in the provision of joined-up support. 

Many of the best examples of successful integration have begun with partners developing a shared vision about the outcomes that they want to achieve for local people. 

Clearly defined and shared aims, objectives and outcomes that prioritise the needs of the children and families are central to effective local partnerships. A key message from EIF’s research with children’s centres and family hubs is the importance of being clear about what a local area is seeking to achieve, and then designing services in a way that is likely to meet this purpose. Questions around who family hubs are for, and what they will do, form the basis of a theory of change. The second stage of our family hubs development process sets out how to go about developing a theory of change to specify your local family hub approach.  

The importance of clarity on strategy, funding and commissioning in local areas developing family hubs, as well as formal and consistent arrangements to support joined-up working, were highlighted in the review carried out by EIF.  

You will need an effective multi-agency board in place to own your family hub strategy and lead delivery across local agencies. The board should also have strategic oversight or be closely linked to other core functions of integrated early help, for example Supporting Families. Governance structures must enable different agencies to take collective responsibility, share risks and jointly invest in the local network of family hubs. 

Strong, shared, collaborative and outcomes-focussed leadership is key to integration: 

1. Leadership should enable staff to transcend traditional professional boundaries and individual organisational interests, and work together systemically towards a shared ambition. 
2. Senior leaders, including local politicians, should speak with ‘one voice’ on the importance of joined-up family hub services, and should champion the delivery of the local strategy and vision for the network of family hubs. 
3. Service managers working in or through family hubs should understand the governance structure and how it relates to them. The whole family hubs workforce should understand one another’s roles as part of the local system, rather than being concerned about who works for which organisation.  

The Social Care Institute for Excellence (SCIE) has developed a checklist of factors that facilitate effective system leadership, including how to develop a shared purpose and resolve difficult conflicts.  

In the review carried out by EIF, joint commissioning of services was seen by those developing family hubs as key to enabling multi-agency working. This is consistent with messages from practice from a range of studies of multi-agency systems which suggest that joint funding and commissioning arrangements are associated with better joined-up support systems of support / help for families.  

With a complex array of providers involved in each local family hub network, joint commissioning bridges the gaps between organisations and makes clearer how families should journey through the network of services. 

Through joint commissioning, local partners can execute their vision and strategy for integration within their family hubs approach.

Joint commissioning means organisations collaborating and sharing responsibility for family hub services and their outcomes. To facilitate effective joint commissioning, there should be a joint commissioning plan between the local authority and partners such as health commissioners for the services accessed through the family hub network. This should be extensive, routine, formally agreed, and cover the majority of family hub services.  

You will need to decide if you are going to align services and budgets or if you want to pool budgets. Pooled budgets combine funds from different organisations to enable them to fund truly integrated services. A well-developed family hubs approach will involve the pooling of budgets from a range of funding sources such as the local authority, health commissioners and potentially other public sector partners.  

Pooling resources requires investment decisions from a range of different stakeholders. In the context of financial pressures, each participating organisation will need to consider costs and benefits, as well as risks and rewards, and how these will be shared. 

SCIE has developed a checklist for pooling budgets: 

1. Consider and agree the aims and objectives of the pooled budget, using documents such as the local joint strategic needs assessment. 
2. Establish which partner organisations should be involved and clarify the role of each one. 
3. Clarify the services in scope and develop business cases with clear outlines of cost and benefit over time. 
4. Based on the business cases, identify how the initiatives are to be funded and how the pooled budget will be managed. 
5. Develop a detailed and shared understanding of the associated risks, both for individual partners and the programme as a whole. 
6. Develop a joint funding agreement with documentation that outlines: 

1. aims and outcomes, and the relevant functions covered 
2. expected benefits and how they will be measured, realised and shared 
3. key risks and how they will be managed, shared and where possible mitigated on an ongoing basis 
4. respective financial contributions and other non-financial resources provided in support of the joint initiative 
5. how the pooled budget will be managed, with associated governance and reporting arrangements 
6. the duration of the arrangement, including the provision and mechanisms for annual review, renewal or termination. 
7. technical matters, such as treatment of VAT, legal issues, complaints, dispute resolution and risk-sharing. 

Evidence and evaluation play a key part in family hub development, informing the approach a locality chooses to adopt and ongoing learning about how we can improve services for the benefit of children and families. 

Different agencies delivering services through the family hub should have a clear view of which parts of the family hub network are working well. They should use this insight to inform strategy and service development and take action to address underperformance. 

For further guidance on using evidence and evaluation to inform family hub development and delivery, please see the evidence and evaluation module. 

Co-location is not essential to integration and may be more suited to some physical locations than others. It can enable practitioners to build closer working relationships, develop a shared workplace culture and help practitioners to share concerns, issues and information. It is important to note, however, that it is the quality of joint working that is most important to effective integration. Two key factors for joint working reported by those developing family hubs are: practitioners working together across organisational boundaries to deliver interventions; and sharing of data about the families that different agencies are working with.  

Co-location can support families’ experiences of services when care and thought has gone into the potential journey a family might take. When relevant services are close to one another it can reduce the burden on families to travel. Familiarity with hub spaces enables more trusted relationships to develop and front-door staff can better maintain consistent relationships, even when families are interacting with multiple specialists. 

Ideally there should be an extensive range of statutory and non-statutory services co-located within family hub buildings, including the majority of 0-5 services. These services span education, health, social care, Supporting Families and other areas. To meet the basic definition of a family hub, areas should have a co-location review or strategy underway. This strategy or review should involve education, health and social care partners, and should aim to determine the extent of co-location within family hubs and necessary plans for change. 

Effective partnership working and co-location with VCS organisations is also key to an integrated family hubs approach. This is particularly true of local grassroots groups, which can enable those who are often underserved by family help systems to become more involved in family hub design and governance. Doing so will be essential if we are to utilise the potential for family hubs to start to redress the inequalities exposed and exacerbated by the coronavirus pandemic. 

In the review carried out by EIF, clear protocols for data sharing were seen by those developing family hubs as fundamental to good interagency working relationships and trust. This is consistent with other studies on multi-agency systems. These studies suggest that effective information sharing, enabled by appropriate hardware and software and taking account of data protection and differing professional practice and habits, support good local partnerships. 

To facilitate integrated working, data from family hub partners should be provided to whole family workers to inform casework, and partners should have access to authority held case recording. Ideally, reportable and quantified outcomes should be available in case management systems, and partnership outcomes data should be used to inform workforce development and strategic and commissioning decisions.   

In the review carried out by EIF, those working within family hubs cited the development of support pathways for families as an important way of creating integration. Some areas had developed child journey maps to improve access and reduce the number of ‘hand-offs’ between services, alongside holistic assessments and simplified referral processes.  

Comprehensive, integrated referral pathways should be used for the full range of family hub services and should include third sector, community and faith sector partners and education settings. Pathways should be shaped to take account of impact, user feedback and new evidence on what works, and services should flex to respond to demand using live data. Using integrated monitoring systems across family hub services will enable you to target interventions to families with different needs. 

An agreed common assessment approach needs to be in place across your local network of family hubs. This sounds include a clear, consistent and aligned process for identifying need and risk and providing appropriate support at an early stage, to support practitioners to work together to meet the needs of families. Practitioners across all agencies in the family hub network should use the agreed approach to ensure effective targeting. You should also actively monitor impact at the individual case level using valid and reliable measurement tools, including tracking over time of any paths between family hubs and other universal or specialist services. 

A common case management system or interoperability between case management systems should be used across your local network of family hubs. This should include the case management elements set out in the Early help system guide: 

1. Do you have a case management system which allows for accurate whole family case recording? 
2. Have you embedded all individual outcomes in your case management system from notification or assessment to closure? 
3. Can you report from your case management system (and design these reports yourself)? 
4. Can you use reports from your case management system to monitor soft outcomes? 
5. Do all whole family workers record on the same case management system, or interoperable case management systems, that ensure workers can view records from partners?