Summary
The goal of social inclusion underpins Valuing
People, but it’s also a strong theme in government policy for
people with mental health problems and other disadvantaged groups.
Social inclusion requires, amongst other things, that specialist
services change the way they offer their expertise: adding to, rather
than replacing, the services that are used by ordinary citizens.
Recent work by the NDT for a specialist health provider made us
look more closely at the relationship between specialist and mainstream
services, and the qualities that are likely to make the relationship
successful. This resulted in a way of thinking about the relationship
that we’ve called ‘triangles of support’. It’s
a very general model, and it’s interesting to use it to think
about a wide range of working relationships, within and beyond health
and social care. But we think it also leads to some useful, and
very practical ideas, about how to improve services for people who
have learning disabilities or mental health problems.
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In the first half of the last century it was generally assumed
that people with learning disabilities or mental health problems
could not, or should not, use the same public services as everyone
else. The result was a system of ‘special’ public services
that ran in parallel to the services used by other citizens. Children
with special needs went to special schools. When they grew up
they went to sheltered workshops or day centres. If they needed
accommodation, they didn’t get offered housing from housing
agencies. Instead they went to live in institutions run by health
services, or residential homes provided by social services. And,
for a wide range of health needs, people were quickly routed away
from ordinary community services and general hospitals.
In spite of some real progress over the last thirty years, that
parallel system still lingers in the pattern of services we have
now. But the government-backed principle of social inclusion places
an obligation on services – and that’s on both the specialist
and mainstream sides – to get rid of it. Ordinary services
must learn to include people who have ‘special needs’
alongside other citizens. The required role of specialist services
is to help the ordinary services to learn the skills they need
and, when necessary, to provide their expertise within the mainstream
services: not substituting different services, but augmenting
those which exist already. For example:
| Need or problem |
The old way - substituting |
The new way - augmenting |
| Special educational needs |
The child goes to a separate special
school |
The child receives extra help in
the ordinary school class |
| Day activities |
The person goes to a day centre |
The person is supported in ordinary
employment or community facilities |
| Challenging behaviour |
The person is admitted to a specialised
challenging behaviour service |
Challenging behaviour specialist
support social care staff and other citizens to work with
the person |
| Sensory impairment |
The person is referred to a clinic
for people who have learning disabilities and sensory impairment
|
The clinic that provides a service
to ordinary citizens who have sensory impairments acquires
the skills to work with people who also have learning disabilities.
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These examples make it clear that we’re not concerned just
with the single issue of specialist services working with, and
within, mainstream services. The example of the challenging behaviour
service shows that it may be a relationship between a specialist
service and an even-more-specialist service. What we’re looking
at is a general kind of relationship in which one worker or service
gets support from another worker or service. Typically the extra
help comes from a source which offers a higher level of expertise.
So what’s the nature of that relationship? And how can it
be made to work so that it produces mainstream (or less specialised)
services that have the competence and capacity to include all
citizens? To answer that question, we went back to the beginning,
and looked at what’s meant by ‘support’.
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The nature of support
Reduced to its most basic, people need support because they lack
the ability, knowledge, or skills that are required in a particular
situation. They might lack the physical ability to reach for the
drink on the table next to them, or the awareness of traffic to
be safe on the streets. They might not be able to cook a meal
for themselves. Or, to take a different kind of example, they
might not have the expertise to diagnose and treat their own illness.
The gap is filled by introducing someone into the situation who
possesses the missing knowledge or skills. This person doesn’t
necessarily have all the competencies required in the situation.
The visiting support worker may know how to cook, but not where
the local supermarket is. The doctor knows about illnesses, but
needs the patient to explain the symptoms. However, as a combination
they have all the competencies required to deal successfully in
the situation. The diagram below shows this idea visually. (Incidentally,
let’s be clear that we’re concerned here with incomplete
competencies, not incomplete people. We all encounter situations
where we don’t have all the competencies that we need to
cope alone.)
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Support versus Care
So the supporter, B, brings their competencies to assist the supported
person, A. However, the terms on which they offer the competencies
– the relationship between A and B – can vary. A few
years ago there was sudden shift in the terminology used to describe
staff who assist people with learning disabilities. They stopped
being called care workers, and became support workers. The reason
– though it’s now all but forgotten - is that care and
support were considered to suggest very different attitudes. Support
is enabling, whereas care is paternalistic. These contrasting
attitudes translate, of course, into the aims and behaviours of
the supporter within the relationship. The table below suggests
some of the main distinctions.
| The relationship between supporter
and individual: |
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‘Care’
|
‘Support’
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| Presumes that the person cannot acquire competencies |
Believes in the person’s capacity to acquire
competencies |
| Aims to substitute competencies. |
Aims to augment competencies |
| Where help is given, control is taken away;
disempowering. |
Control left with person wherever possible;
strives for empowerment |
| Judges the person’s competence level,
then delivers fixed level of substitute skills. |
Monitors the person’s performance, and
adjusts input up and down as required |
| Competency development not part of role. |
Assists development of competencies through
modelling and task-sharing. |
| Problems resulting from gaps in competence
likely to be viewed as the person’s failure, and used
to justify indefinite extension of substitute competencies. |
Gaps in competence are noticed before problems
occur. Response is short-term compensating rise in input,
and increased skill-sharing effort. |
| Requires only a coarse ‘alarm bell’
feedback arrangement. |
Requires reliable and efficient feedback. |
| Direct contact can be limited to level required
for delivery of care |
Requires high levels of direct contact for
monitoring and competency development.
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One of the interesting points from this table is that a support
relationship requires a high level of contact between A and B.
Without it, the level of support can’t be adjusted quickly
in response to the person’s changing need. In most situations,
the contact will also be essential in order to increase A’s
competencies, whether through modelling, guidance, or more formal
teaching. Close contact and good feedback do not in themselves
guarantee a support relationship; but without them the relationship
is likely to be one of care.
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The triangle of support
The situation becomes much more interesting when we add in the
third person, C. The need for C arises when A and B, even in
combination, don’t have the competencies required by the
situation. C brings the missing competencies.
There are many ways in which C could provide their skills. They
might offer advice to B over the phone, or visit occasionally
to meet both A and B; or become B’s full-time colleague.
The arrangement is likely, however, to tend toward one of two
forms. In one form, C works directly with A, alongside B. In
the other, there’s a chain of support: C supports B, B
supports A. These two types are shown in the diagram below.
In the triangle arrangement, C gets information directly about A’s changing
needs, abilities, and wishes, and this makes it possible for
C to respond as required. This feedback loop is not automatically
present in the chain.
In the chain arrangement there is a support relationship between
B and C. The chain could be even longer, with a D and an E,
each delivering (for example) increasingly specialist advice.
We also think the model can be extended to cover not only relationships
between individuals, but also between services and agencies.
It’s reasonable to suppose that the B-C relationship can
also be one of care or support. In that case we can go back
to the table that contrasted the two kinds of relationship,
and see how it fits the relationship between specialist workers
or agencies, and mainstream (or less specialised) services.
It turns out, as shown in the table below, that it fits very
easily.
| The relationship between
specialist agency and generic agency |
|
‘Care’
|
‘Support’
|
| Presumes that other agencies
cannot acquire the competencies to include people with special
needs, and that the community will not learn to include
people with learning disabilities. |
Believes in the potential ability
of other agencies, and the community in general, to increase
their capacity to include people with learning disabilities. |
| Aims to sustain a discrete set
of services, on which other agencies will be dependent. |
Aims to augment the competencies
of other agencies, where necessary. |
| Hand-over of control is a condition
of access to services. |
Input delivered as and where
required, allowing others to continue their primary support
role. |
| Judges the competence level of
other agencies, then delivers fixed level of specialist
skills. |
Works cooperatively with other
agencies, adjusting input up and down as required. |
| Competency development not part
of role. |
Capacity-building work is a high
priority. |
| Problems resulting from gaps
in competence likely to be viewed as failure by generic
services (or the community in general), and used to justify
indefinite extension of specialist service input. |
Gaps in competence are noticed
before problems occur. Response is short-term compensating
rise in input, and increased skill-sharing effort. |
| Requires only a coarse ‘alarm
bell’ feedback arrangement. |
Requires reliable and efficient
feedback. |
| Direct contact can be limited
to the level required for delivery of services. |
Requires high levels of direct
contact for monitoring and competency development.
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Earlier it was suggested that a support relationship demanded
a high level of contact. This presents a challenge for chain
ABC relationships, as there may be little or no direct contact
between A and C. C is reliant on B to provide information about
A’s changing needs. Moreover, C’s involvement may
be experienced by A as very disempowering. It’s easy to
think of ‘everyday life’ examples of this: the person
on the telephone helpline who will do no more than pass on the
decision made by some unknown service manager; or being treated
in hospital but never getting a chance to speak to the consultant.
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Using the triangle of support
We’ve found the model very useful in thinking about different
working arrangements between specialist and mainstream services,
and in assessing whether a specialist service is working in a
way that will increase social inclusion.
Specialist agencies that are operating in the paradigm of care
will not help mainstream services to learn how to include people
with learning disabilities or mental health needs. Their belief
in the inability of mainstream services is likely to be a self-fulfilling
prophecy. There’s a paragraph (6.3) in Valuing People that
describes this happening:
Because mainstream health services
have been slow in developing the capacity and skills to meet
the needs of people with learning disabilities, some NHS specialist
learning disability services have sought to provide all encompassing
services on their own. As a result the wider NHS has failed
to consider the needs of people with learning disabilities.
This is the most important issue which the NHS needs to address
for people with learning disabilities.
Changing the culture of specialist services, to match the characteristics
of support relationships, is a vital first step to developing
an organisation that will progress social inclusion. The care/support
table could also be translated into a set of indicators to measure
how well the change is progressing. But there are also other practical
implications of the triangle of support:
• Is the specialist agency
extending its work in mainstream services (such as primary health
care) and more generic services (such as social care settings)
using working arrangements that enable skill-sharing between specialists
and non-specialists?
• Do the working relationships
between the specialist and mainstream providers have the flexibility
for support to be added or reduced in response to the changing
needs of the mainstream provider?
• Is the specialist support
to mainstream providers offered on terms (whether stated in contracts,
or otherwise implied) that do not undermine the lead role of the
mainstream agency? (Or is the message, in effect, “If
you want us to help, you’ll have to let us take charge”?)
• How effective is the feedback
loop between specialist and mainstream providers, to enable the
specialists to know how and when to change their input?
• Is there a strong feedback
loop between the specialist provider and the people who are the
ultimate, though indirect, recipients of their services? Feedback
may need to include direct contact between specialists and service
recipients, and also arrangements that support genuine participation
and consultation.
• Is the relationship between
the specialist agency, and organisations that have strategic responsibility
for service development (commissioners, for example), characterised
by the qualities of the support relationship?
Perhaps the key lies in the somewhat old-fashioned notion of humility.
The participants - mainstream services, specialists, the people
who require support, and the wider community - all have gifts
to bring to the task of achieving an inclusive society. They all,
equally, have their limitations. Accepting that truth will surely
make the best starting point for partnerships that have the hallmarks
of a true support relationship.
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