Leading for outcomes: integrated working, Part three

Practising and sustaining the outcomes-focused approach in integrated working
By Iriss
Published in Tools on 13 May 2013
  • Identifying different types of outcomes
  • Achieving an outcomes-focused approach
  • Addressing the challenges of introducing an outcomes approach
  • Involving service users and carers in identifying outcomes
  • Sustaining an outcomes approach
  • Providing leadership for an outcomes-focused approach

The challenges of working in an outcomes-focused way in integrated working

Many people who receive support will be used to a service-led approach, with the professional in the role of expert who assesses need and then decides what services or interventions the person requires. An outcomes-focused approach requires a more conversational interaction between the practitioner and the person receiving support (and their carers) in order to understand what goals and outcomes are important to them. This requires skilled and knowledgeable staff who can engage constructively with others. Good communication is at the heart of an outcomes approach. Many practitioners will welcome the approach as they see that it builds on skills fundamental to professional practice across health, social work and housing professions. The approach is also in tune with recent developments in areas such as self-management in health, and personalised care through self-directed support in social care, with co-production as a basic underpinning principle core to the identification and provision of support. It needs to be acknowledged, however, that as with any change, some staff may initially see the approach as a threat to their professionalism, or perceive that it requires skills from them that they feel unsure about.

There is a particular opportunity when working in an integrated way to ensure that the range of health, housing and social care outcomes is addressed. This is the focus of the following exercise.

Exercise five: Identifying different types of outcomes

Learning outcomes

  • Identifying the importance of different types outcomes
  • Understanding how different types of outcomes can be supported by the team and by others


  • No more than 45 minutes


  • Scenarios, flip chart


  • Divide your team into small groups and ask them to choose one of the scenarios relevant to their practice (Iqbal, David, Isobel, Duncan or Rosie). Focusing on the Quality of Life outcome ‘feeling safe’, the process outcome of ‘being treated with respect’, and the Change outcome of reduced symptoms’, discuss what this could mean for the individual.
  • Discuss what contribution the team and others could make to helping the service user achieve this outcome. Make note of the ideas that are presented.
  • Lead your team through a discussion that touches on the following key ideas: a) communication is key to identifying outcomes, b) once outcomes are identified the outcomes-focussed approach requires that we think creatively of ways in which these might be met, c) outcomes can be reached through a variety of different approaches, some of which may involve services, others which may not.

Scenario one: Iqbal

Iqbal (78 years old) has her own tenancy within a very sheltered housing complex, with warden support during the day and a community alarm for summoning assistance out of hours. She was recently discharged from hospital after falling and fracturing her wrist. After an outcomes-focused conversation with the social worker from the Home from Hospital Team, it was discovered that Iqbal used to manage her own catering business before she retired. As she became more comfortable with the social worker she confided that she rarely left the housing complex after experiencing racial abuse from a neighbour’s children.

Scenario two: David

David is 89 years old and has moderate dementia which has resulted in him sometimes forgetting to switch off the cooker and other appliances. In other aspects of his life he manages without much difficulty. Until recently he was supported at home by his wife but she died suddenly after a brief illness. His daughter, who lives some distance away, is anxious about the risks her father faced and contacted the social work department to ask that he be admitted to a residential care home. The duty social worker contacted the Crisis Care at Home Team and after an outcomes-focused discussion with David found that he was determined to stay at home, and that he had supportive neighbours and visitors from the local church.

Scenario three: Isobel

Isobel is 30 and spent much of her childhood in foster care. She has been treated for depression in the past, is maintained on methadone as a result of her heroin addiction, and has had a number of short-term prison sentences as a result of offences of shoplifting and assault. For the last three months since her last discharge from prison she has been staying for short periods with a number of friends and acquaintances.

Scenario four: Duncan

Duncan is 42 and has a diagnosis of schizophrenia. He lives in his own tenancy with floating support from a mental health project worker and is scheduled to have monthly contact with his CPN. He has missed his last two appointments and is reported as having low mood. His sister has contacted the community mental health team to express her concern that he is looking unkempt and his behaviour is increasingly bizarre.

Scenario five: Rosie

Rosie is a 24 year-old single mother of two children (six year-old male, four-year old female). She has been a housing association tenant in a four apartment house for two and a half years. Her son attends the local primary school. Her daughter attends the nearby nursery school and receives ongoing treatment from the GP for a chronic asthmatic condition.

Rosie has had a previous history of drugs misuse, but is now drug-free following a period of time spent in a drugs rehabilitation unit after which she was granted custody of her children following an 18 month-long separation. She now has £1200 rent arrears following an overpayment of housing benefit as a result of undeclared family credit and the wages received from a part-time job.

The local housing association has advised that it intends to take legal action to pursue eviction for rent arrears and has referred the case to Homelessness Services, following a series of unsuccessful meetings with Rosie in an attempt to resolve the situation. At the initial meeting with Homelessness Services, Rosie reveals a list of outstanding credit owed by her to various creditors (catalogue, storecard and hire purchase agreement from a furniture retailer) which leaves her with little or no excess disposable income after buying weekly essentials.

Exercise six: Skills in working with people in an outcomes-focused way

Learning outcomes

  • Recognising the skills required to be effective in outcomes-focused practice
  • Identifying ways in which individuals can improve on existing skills


  • No more than 40 minutes


  • Scenarios, flip chart


  • Provide your group with relevant scenarios from the five available (Iqbal, David, Isobel, Duncan or Rosie, see exercise five).
  • Ask the group to work in pairs to identify and write down what skills they already have in working with similar individuals.
  • Ask individuals to note down any areas where they may need to develop their own skills or ask others to effectively identify the outcomes that are important to those being supported through integrated working. Pay particular attention to areas where individuals feel they would need input from another profession.
  • Collect feedback from the group.
  • Lead a discussion with the group around these skills and explore ideas about what measures could be taken to improve communication skills for better outcomes-focused practice.

One of the papers written by Emma Miller as part of her work with the Joint Improvement Team highlights the types of questions that are useful in opening up an outcomes-focused conversation (Miller, 2011). These can include:

  • What is important to you in life?
  • What would you like to achieve?
  • What are the things you are good at?
  • What sort of things have helped you in the past?

Particular strategies can include asking about a ‘good day’, an ‘ideal future’, or a ‘miracle solution’. The use of an outcomes approach accords with the adoption of an assets or strengths based approach rather than a discussion focusing on needs and deficits. See also Exercise Four in the parent guide.

Exercise seven: Achieving outcomes in integrated working

Learning outcomes

  • Identifying challenges in outcomes-focused practice
  • Thinking creatively to overcome challenges to outcomes-focused practice


  • No more than 75 minutes


  • Scenarios (Moira, Tariq, Gary); flip chart


  • In small groups, allocate one of the scenarios (Moira, Tariq, Gary).
  • Ask each group to list the outcomes that seem important to their scenario. Encourage individuals to think about all categories of outcome.
  • Ask each group to consider the challenges there may be to meeting these outcomes.
  • Ask each group to choose one or more of the challenges to achieving the desired outcomes and devise a strategy for overcoming them.
  • Ask each group in turn to present their scenarios and possible solutions to the wider group. The presentation should include:
    • Reasons why the particular solutions are favoured.
    • Resources that would be required. Encourage thinking beyond traditional services, to include the third sector and informal carers/networks.
    • Challenges that might be encountered in implementing the proposed solution.
    • How those challenges could be overcome.

Scenario one: Moira

Moira is 42 years old with a degenerative neurological disorder. Her mobility is poor and she experiences frequent falls. She has been referred to the Rapid Response Team due to deterioration in her condition which may result in a hospital admission if she does not receive intensive support at home. She lives alone and has personal care needs (support with toileting and washing) which necessitate a paid carer visiting four times a day. She also receives meals on wheels. Mentally she is very alert but often experiences low mood and lack of motivation. She expresses some loneliness and isolation and has been attending a day centre (the majority of those attending have learning disabilities) twice a week. She is conscious that this is not the type of social activity she would have chosen for herself. She would also like more choice in her daily life, such as what times she gets up and goes to bed, and what to eat.

Scenario two: Tariq

Tariq is 70 years old and moved to Scotland from his home in Pakistan 40 years ago. He had an emergency admission to hospital as a result of a fall, but is now fit for discharge. He has diabetes which has resulted in visual impairment and skin infections. He lives with his wife who is being treated for anxiety and depression. Unlike her husband, she does not speak English and relies on him and her children to support her in any activities that require her to communicate with non-Punjabi speakers. She receives support from a CPN. The couple have two sons and five grandchildren who live in the same town. Tariq refuses to attend a day centre or to have paid carers in his home. His family and religion are important to him and he wishes to continue to visit his sons and grandchildren weekly, and attend the local Mosque. The couple have financial difficulties and are finding it difficult to pay essential bills, such as for rent and heating.

Scenario three: Gary

Gary is a 16 year old male, who was recently discharged from a residential care setting. He has a history of care placements, going back to the age of 10. The residential care setting was deemed no longer appropriate as Gary had been displaying extreme behavioural problems which were impacting on the health and safety of other children within the home. Gary is an open-case to the Children and Families Throughcare Team, has an allocated social worker and receives several hours of support per week from both a social worker and a commissioned support provider.

Gary was initially accommodated in a temporary furnished flat in the community. However over the course of two weeks, with no experience of independent living, he was unable to control his front door. This led to a succession of acquaintances coming to his flat and the ensuing anti-social behaviour and allegation of drug-taking sparked confrontation with neighbours and police involvement. The council’s Anti-Social Behaviour Team insisted that Gary be moved from the flat in the interests of community safety. The flat was extensively damaged with repairs assessed at £1500.

Gary was moved to a homeless hostel but within two weeks had again displayed a pattern of unmanageable behaviour which included excessive alcohol use and aggressive/abusive behaviour towards staff and other residents. He has now been removed from the hostel and there is no alternative accommodation available.

Gary’s parents are separated and have their own tenancies, but neither is willing to accommodate Gary overnight for a variety of reasons, including previous issues surrounding an alleged theft from his mother’s purse, and an entrenched position on his uncontrollable behaviour, especially around younger siblings.

Exercise eight: Overcoming challenges to working with personal outcomes in integrated working

Learning outcomes

  • Sharing experience of different strategies to overcome challenges
  • Thinking more creatively about different ways to support people to achieve the outcomes they are looking for


  • No more than 45 minutes


  • Paper and pen


  • Each individual to identify one of the challenges to working in an outcomes focused way – these may have emerged earlier eg
  • Each individual to write a story of how this challenge has been successfully overcome and personal outcomes for an individual achieved. Ideally this should be based on live experience but if the individual has a post without such experience it can be imagined. Encourage everyone to be creative: ‘once upon a time…’ Each story should include a pen portrait of the individual, the outcomes they had identified and how the particular outcome was met. Give people about 15 minutes to write their individual story.
  • Ask people to read out their stories in turn – depending on numbers there may only be time for a selection of stories.
Sustaining outcomes in integrated working

Interventions in integrated working may be short-term (typically two to six weeks for example in the case of intermediate care or reablement) or may be long-term (for example where there are major mental health issues). Even if the person has regained sufficient skills and confidence not to require ongoing services from health, housing and social care, it is important to discuss longer-term outcomes with the person and their carers prior to the end of involvement and to help them agree a plan for addressing these. It may be that some of the longer term outcomes identified by people (eg keeping alert and active and sustaining social contacts) do not on the face of it appear to be related to the core support provided by health and social services, but providing information about local community organisations may enable people to achieve and maintain these predominantly quality of life outcomes.

The challenge of sustaining outcomes encompasses two other challenges:

  1. the limited time frame in which support workers may operate.
  2. the challenge of ensuring that appropriate transition is accomplished in terms of support.

There can be an initial focus on change outcomes as the person is supported following a period of illness or injury; however teams must stay mindful of how outcomes can be sustained. It is vital that the integrated care team along with the person receiving support and any unpaid carers look at how these gains in terms of change outcomes can be maintained. As well as ensuring that the person receiving care is supported to manage their own condition, this may include onwards referral to wider community based sources of support.

For example in terms of quality of life, people managed at home by intermediate care services are reported to feel safe and have improved confidence. However some people felt vulnerable at night (Petch, 2003; Regen et al, 2008). It is important that reablement or intermediate care teams consider quality of life for people following the withdrawal of the service. It is important that people continue to feel safe, stay well, have things to do, and maintain contact with other people. Intermediate care and reablement teams need to facilitate any transition to mainstream services, to the voluntary sector, or to informal supports and networks of family and friends. To sustain these outcomes clear communication with the individual, their carers and any ongoing services is essential.

In looking to sustain outcomes in the longer term, consideration of the three case studies at Appendix One (Margaret, Bob and James) will focus on a number of key issues:

  • Breadth of outcomes important to individuals (quality of life, change, and process outcomes).
  • Timescales: outcomes are important throughout an individual’s life and do not stop being important when a particular service ends.
  • Transitions are important. Individuals should be put in touch with organisations or groups that will sustain outcomes once support from integrated services ends.
Exercise nine: Sustaining outcomes in integrated working

Learning outcomes

  • Identifying longer term outcomes
  • Understanding how longer-term outcomes can be achieved and sustained
  • Developing strategies to sustain outcomes


  • No more than 45 minutes


  • Part one of the case studies from Appendix One; flip chart


  • According to the size of the group, use one or more of the case studies. Read part one of the case study in appendix one.
  • For each case study being used, ask one of the group to take on the persona of the individual in the case study (Margaret, Bob or James) and to have access to part two of the case study. The rest of the group to ask them questions and consider what kinds of outcomes are likely to be important to that individual and informal/family carers in the longer term after the integrated working involvement ends. If appropriate to the group this can be run as a role play.
  • Discuss with the individual what supports and services may be helpful in achieving or sustaining these outcomes.
  • Devise a strategy to ensure that outcomes are sustained, identifying the outcomes of particular importance.
  • Following the discussion compare with the Part two examples.

Leaders and managers are seen as being key actors in bringing about effective integrated teams, and they can help bring about increased job satisfaction, development of a shared culture, improved communication – allowing teams to meet individuals’ outcomes more readily (Maslin-Prothero and Bennion, 2010). It is recognised that managing integrated care services is challenging, and that leaders require skills around change processes, including promoting organisational learning, that encourage staff engagement and empowerment (Alban-Metcalfe and Alban-Metcalfe, 2010). As a leader or manager you may find useful the paper by Johnstone and Miller (2010) on how to provide staff support and supervision for outcomes-focused working.

There is also, however, the opportunity for work around developing an outcomes focus to provide a common sense of purpose that binds a new team or partnership together. It offers the opportunity to clarify the respective roles of different individuals in contributing to the achievement of this common purpose and, with good leadership, should provide a route to transcending traditional tribal divisions between professions or agencies.

Exercise ten: Leading an outcomes-focused approach in integrated working

Learning outcome

  • Strategies for leading an outcomes-focused approach in integrated working


  • No more than 45 minutes


  • Post-its; flip chart


  • Divide the group into pairs; one of the pair to act as ‘leader’ the other as ‘worker’.
  • The worker of the pair to raise examples of actual and potential challenges in operating in an outcomes-focused way in an integrated working context.
  • The leader of the pair to suggest potential strategies for overcoming these challenges.
  • The group to pool their challenges and solutions and work towards a set of suggested strategies.

This guide has had a long gestation period, a period during which formal proposals for integrated working in Scotland have developed momentum. We would like to thank Fraser Mitchell from Fife Council to whom we are indebted for some of the early writing and case studies; Ann Wardlaw and members of the homelessness team in Inverclyde for early piloting of the exercises; and Donellen Mackenzie, Nigel Small, senior managers in NHS Highland and health and social care staff in the emerging older people’s teams in Skye, Lochalsh and Wester Ross,

Caithness and Sutherland, East Ross, and Nairn for more recent trials of the exercises.


  • Alban-Metcalfe J and Alban-Metcalfe B (2010) Integrative leadership, partnership working and wicked problems: a conceptual analysis, International Journal of Leadership in Public Services, 6 (3), 3-13
  • Bennett T, Cattermole M and Sanderson H (2009) Outcome-focused reviews: a practical guide, Department of Health: Putting People First
  • Cook A and Miller E (2012) Talking Points Personal Outcomes Approach: Practical guide, Joint Improvement Team
  • Devlin N and Appleby J (2010) Getting the Most out of PROMS, King’s Fund and Office of Health Economics
  • Glasby J, Dickinson H and Miller R (2011) Partnership working in England – where are we now and where we’ve come from, International Journal of Integrated Care, 11, March
  • Glendinning C, Clarke S, Hare P, et al (2007) Progress and problems in developing outcomes-focused social care services for older people in England. Health and Social care in the Community 16(1), 54-63
  • Johnstone J and Miller E (2010) Staff Support and Supervision for Outcomes Based Working (PDF)
  • Jelphs K and Dickinson H (2008) Working in teams, Bristol: Policy Press
  • Leathard A (ed) (2003) Interprofessional Collaboration: From Policy to Practice in Health and Social Care, Brunner-Routledge
  • Maslin-Prothera S and Bennion A (2010) Integrated team working: a literature review, International Journal of Integrated Care 10 (29/04/10) 1-11.
  • Miller E (2011) Good conversations: Assessment and planning as the building blocks of an outcomes approach, Joint Improvement Team
  • Netten A (2011) Overview of outcome measurement for adults using social care services and support, School for Social Care Research, Methods Review 6
  • NHS Confederation (2010) Where next for health and social care integration? Discussion Paper No 8
  • Petch A (2003) Intermediate Care: What do we know about older people’s experiences? Joseph Rowntree Foundation
  • Qureshi H and Nicholas E (2004) Make outcomes your big idea: using outcomes to refocus social care practice and information, Journal of Integrated Care 12(5), 13-19
  • Regen E, Martin G, Glasby J et al (2008) Challenges, benefits and weaknesses of intermediate care: results from five UK case study sites, Health and Social Care in the Community, 16 (6), 629-637
  • Robertson H (2011) Integration of health and social care: A review of literature and models – Implications for Scotland, Royal College of Nursing Scotland
  • Stewart A, Curtice L and Petch A (2003) Moving towards integrated working in health and social care in Scotland: from maze to matrix, Journal of Interprofessional Care, 17 (4), 335-350

Related Iriss resources

Appendix one: case studies outcomes for a person receiving support and their carers

Case study one: Margaret

Part one

Margaret is a 61 year old woman who has moderate learning disabilities, especially in the area of communication. She lives alone but has a supportive family and neighbours. She employs a private cleaner

and gardener. She stopped attending a learning disability day centre some years ago but until recently has led an active life, visiting friends and relatives and taking the bus to the shopping centre. She finds satisfaction in helping older neighbours with small tasks such as visiting those who are unwell or housebound and keeping an eye on their homes when they go on holiday, but has been unable to do these tasks in the past year.

Margaret is obese, has chronic venous leg ulcers, and high blood pressure. Her mobility has deteriorated considerably in the past year due to arthritis in the hip which caused her constant pain and largely confined her to her home. This led to increased isolation and deterioration in her mental health, with feelings of loneliness and hopelessness. Relatives and friends became concerned by her low mood. The hip replacement operation was postponed to allow her leg ulcers to be healed and for her to lose weight. She received regular visits from the district nurse and the dietician. Over the period of a year her leg ulcers improved slightly but remained a problem and after an initial slight weight loss her weight stabilised. The hip replacement only went ahead because the Consultant became so concerned by the state of her hip.

The hip replacement was a success and she was discharged home with the support of the Early Supported Discharge Team. The keyworker from the team met with Margaret and her brother to discuss her needs and her goals. Her brother helped her to understand the role of the team and helped her express her desired goals.

The key outcomes identified with Margaret were:

  • Improving her mobility and confidence in walking
  • Getting out of the house again to visit friends/relatives and shops
  • Being free from pain
  • Maintaining weight loss
  • Having access to her upstairs bedroom

Part two

A support plan was drawn up based around these outcomes. In discussion with the team’s occupational therapist, the brother moved Margaret’s bed downstairs so that she could access the bathroom and allow her to be discharged home. Once home, rehabilitation care assistants helped Margaret follow the physiotherapist’s plan to help her regain skills and confidence in using the stairs, so that after two weeks the bed could be moved back to the bedroom.

Margaret learned how to use a stick to support her walking and within a few weeks she had the confidence to walk the short distance to catch the bus to the shopping centre. On the first few trips she was accompanied by a volunteer from a local charity to ensure her safety.

It was identified that one of the difficulties Margaret had with her diet was a lack of variety due to her reliance on convenience foods that could be heated in a pot or under a grill. She was reluctant to eat more fresh fruit and vegetables and did not wish to learn new skills in food preparation. However, she pointed out that one of her friends had a microwave and she thought she could learn to operate one. Her brother purchased a microwave and helped her understand the basic settings. Given her difficulties in carrying heavy shopping, he set up a weekly home delivery from a supermarket. This allowed her to have a wider selection of ready meals and the order always included grapes (the one fruit she enjoyed), and reduced the time he spent doing this task. She could continue to visit the shops for smaller food items, clothes shopping, and collect her pension at the post office.

The district nurse continued to visit to treat the leg ulcers and the GP advised on pain relief.

Within a few months she regained her ability to travel independently and once again has a good social life. Her general health has improved and this is supported by her improved diet. She is largely free from pain.

The result was that her mobility, physical and mental health are much improved and that her friends and relatives feel less anxious about her, and have regained a positive relationship with her.

Case study two: Bob

Part 1

Bob is a 78 year old man admitted to hospital after suffering a stroke which resulted in upper and lower limb weakness, loss of sensation, difficulty walking and reduced cognitive ability.

Prior to the stroke Bob lived with his wife Nan in a large, detached property with stairs. The bedroom and bathrooms were located in the top half of the house whilst the living areas and kitchen were situated downstairs. Bob had no previous contact with social services and lived an active and independent life with his wife. Bob and his wife have three grown up children and many grandchildren, all of whom live abroad. To stay in touch with family members Bob enjoys using the internet.

Bob underwent an extensive period of rehabilitation in hospital and after a two-month stay his discharge was planned with the help of the community rehabilitation team. The reason for referral to the team was to support Bob for a short period at home, to continue with his rehabilitation programme which included occupational therapy and physiotherapy tasks, as well as helping Bob to return to mobilising outdoors, and to his favourite hobby, bowling.

On assessment by the team the main findings were:

  • Bob was independent with all aspects of his personal care
  • Despite making an excellent recovery, Bob still had residual upper and lower limb weakness
  • Bob tired quickly and had reduced exercise tolerance
  • Reduced outdoors mobility
  • Problems with cognitive functioning, which troubled Bob as he previously dealt with all of the family banking and financial affairs
  • Poor concentration

At this point the team explained their role to both Bob and his wife, who were very happy to receive support from the team on discharge. The stroke support nurse also arranged to visit Bob.

Part 2

A member of the team visited on the day of discharge to ensure that Bob could manage safely at home. His mobility, stair climbing ability and transfers were all re-assessed and Bob managed with ease. To allow Bob time to settle in at home the team agreed to visit in two days time to establish shared goals and desired outcomes.

The team physiotherapist and occupational therapist visited Bob and completed their assessment. The physiotherapist established an exercise programme, which included Bob walking outdoors.

Both the exercise and walking programme were to be carried out by a rehabilitation assistant who worked as part of the team. The rehabilitation assistant had completed a range of competencies and was able to carry out a range of delegated, generic tasks. These tasks also included tasks delegated by the occupational therapist (OT) which involved computer based activities to help Bob improve his concentration and stay in touch with his family. Bob and the OT hoped that this would in turn help improve his ability to manage the family’s financial affairs.

Bob in discussion with the team set the following goals:

  • To be independent walking outdoors to the local shops
  • To return to indoor bowling
  • To increase the length of time spent at the computer
  • To manage part of the family banking with support from his wife

Bob and the team then set about his programme. As well as regular sessions with the rehabilitation assistant, Bob had a self-management programme to complete. Bob was reviewed weekly by the occupational therapist and physiotherapist. Throughout this period he was also visited by the stroke support nurse.

Following a six-week period of rehabilitation and support at home Bob could walk to the local shops and back. He had not attempted bowling as he previously walked to the club and this was just too far for him to manage at this stage. The team contacted a local voluntary sector service that offered buddy support for older people accessing local activities. The scheme agreed to support Bob by driving him to the bowling club and back. Bob was delighted and with the help of his friends gradually increased the amount of time he spent on the bowling club.

Bob’s computer sessions were also increasing in length and he had been able to carry out some of his personal banking. Whilst this had taken a lot of concentration and was tiring for Bob, he felt a tremendous feeling of achievement, which really boosted his confidence.

The team met with Bob to review his goals. Bob agreed that he had met his initial goals and now felt that he could achieve more. However, Bob felt that he was at a stage that he could undertake this himself. In order to sustain the outcomes that had been achieved, the team established links for Bob with the voluntary sector as well as ensuring he could manage certain aspects of his long-term condition. The team explained to Bob that he could self-refer back to the team if he felt that he required their support in future.

Following his discharge from the team Bob began to attend an exercise class at his local leisure centre, and became an active member of the local stroke support group.

Case study three: James

Part one

James is 61 years old. When he came into contact with the homelessness service he was living alone in a private let. He was vulnerable due to his failing health and alcohol use; his finances were controlled by acquaintances that provided a few provisions in return for all his benefits. His living conditions were extremely concerning in terms of health and hygiene hazards, he had trouble walking and his flat was in the top floor of a tenement building. James was beginning to suffer from personal health care problems, isolation, neglect and financial abuse.

He was not in contact with social services and received no support from either his family or the local authority.

James was discharged from hospital and was referred via the hospital discharge protocol and homelessness services took charge of the case. He therefore presented as potentially homeless due to the standard of his private let and concerns about returning there due to hazardous and below tolerable living conditions.

James was placed in temporary accommodation (furnished flat in the community) with home care support and a commissioned housing support package provided by a third sector organisation. However James was again referred to the homelessness service by the duty social worker from the health centre. Home care had been withdrawn for health and safety reasons as his electricity meter had again been tampered with and third sector organisation workers were only linking with him one day a week. He was again the victim of acquaintances ‘managing’ his finances.

Part two

An outcomes-based assessment conversation was held with James by a member of the homelessness team. James indicated that he wanted to get away from his current flat and company but felt powerless to do so. His increasing health problems had started to affect every aspect of his day-to-day life and he was concerned that things could only get worse. However he also indicated that he was willing to move to another part of town as there was no reason for him to remain in the local area. James agreed to make an application for a flat in a sheltered housing development for older people where he would be in a more secure environment and would have an opportunity to put some of his problems behind him and to make new contacts within the development. He could also start to address other aspects of his life including a desire to start playing music again. It was established that there would be a two month period before James could be allocated a flat. In order to maintain momentum during this waiting period, James was moved to alternative temporary accommodation in the new part of town and the third sector organisation was commissioned to provide support twice weekly until the flat was available. During this period James was also put in touch with a drop-in centre in the new area and encouraged to go along.

The two months passed slowly for James and at times he became despondent. However he resisted the temptation to return to his old haunts and finally moved into his sheltered flat three months after the initial outcomes-focused discussion. A year later he has settled well and is starting to get involved in some of the activities in the development and to have more contact with others living there. His health has stabilised as a result of his improved living conditions.

Appendix two

drivers and barriers to integrated working (Stewart, Petch and Curtice, 2003)




A National policy frameworks

  comprehensive and integrated piecemeal and contradictory
  encourage strategic approach promote ‘projectitis’
  legal, financial and guidance frameworks facilitate legal, financial and guidance frameworks inhibit
  realistic timescales unrealistic timescales/change agenda
  some non-negotiables anything goes!
  establish accountability for user focused outcomes no national pressure to demonstrate user benefit

B Local planning context

  planning and decision cycles mesh incompatible planning and decision cycles
  all stakeholders involved from the beginning, unions, operational staff, users and carers partial/tokenistic involvement of stakeholders
  joint acceptance of unmet need not needs led
  agreed, comprehensive vision, owned at all levels issues seen in isolation, priorities not agreed, based on lowest common denominator
  user outcome driven driven by vested interests
  provides evidence that alternative models can work a paper strategy
  runs with ‘good enough’ plan, ‘leap of faith’ waits for the perfect plan
  use of budgets reflects strategic priorities ‘spend this money NOW!’





  some stability constant restructuring
  shared location dispersed locations
  small can be good – knowing the people (but no alternatives!) complexity a barrier (but can be an incentive too)
  builds on existing good working relationships, ‘success breeds success’ no track record of successful collaboration, ‘it has never worked here’
  restricted resources induce innovation - need to share, ‘less means more’, Dunkirk spirit resources induce complacency - rest on laurels, ‘more of the same’
  pressure to innovate / change to meet need, ‘we can’t do it alone’ ‘necessity is the mother of invention’ no incentives to change ‘it won’t work here’ ‘it won’t work now’
  sense of momentum - ‘the time is now’ baggage of the past

C Operational factors

Relations between partners
  partnership model fragmentation of market
  balance of power power imbalance, strong empires, personal sovereignty
  task complex, cannot be achieved by single agency task simple, no perceived need for outside help
  integrated or networked eg a new community care organisation OR working as if one agency islands
  accountability agreed/shared accountability disputed/separate
  trust between agencies- permits risk-taking lack of trust- prevents risk-taking
  pooled resources different budgets/funding streams
  partners share information and skills for the bigger picture partners have energy only for own agenda
  open, honest, transparent communication defensive, limited communication
  shared records/systems - creative use IT information not shared - IT an excuse





  understands other’s limitations no allowances
  respects identities of other agencies ‘if only they did it our way!’
  integrated working embedded in policies and structures at all levels integrated working depends only on personal links
  informed by knowledge across settings eg through joint posts and well selected managers imbalanced by one agency or profession’s priorities
  harmonisation of practice to serve local community policies, boundaries and catchments not co-terminous

Organisational culture

  perceived interdependence isolationist
  willing to share/adopt good practice competitive
  it is everybody’s agenda including accountants, administrators the professionals’ business only
  ‘can do’ culture sees institutional and legal barriers
  organic, flexible, more autonomy/delegated responsibility eg devolved budgets rigid, high bureaucratic controls, ‘everything has to be checked’
  cross boundary work WITHIN agencies departmentalism, preciousness
  values difference worships uniformity
  collective responsibility publicly demonstrated senior figures devalue/disown common purpose

Change management

  task focused bogged down in resolving organisational problems
  service managed as a system to reduce confusion complexity
  commitment and flexibility to solve ongoing problems hides behind legal barriers
  rewards success, carrots and sticks blames, only sticks
  willing to devolve responsibility to joint service managers confuses accountability with direct responsibility for spending





  dedicated resources for development, margin for change and innovation resources too tight, fully committed to existing buildings/staff/ways of working
  commits development resources to engineer system change notches up new projects, mainstream services unaffected
  promoted by management at critical stages stifled/undermined by management
  process driven by committed leaders/managers with knowledge of different settings no champions
  flexible enough to learn as goes, listens/evaluates, honest about what works presses on regardless
  sustains and rolls out good practice when champions leave, innovation dies

Enabling staff

  supports champions who work across boundaries supports those who maintain empires
  invests in ownership by staff and users a management issue
  clarity of purpose transmitted to staff and users ‘more paperwork! more procedures!’, ‘what is the purpose of all this?’
  enables innovation to come through stifles the creativity of others
  clear co-ordination mechanism nobody’s responsibility
  clear written protocols, confidentiality concerns addressed ‘no map, I will have to consult my line manager’
  clarification of remits, agreed roles and procedures eg joint protocols, team structures unclear responsibilities, conflict
  efforts made to reduce complexity staff left to resolve variation in everything
  time to develop and service integrated working - and have joint training, team building rush in, staff too pressured to collaborate or prepare
  collaboration and negotiation valued and part of training ‘another meeting – I suppose you were networking again!’
  training available for new skills ‘I feel de-skilled by these changes’
  promises opportunities fear of job and skill loss





  creativity valued ‘we’ve always done it this way!’
  staff valued staff expendable
Professional behaviour
  willing to change burned out
  centred on user need tribal, protectionist, different terms and conditions
  confident and flexible threatened and restrictive
  accept challenges to mindset and learns retreats when challenged
  willing to take risks covers own back


  ‘we have nothing to lose’ ‘we have everything to lose’
  ‘we have everything to gain’ ‘we have nothing to gain’
  ‘stolen with pride’ ‘not invented here!’
  ‘that’s a great idea’ ‘not as interesting as my pet project’, ‘not a model we recognise’, ‘doesn’t fit our procedures’
  ‘we all own this!’ ‘WE own this!’
‘I am confident in my skills - though I have more to learn and I respect your skills’ ‘I’m not sure what I know and I’m threatened by what you know’, ‘this is my turf!’
  ‘we will find a way’ hide behind legal barriers ‘no way’


  user focused and defined outcomes outcomes only seen from agencies’ agenda
  visible outcomes invisible outcomes
  benefits shared winners and losers
  some short-term gains only long-term gains