There are approximately 15,000 children (aged under 18) with complex and profound learning difficulties in England (DCSF, 2008, School Census). The Department for Children, Schools and Families (DCSF) define complex and profound leaning difficulties in the following terms:
In addition to very severe learning difficulties, the children will have other significant difficulties, such as physical disabilities, sensory impairment or a severe medical condition. They require a high level of adult support, for their personal care as well as for their learning needs. They are likely to need sensory stimulation and a curriculum that is broken down into very small steps. Some children with profound and multiple learning difficulties communicate by gesture, eye pointing or symbols; others communicate by using very simple language.
For the purpose of this study, in line with the DCSF definition, pupils with complex and profound learning difficulties are defined as those who share two characteristics:
a profound cognitive impairment or learning difficulty; and
a complex interaction of difficulties in more than one area of functioning.
Evidence suggests that locally coordinated provision is being adopted nationwide as a person-centred approach to the needs of children with complex and profound learning difficulties (Hirst and Baldwin, 1994). Despite this, the Further Education Funding Council for Learning Difficulties and/or Disabilities Committee (FEFC, 1996) suggests there are still advancements to be made in planning between professional groups in order to promote educational progression and social inclusion (Department of Health, 2001). In relation to these findings this paper describes a research study that aims to evaluate the effectiveness multi-agency working within a provision for children with complex and profound learning difficulties.
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Multi-agency working: a debate over conceptualisation
In past research, the terms inter-agency and multi-agency have been used interchangeably, making the concept of multi-agency working less clear. Some researchers, such as Carpenter (1995) have suggested that the distinction between the two is numerical, whereby; ‘inter-agency’ refers to two professionals workings together, such as a teacher and teaching assistant, whilst ‘multi-agency’ working refers to a situation when there are more than two professional groups are involved, such as a primary school teacher, physiotherapist and learning support teacher.
Other writers suggest the difference between inter-agency and multi-agency working stems from issues of professional boundaries. For example, inter-agency working could be seen as “like you are crossing into another space…” (Pirrie et al., 1998, p.213) where there are clear role definitions, whilst multi-agency working can be seen as promoting blurred boundaries between professional groups (Wilson and Pirrie, 2000).
The DfES defines multi-agency working as:
“… different services and teams of professionals and other staff working together to provide the services that fully meet the needs of children, young people and their parents or carers.” (DfES, 2004, p.18).
It is believed that the term ‘multi-agency’ working covers a broad array of involvement, which could range from meetings between professionals from different agencies to professionals working collaboratively over long periods of time and across local communities (Barnes, 2008).
For the purpose of this study, multi-agency working will involve different professionals working together on a regular basis over a considerable period of time at The Meadows to meet the needs of the pupils who attend.
Multi-agency working to support children with complex and profound learning difficulties: the need to coordinate services
Over time, there has been a gradual shift in the perception of individuals with complex and profound learning difficulties. Whereby, the medical model, with its concentration on personal deficit, is gradually evolving into a social model which highlights the impact of environmental factors, social factors and access to educational opportunities on the lives of those with complex and profound learning difficulties (World Health Organization, 2001).
The increasing focus on quality of life has highlighted the need for professional agencies to work collaboratively, if those with complex and profound learning difficulties are to lead richer lives (Mencap, 2000; Barnes, 2008). Also, multi-agency working is being increasingly seen as a means of enabling improved access to specialist support and resources, facilitating inclusion and resulting in raised attainment (Forbes, 2007).
Roaf (2002) suggests that multi-agency working enables children with complex educational needs to reach their full potential, saying:
“Despite the complexity of their difficulties, in school, teachers often find that when professionals work closely together, young people reach their educational potential…” (p. 2).
Roaf (2002) also highlights how, in contrast to multi-agency working, accessing services which are fragmented can often lead to delays in accessing support and children can at times get ‘lost in the system’. Further research suggests that children with complex and profound needs often experience co-occurring and overlapping difficulties (Maras et al., 2002) which require a holistic assessment of individual needs through multi-disciplinary working.
Multi-agency working has been identified as an effective method of early identification and intervention to address complex needs (Carpenter, 2000) and the need to improve multi-agency working to support individuals with complex and profound learning difficulties was highlighted in the White Paper Valuing People (Department of Health, DoH 2001). Valuing People advocates a person-centred approach to delivering “real change in the lives of people with learning disabilities” (p. 5) by providing “a single, multi-agency mechanism for achieving this” (p.5). The paper suggests that in order to reach the key objective that “disabled children gain maximum life-chance benefits from educational opportunities,” (p. 122) it is essential that health care and social care should adopt a multi-agency, coordinated approach to support individuals, as well as their parents or carers. The overarching aim of coordinating services through joint working practices across health, social care and education is to provide a ‘seamless service’ (DfES, 2003, 2004) to give children the best possible start in life and to overcome the difficulties otherwise faced by families through fragmented services (DoH, 2006).
The research base in this area proposes that multi-agency working is a key facilitating factor for enabling children with complex and profound learning difficulties to gain improved life-chances and educational opportunities as well as providing support for parents and carers. The next step is to consider how effective multi-agency working can be achieved.
Drawing on the evidence: factors which facilitate effective multi-agency working
Literature from an organisational psychology perspective suggests that simply putting individuals from professional groups together does not necessarily lead to effective multi-agency or collaborative working (Clark, 1993; Pirrie et al., 1998). Instead it is proposed that effective multi-agency working is dependent on wide range of factors, such as a blurring of professional boundaries which leads to the formation of “trust, tolerance and a willingness to share responsibility” (Nolan, 1995, p. 306). Also, success depends on the creation of a new way of working that identifies common goals (Pirrie et al., 1998), offers clear direction at a strategic level (Atkinson et al., 2005) and encourages a personal commitment from team members (Wilson and Pirrie, 2000).
Guidance from Every Child Matters: change for children, states:
To work successfully on a multi-agency basis you need to be clear about your own role and aware of the roles of other professionals; you need to be confident about your own standards and targets and respectful of those that apply to other services, actively seeking and respecting the knowledge and input others can make to delivering best outcomes for children and young people. (DfES, 2004, p. 18)
A detailed study carried out with 139 members of multi-agency teams (Local Government Area Research Report 26; Atkinson et al., 2002) found that the primary skills identified for successful multi-agency working across a range of settings include:
a commitment from all involved;
understanding own and other’s roles and responsibilities;
having common aims and objectives to work towards;
effective communication and information sharing;
strong leadership;
having funding or resources needed; and
good working relationships and having adequate time.
Sloper (2004) found factors at an organisational level which facilitate multi-agency working include:
the planning, implementation and ongoing management of multi-agency services;
clear and realistic aims and objectives that are easily understood and accepted;
clearly defined roles and responsibilities with clear lines of accountability;
strong leadership from a multi-agency steering or management group;
ensuring good systems of communication and information sharing at all levels; and
an agreed timetable and incremental approach for change.
In summary, settings where effective multi-agency working has been established with a strong commitment from professionals involved has lead to better outcomes for children with complex and profound learning difficulties; however, the way in which this is achieved is not simple. There are key components identified within the research which are thought to facilitate multi-agency working but achieving effective multi-agency working is not a straightforward process and may vary from one setting to another. Based on a review of the literature around factors which affect multi-agency working, recurring themes include: the understanding of roles and responsibilities; effective communication and information sharing; positive working relationships between individuals from different agencies; and organisational factors such as how multi-agency working is managed.
The Present Study
At a whole-school staff meeting, The Meadows identified a desire to evaluate the effectiveness of multi-agency working centered on pupils with complex and profound learning difficulties. At this meeting the school staff reported that they would like to evaluate current multi-agency working within the school to learn about how that might be improved for future service delivery. This was then discussed at a planning meeting involving the researcher, the school SENCo (Special Educational Needs Coordinator) and deputy head teacher. The present study is an exploratory investigation into multi-agency working within this specialist provision for children with complex and profound learning difficulties.
The context for this study is The Meadows School which was established in September 2000 following the reorganisation of provision for children with special educational needs in Newtown and is now currently the only primary school within Newtown Local Authority catering for the needs of children with complex and profound learning difficulties or disabilities.
In September 2006, The Meadows moved into a building which was brand new and purpose built. Along with teaching and classroom support staff, the school is supported by a multi-agency team of: physiotherapists, occupational therapists, speech and language therapists, a specialist teacher of the visually impaired, a specialist teacher of the hearing impaired, clinical psychologist, educational psychologist and medical staff, such as the school nurse and the consultant paediatrician.
There are currently 124 children attending The Meadows, ranging in age from 2 years to 11 years. All are described as having complex and profound learning difficulties, which include: severe autism, complex medical conditions, physical and mobility difficulties, as well as severe developmental delay.
There is a high proportion of pupils from an ethnic minority background and a small number of looked after children who attend The Meadows. An OFSTED inspection in summer 2007 rated the school as being ‘Good’ overall and the following were rated as outstanding: Foundation Stage provision, Personal Development and Well-being, Care, Guidance and Support and Curriculum Activities. OFTSED report that “There are excellent working relationships with other providers and agencies and these have a positive effect on the development of curriculum activities.”
Aims
The aim of this study is to evaluate the effectiveness of multi-agency working at The Meadows. This will be achieved by answering the following questions:
1. How is multi-agency working organised and structured at The Meadows?
2. How do multi-agency professionals (MAPs) at The Meadows perceive their own and others’ roles?
3. How could multi-agency working at The Meadows be improved for future service delivery?
Method
Procedure
This study was conducted over a four month period from September to December, 2010. Table 1 presents a timeline which illustrates the procedure (data collection methods are described in more detail in the Measures section of this study).
Time
Action
RADIO model (Timmins et al., 2003) stage
September
On an informal visit to the setting, The Meadows staff mentioned a need for research to be conducted within the school. They felt research could help the school develop future service delivery. I suggested a discussion is held with school staff to identify some potential research areas.
Stage 1: Awareness of needraised by the school.
Early October
I met with school SENCo to discuss potential research areas. The evaluation of multi-agency working is agreed. I was asked to conduct the research.
Stage 2: Invitation to actis given by the SENCo on behalf of the school
Mid October
I met with the SENCo, early years coordinator and deputy head teacher to discuss research questions and aims to be investigated.
Stage 3, 4 &5: Identifying stakeholdersand discussing who the outcomes will affect and agreeing the focus of concern.
End October
A research brief is emailed (See Appendix One) outlining the aims of the research, research objectives, approach, methodology, timings and contact details, including why information will be collected and how it would be used. Staff are asked to provide feedback on research brief.
Stage 5 &6: Identifying stakeholdersand discussing the focus of concernas well as shaping a framework for data gathering.
Early November
I visited The Meadows to conduct a semi-structured interview with the early years coordinator, deputy head teacher and head teacher to learn about the school and how multi-agency working functions.
Stage 7: Gathering Informationphase 1.
Mid November
I conducted observations over two mornings (approximately seven hours) to collect data. The purpose was to describing four things: the skills and knowledge staff were employing in their role, working relationships between multi-agency staff, how multi-agency working was structured or organised and what kind of support was offered by MAPs.
Stage 7: Gathering Informationphase 1.
End November
I explored pupil files for information. The purpose was to evaluate the skills and knowledge MAPs were employing in their role and how multi-agency working was structured.
Stage 7: Gathering Informationphase 1.
December
Data was collected through the use of questionnaires.
Stage 7: Gathering Informationphase 2.
Measures
The overarching aim was to evaluate multi-agency working at The Meadows with an interest in identifying ways of developing future support for children with complex and profound learning difficulties at the school.
A multi-method approach was used involving two phases. Phase one, was primarily analytic-inductive (Robson, 2002), employing an interpretive approach as the basis for enquiry, whereby, semi-structured interviews were conducted, pupil files were explored and observations were used to produce rich, qualitative information. Phase two consisted of structured questionnaires used to investigate themes arising from the interview responses and explore relationships between variables to produce quantitative data.
Semi-structured interviews
I visited The Meadows to conduct a semi-structured interview with the early years coordinator, deputy head teacher and head teacher to learn about the school and how it operates as a multi-agency team.
A semi-structured approach with open-ended interview questions was used, as suggested by Cohen and Manion (1989) to allow the researcher to be flexible throughout the questioning process, so that a free-flow of information could be achieved. An interview schedule of questions was created based on themes which had emerged from a review of the literature.
A list of potential questions was written (see Appendix Two) to prompt the interviewer regarding the key points to cover and topics to address. As recommended by Robson (2002) there was flexibility over the sequencing of questions, their exact wording and the amount of time and attention given to different topics depending on the response of the participant.
The interviews were tape recorded which Robson (2002) suggests is good practice to provide comprehensive data for later analysis. This method also allowed me to focus on building rapport which is an integral part of a successful interview process (Dexter, 1970).
At the start of each interview I described the interview process, approximately how long it should last, and the general subjects to be covered. I asked the interviewee’s permission to record answers and reassured confidentiality. The interviewees were asked if they had any questions before starting the interview and again at the end.
After the interviews were complete, through informal discussion, participants were asked to reflect on the interview process. From feedback, it was found that respondents felt they had been able to answer questions in their own time and in their own way. Participants said they felt relaxed and liked my interview style, as it was informal and “put them at ease.”
Observations
I conducted observations over two mornings and observed fifteen members of staff working across four classes including, teachers, learning support practitioners, physiotherapists and speech and language therapists.
Before commencing observations, I introduced herself by referring to the information outlined in the research brief and asking for each participant’s consent to be part of the research process.
The observation technique involved studying a range of adults working with children and describing four things: the skills and knowledge staff were employing in their role, working relationships between multi-agency staff, how multi-agency working was structured or organised and what kind of support was offered by MAPs. This was recorded on an observation record sheet (see Appendix Three for sample record sheet).
As proposed by Robson (2002), information was recorded during observations and additional information was added shortly after each observation period, including interpretive ideas and subjective impressions.
Questionnaires
The aim was to sample as wide a range of agencies as possible and collect data through the use of questionnaires from a range of professionals from different agencies who support pupils at The Meadows. An explanatory letter, along with a structured questionnaire (See Appendix Three) were sent to each member of staff at The Meadows through the use of the school’s internal postal system and through electronic mail also.
The questionnaire was structured into six sections. These sections were based on themes arising from the review of literature, interviews and observations conducted previously. The six sections were as follows:
background information, which explored the respondents’ role and time worked at The Meadows;
communication between MAPs including: teaching staff; physiotherapists; occupational therapists; speech and language therapists; a specialist teacher of the visually impaired; a specialist teacher of the hearing impaired; clinical psychologist; and educational psychologist.
understanding of own and other multi-agency professional’s roles at The Meadows;
perspectives on organisation and structure of multi-agency working at The Meadows as these facilitated or inhibited each respondent’s own work and overall multi-agency working within the school;
environmental factors which may affect multi-agency working; and
other Factors influencing multi-agency working.
The questions were a mixture of open-ended questions which had no predetermined response options and required respondents to record their answers in sentences and scaling questions which required respondents to tick a corresponding response on a five-point ordinal scale.
A pilot questionnaire was administered to four participants. Through informal questioning, respondents gave feedback which was incorporated into the final questionnaire design.
20 questionnaires were returned (N=20) from a range of agencies, including:
learning support assistants (N=3);
educational psychologist (N=1);
occupational therapist (N=1);
speech and language therapists (N=2);
physiotherapist (N=1);
teachers (N=6);
librarian (N=1); and
senior Management staff (N=5).
Results
The results will be reported in relation to the research aims below:
1. How is multi-agency working organised and structured at The Meadows?
2. How do MAPs at The Meadows perceive their own and others’ roles?
3. How could multi-agency working at The Meadows be improved for future service delivery?
How is multi-agency working organised/structured at The Meadows?
In order to gain insight into how The Meadows operates as a multi-agency team, observations across the school were conducted, pupil files held at Newtown Inclusion Support were explored and information was gathered through interviews with the school’s early years coordinator, deputy head teacher and head teacher.
Content analysis of the data from observations and interviews (See Appendix Four for procedure) suggests that The Meadows operates as an operational multi-agency delivery team. Diagrammatic representation of this type of approach is provided in Figure 1.1.
Figure 1.1 Operational team delivery model
During the interviews participants (head teacher, early years coordinator and deputy head teacher) were asked to list all the agencies that regularly work at The Meadows and describe how services are coordinated and delivered to support pupils at the school. From their responses, it was possible to construct a figure to show the agencies and their connectedness (See Figure 1.2). When asked, interviewees described multi-agency working at The Meadows as “a range of experts who work in close proximity and work together to deliver support to pupils,” (head teacher) with the overall aim being, to achieve “a two-way exchange of knowledge, ideas and skills” (head teacher) between all those involved (as indicated in Figure 1.2).
The Meadows Multi-agency team delivery model
Figure 1.2 The Meadows’s multi-agency team delivery model.
Health professionals: physiotherapist, occupational therapist, speech and language therapists, clinical psychologist, paediatric consultant, Educational Psychologist.
Education professionals: Educational Psychologist, teachers, learning support practitioners, senior management, co-ordinators.
Other services: Parents, volunteers, meal-time supervisors, site staff, administration staff, drivers, librarian
Social services: Social workers.
The aim of the operational delivery team was reported to be for professionals from different agencies to work together on a day-to-day basis and to form a cohesive multi-agency team that delivers a person-centered service directly to pupils who attend The Meadows. By using this approach senior management at The Meadows hope to provide a “seamless service for parents” which offers a wide breadth of expertise, skills and experience and hope this approach encourages “joined up thinking” between agencies, “an efficient free flow of information” and would encourage “more creativity.”
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Through questionnaires, MAPs who work at The Meadows were asked to rate their knowledge and understanding of various structural and organisational elements of multi-agency working at The Meadows such as the staffing structure and the organization of the curriculum. Respondents were asked to rate the extent to which they were involved in shaping these elements and how they impacted on their involvement in multi-agency working. Chart 1 below represents the average questionnaire response from staff (larger sized chart available in Appendix Five).
The responses were divided into three groups: senior management, teaching staff (including learning support practitioners) and professionals who are employed by external agencies such as speech and language therapists, occupational therapists, physiotherapists and psychologists. This was done to see whether there were differences between groups.
Although ratings across all areas were high for all groups, it was found that senior management rated their knowledge of the structure of The Meadows and involvement in shaping service delivery as highest across most categories. Teaching staff rated second highest across the same areas and external agencies rated lowest across these areas. This suggests that external agencies perceive they have the lowest understanding of The Meadows’s curriculum, the least opportunities for joint planning and training delivery and the least input into future service delivery. Qualitative responses on the questionnaires from professionals employed by external agencies, suggest that time constraints are the main reason for the lack of involvement in joint planning and training.
Additionally, during interviews some staff reported that some MAPs do not have a clear understanding of The Meadows’s thematic curriculum, which leads to them to suggest additional targets which are ill-fitting with the curriculum targets already in place. It was felt this often puts increasing demands on teaching staff who are responsible for implementing targets suggested by external agencies.
How do MAPs at The Meadows perceive their own and other’s roles?
Through questionnaires MAPs were asked to list the key skills and knowledge they considered that they implemented in their role at The Meadows. This information was triangulated with data from observations and individual pupil files. Figure 2 illustrates the key skills and knowledge used by multi-agency staff at The Meadows in their day-to-day working.
Figure 2. diagrammatic representation of key skills and knowledge
Common Skills &Knowledge
– specialist knowledge;
– assessing pupil progress;
– communicating with other professionals &parents; and
– experience.
Speech and Language Therapists:
– knowledge of communication
development and swallowing
difficulties; and
– sign language and
alternative
forms of
communication.
Physiotherapists:
– expertise in fine and gross motor
development; and
– positioning and
seating options.
Teaching Staff
(including learning
support practitioners):
– communicating with parents
& a wide range of professionals;
– experience of working with children
with a wide range of need; and
– plan, teach &assess pupil progress.
Educational Psychologist:
– advice on behaviour
management principles;
-advice on accessing
the curriculum; and
– support pupil’s academic
development.
The central circle in Figure 2. entitled ‘Common Skills and Knowledge’, identifies a set of common skills that all MAPs employed in their work at The Meadows. The qualitative responses from questionnaires suggested that some MAPs felt that there was some “role overlap” and “lack of clarity” regarding the key responsibilities of some professionals they worked with, which at times lead to repetition in the work carried out by different individuals, particularly when assessing pupil progress. This will be explored further in the Discussion section of this paper.
The next step was to explore how staff at The Meadows perceived their own roles. Through questionnaires staff were asked to rate statements relating to their role and the roles of other MAPs. Results are presented in Chart 2 (larger sized chart available in Appendix Five).
The majority of MAPs felt that they had a very good understanding of their own role and others’ roles. All staff members viewed themselves primarily as a member of The Meadows’s staff team. Those who are employed by an external agency viewed themselves as primarily members of The Meadows staff team and also view themselves as part of an external agency. Qualitative responses from this group suggest that some individuals found that belonging to two organisations can be “difficult to manage at times,” can sometimes be “frustrating” and can at times “lead to conflict.” Overall, respondents felt that professional boundaries were not difficult to cross and they perceived that professional boundaries were slightly blurred.
Through questionnaires, staff were asked to rate the degree to which they understood the roles of other professionals who worked at The Meadows and how frequently they had contact with them. The results are presented in Chart 3 (larger sized chart available in Appendix Five).
The results show that there are variations in the level of understanding of some professional roles and in the level of contact with some professional groups. From the average overall responses it is suggested that most respondents felt they had the clearest understanding of the roles of: teaching staff, learning support practitioners, speech and language therapists, the teacher of the visually impaired, nursery nurses, the health care team and administration staff. These groups were also rated as having the highest level of contact, which suggests that high contact can lead to better understanding of others’ roles.
There was least contact with the clinical psychologist, the teacher of the hearing impaired, social workers and the educational psychologist. Qualitative responses from the questionnaire suggested that time restrictions affect contact with some professional groups, especially those with only one member such as the clinical psychologist, the teacher of the hearing impaired, social workers and the educational psychologist, which adversely impacted other workers’ understan
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