A siloed service system

Interagency collaboration is more widely recognised as the future of community services. In 2011 the Government’s paper, Human Services: The case for change outlined the fragmentation and ineffective organisation of the current system (p5, Department of Human Services, 2011). Professor Peter Shergold, in his discussion paper: Towards a more effective and sustainable community services system, spoke of the “value of better engaging individual citizens in the management of the services intended to support them at times of need” (2013). His and others’ independent inquiries into the Victorian community services system have been vital in shaping the future of reform for the service sector.  These key publications called for a more integrated system in order for people to have control over the positive changes they wish to make in their lives. ‘The case for change’ set out that the first principle for an integrated human services system is that “people are at the centre of everything we do” (p19, Department of Human Services, 2011).

Person-centred services and care is the number one strategic direction of the 2016 Department of Health and Human Services strategic plan and integrated care is part of the priority actions (DHHS, p25). Although the government continues to attempt structural changes in response to these recommendations, Shergold strongly recognises that not-for-profit organisations must collaborate with government to shape public policy in an innovative way (p1, Shergold).  The person-centred approach to partnership is a collaborative way for community organisations to influence social innovation. It is something the sector can embed regardless of specified funding from authorities in order to progress it.

Partnership and Person-centred care

The Services Connect Adventure (Southern Melbourne)

The Southern Melbourne Services Connect Partnership consisted of eleven agencies in the region and provided support to disadvantaged people through fifteen dedicated ‘keyworkers.’ The partnership also had a larger network of over fifty agencies supporting and contributing to the project. Services Connect was a state-wide pilot testing the reform elements of a person-centred, outcomes-focused, holistic, strength-based and family sensitive approach (DHHS, 2015, p6). It aimed to achieve its goals through active client engagement, new ways of working and joined-up approaches. “The consensus view among stakeholders  was that Services Connect [was] an attempt to break down the ‘silos’ that exist for clients when accessing support services” (Hodges, p13).

In early 2016 an independent evaluation was conducted on the Southern Melbourne Partnership. It found a strong sense from stakeholders who had been consulted that previous system initiatives designed to achieve a person centred approach had not worked and agencies would often revert to familiar procedure (Hodges, p13). Conversely they found the Services Connect initiative to be a real chance to change practice: to prioritise the needs of clients over the prescriptive nature of funding models (Hodges, p13). Workers involved in the project reflected that they had believed their approach to practice had been person-centred previously but that the experience had challenged that assumption and enhanced their approach (Hodges, p16). The collaborative nature of the project created previously unrealised opportunities: for example increased incidence of aboriginal clients engaging with non-aboriginal organisations due to the strong worker relationships between VACCA (Victorian Aboriginal Childcare Agency) and other partner agencies (Hodges, p16).

Challenging the person-centred rhetoric

The values of “client focus” have been central to the Government’s Department of Human Services prior to the “case for change” report. This begs the question about what exactly is different about a principle of people being at the centre of everything we do, what is the difference which can truly transform the system?  Among not-for-profit community organisations there is similar person-centred rhetoric. It is tempting to believe that we in the community sector have got it right and only structural changes out of our control can improve our person-centred approach. So how can we truly know we have it right unless we hold a mirror up to our work and openly and critically compare it with others in the sector? Further information on person-centred care from the Client-centred and holistic section of the AOD toolbox

It is tempting to believe that we in the community sector have got it right and only structural changes out of our control can improve our person-centred approach.

The Drug and Alcohol Context

In the drug and alcohol sector, our funding is based upon people presenting with problems related to drugs and alcohol. Pichot (2001) points out “while many AOD treatment agencies profess that their services are individualised according to client need, the content of the program has usually already been determined before the client seeks admission.”  How we are positioned in the system and how we must account for our work to achieve funding distorts our perspective because it immediately sorts people in relation to their issues. It also affects how others in the sector view the work we do. There may be implicit and explicit expectations of our role from professionals of other disciplines, usually an expectation to focus on and eliminate the drug and alcohol issue. However we know that support needs to be holistic, promoting the health and wellbeing of the individual.

The Turning Point ‘Review of integrated working strategies’ for the Victorian drug and alcohol sector highlighted the need for guidance in integrated work due to the multiple and complex needs of most people supported by the sector and the history of serial or simultaneous treatment with other systems of care (2014, p7). It was asserted that co-ordination of such co-existing care has been lacking and people have to navigate a very complex system to get all the support they need.

Improved partnership with universal services can both improve our holistic practice through easy access to specialist consultation or referral and assist others to understand and take part in our approach.

The theories which underpin the approach

Motivational Interviewing

Motivational Interviewing is a thirty year old clinical method for conversations about change guided by a person-centred philosophy (Miller and Rollnick).

Motivational Interviewing is underpinned by the Rogerian person-centred approach. This Humanistic philosophy asserts that given the right conditions a person will self-determine in a positive direction (Rogers, pxi). The most essential condition being that the person is at the centre of all decisions made about their care.

When applied to the creation and facilitation of a partnership, the person-centred approach also allows an often ineffective and uncoordinated system to thrive. Partnership is the first vital aspect of the spirit of Motivational Interviewing, endorsing a collaborative approach to practice between the person and their worker. For a successfully integrated service system this idea of partnership along with acceptance, compassion and evocation, must occur between services and between management and practitioners. Just as Motivational Interviewing helps people change, its philosophy applied to service integration can help systems change.  Link to Motivational Interviewing – AOD Toolbox.

Client-centred or person-centred?

 In ‘A Way of Being’ Rogers expounds that he uses the word person as opposed to client because he has learnt that his approach is more intrinsically a philosophy to fit any situation (Rogers, pxvii). Similarly this partnership approach is an application of the person-centred and Motivational Interviewing principles which attempts to view all members of the Partnership, those supplying a service and those receiving a service, as equally valuable contributors. It is important to recognise that a professional in the service system may also at the same time be accessing support from the system or visa-versa. The approach also argues the value of management and co-ordination at operational and strategic levels taking a person-centred perspective in the management of systems and staff. This learning module therefore, attempts to avoid the use of the word ‘client’ as a potentially limiting view of a person and looks at the potential of person-centred beyond direct practice.

Trauma-informed care

The trauma-informed framework for practice has been an exciting addition to the clinical work in the drug and alcohol sector and broader service system. Yet it is recognised that trauma-specific interventions are not necessarily effective without being part of a trauma-informed system of care (Wall et al, p4). For example, many traditional therapies are limited in their time and duration restricting the scope of work required to support meaningful change for people (Perry and Hambrick 38-43). A flexible approach to program provision is called for, so that practice can be altered when it is not in the person’s best interests. This flexibility cannot be isolated to single workers or even agencies.  “Systemic change is important because it enables people to receive services that are sensitive to the impact of trauma regardless of whether they enter through any particular service setting or intervention” (Wall et.al, p14).

The Australian Childhood Foundation highlight the need for an integrated trauma-informed system where workers are less isolated, knowledge is shared, risk is reduced and care for people with complex needs can be co-ordinated (ACF, p49).

Partnerships provide a stepping stone for integration of the system and for a more uniform understanding of, and response to, trauma in the system. The meaningful cross-sectorial relationships created by partnerships support trauma informed learning to “move towards a more holistic understanding of the inter-related biological, psychological and social dimensions of trauma.” (Wall et.al, p14). Shared training with members of a partnership of professionals from different disciplines can assist in richer learning and consistency of response. “Ideally the care of the maltreated child must extend to every influential person the child encounters” (Perry & Hambrick, p43). Link to Trauma Informed Care module – AOD Toolbox.

Collective Impact

Collective Impact is a co-ordinated approach to partnership that recognises long-lasting and effective social change can only be achieved together (Aigner and Skelton). The conditions for Collective Impact to be successful are: common agenda, shared measurement, mutually reinforcing activities, continuous communication and a backbone organisation. The person-centred approach to partnership adds a philosophical stance to these elements of cross-sector collaboration, which forms an assumption that the person is centre to the shared vision held by the partnership. Similarly, the agreed outcomes to measure must be consistent and accountable like in Collective Impact, but the most important accountability is to the person/people receiving the service.

There is also an assumption that a person-centred partnership will result in mutual benefit because all members are viewed as having valuable expertise to contribute and all members can benefit from the expertise of others, particularly the expertise of the person being supported about their aspirations and life.

This approach does not explore the backbone organisation as it is discussed in Collective Impact, but rather talks about the importance of a facilitator or convenor to drive the initiative as well as the multi-layered investment needed from members of the partnership. These elements are further discussed in the section on Facilitation/Co-ordination.

Other theories that align with the approach

Effective partnership from a person-centred perspective values family competent practice because a drug and alcohol specialist practitioner can build relationships with family specialist practitioners to enhance their practice. “Mental Health (MH) and Alcohol and Other Drugs (AOD) services are increasingly expected to work collaboratively with the families and social networks of clients.” (Bouverie, p4).  Family is also viewed in a different way because the person-centred approach recognises that support for the family is just as legitimate and important as support for the person for whom our program is funded to service.

Narrative Therapy is a valuable practice approach that honours the skills, knowledge and story of the individual and aligns well with the person-centred philosophy. Similarly the single session approach values the person’s own control over their life and circumstance.

Collaborative leadership

Collaboration across physical distance

The Southern Melbourne Services Connect partnership was an innovative model where keyworkers involved remained posted at their home agency whilst building a team in the multi-disciplinary partnership.  Working in this de-centralised team incurred challenges for example to having shared access to information and resources. On the other hand, this situation allowed workers to maintain the crucial ties to their practice specialty which assisted such a dynamic learning environment. Workers were able to conduct active consultations with each other that would draw upon the greater agency knowledge of each worker. It was for these reasons that during establishment the partner agencies chose the model. They believed meaningful collaborative relationships could be achieved by strengthening bonds between existing agencies that already have the expertise and resources to do good work. The collaboration in itself becomes the way that services are improved and resources pooled. This original vision of the Southern Melbourne Services Connect partnership implies that not only does there not need to be a team located together in a physical space to form such bonds but that it can also be possible without a common program or funding tie.

The partnership formed enabled there to be greater sectorial knowledge on a practice level but also on an executive level, a CEO of one of the agencies has commented that they felt ‘Services Connect bought together agencies that would never have previously had anything to do with each other and by not co-locating it has made us [the CEOs] get together once a month and talk to each other’.