MENTAL HANDICAP VOL. 16 JUNE 1988 I, 1

RHANIAD blmh GYMREIG STRATEGAETH CYMRU GYFAN

WELSH DIVISION

ALL WALES STRATEGY

Getting on with the real work

Ian Macdonald

This article is an analysis of the work of professionals providing a service to people with mental handicaps and their families in the Rhondda Valleys (Macdonald et af., in press; Rhondda Vanguard Service, 1986). It attempts to show that a critical part of providing an integrated community service involves more than valuing or even carrying out direct service work. Although the direct delivery is sometimes seen as the only “real” work, other work which is less immediately rewarding is necessary if the service is to be delivered in a coherent way. Further, it seeks to demonstrate that in order to enhance the actual service delivery great care and effort is required in the design of systems which make sense to the service users, their families, and the service providers. This article does not attempt to summarise the entire Rhondda Vanguard Service or the Research Project.

The Mental Handicap Services Unit of Brunel University (MHSU) and the British Institute of Mental Handicap (BIMH) have been involved in a two-year project of action research with the Rhondda Vanguard Team (Macdonald, 1988). The Rhondda Vanguard Service (RVS) is part of the All Wales Strategy (Welsh Office, 1983) which is currently being implemented throughout the principality. However, the analysis is not limited to the Rhondda, or even Wales. Work in the Rhondda crystalised previous experience drawn from service delivery in other areas, and indeed it relates to similar problems encountered by different organisations providing services to a wide range of people.

Problems do not come in disciplines The All Wales Strategy is well-known for its policy

statements. The three essential principles concerning normal patterns of life, treatment of people as individuals, and support from the community to help them realise their potential, are complemented by the aim of participation by people with mental handicaps and their families. They should not, however, obscure a central problem which the Strategy aimed to solve; that of uncoordinated service delivery.

The resulting services were intended to achieve the objective of providing an integrated service. Previously,

community-based services could be confusing to service users and their families. It was not unknown for people to receive services from a social worker, community nurse, teacher, and volunteer without any real shared awareness of the plans and purposes of each one. With the development of other professions - such as occupational therapy, music therapy, speech therapy, physiotherapy, clinical psychology, and educational psychology - the family is faced with a bewildering range of talent; but the different professional backgrounds result in different methods of approach and people employed by different agencies.

Service users do not usually immediately associate a social problem with a particular discipline (Macdonald, 1981). Someone’s apparent “aggressive or difficult’’ behaviour at home may be due to frustration because the person is unable to communicate with others or to physically control personal actions; or it may be a reaction to other people’s behaviour; or to boredom, anxiety, even a bad diet; or it may be caused by none of these.

The primary need of service users is a point of contact; one where there is sufficient knowledge as to where they might get help. Often their needs do not require highly specialised skills. It may be that they simply need a break, or help with housework or shopping, so that they can continue to provide care or sustain their lives. Whatever the need, family members and the person with a mental handicap become less anxious if they feel there is a coordinated pattern of care centred upon their particular situation, and not a fragmented delivery based on bits of it. What is required, therefore, is a system of care where the parts form an interrelated whole. Easier said than done.

In the Rhondda two questions arose:

0 Who would manage unqualified staff providing basic services - Social Care Workers (SCW’s)?

0 How would qualified staff from different professions and employing agencies work together?

These questions raised the underlying issue of whose work it was to ensure this happened. Whilst the Service Coordinator could do some of the work it was clear he could not coordinate the direct service provided to all service users. The first step was to make it clear that the work of management would be shared. SCW’s would be equally

IAN MACDONALD is Director of the Mental Handicap Services Unit, BIOSS, Brunel University, Uxbridge, UB8 3PH.

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available to all service staff; that is, there would not be specific SCWs for nurses, social workers, psychologists, or other professional groups. Also, in each of the three geographical “zone” teams key workers would be responsible for coordinating and delivering appropriate services to each person with a mental handicap.

Three components of work However, it was not as simple as that. What had been

underestimated was the amount of work involved in answering the two questions, which led to the analysis of all work into three components. This analysis was developed from findings in industrial settings (see, for example, Brown, 1971 ; Jaques, 1976).

Specialist work. This work is based and dependent upon a particular training and background. It requires a specific technical expertise in methods and usually theory.

Shedding work. This work involves programming, organising the work of oneself and others. It is classically that of plan coordination (such as compiling an Individual Plan). It includes the work of gaining knowledge of relevant contributions, and arranging meetings, venues, and appointments.

Communicating work. This work is what is generally known as “management” but is broader since it also involves exchanging information with colleagues or seniors. It includes clearly explaining tasks, allocating work and, in relation to SCW’s, discussing and reviewing progress.

One problem in the teams was the concern that the specialist role was being eroded. At first it appeared to be a “nursing problem”; an anxiety that nurses might lose their professional identity and become indistinguishable from social workers. Using the components of work analysis, however, it became clear that this concern was not specific to one profession. The need to manage SCWs and coordinate plans inevitably reduced the amount of time available to deliver specialist work, no matter what the profession. This leads on to a more general finding that is not only relevant to the RVS.

Real work Amongst the caring professions scheduling and

communicating work is often devalued. It is not seen as real work, compared to the delivery of direct care to a service user employing the specialised skills learnt through training. This work must be done if a fragmented service is to be avoided; but too often, it is seen as “boring admin.”, the view being that “such tasks should be obvious anyway and besides there are just too many meetings”. This view is compounded at times of stress; for example, while a service is changing or, as in the case of the RVS, developing. People under stress hang on to their core identity and look for work which gives them immediate and demonstrable feedback and reward. This is most easily to be found in the specialist component. It feels more like real work, doing something, the action in itself tending to reduce anxiety. Scheduling work, on the other hand, feels like delay, which in one sense it is. Both scheduling and communicating work involve reflection, a case of “look before you leap”. This can be time-consuming, especially the arranging of meetings and appointments. It can also be frustrating and seen at times as an unnecessary

waste of time, “when you could be out there doing something”. It is tempting to forget that “getting out there doing things” can actually lead to confusion if others are not clear why and what you are doing.

Thus the overall difference between the previous and current service is the formal requirement of scheduling and communicating work. This analysis may seem to miss out the aspect of service development, but this work should occur anyway; and, if anything, learning and developing new methods of delivering a service may further devalue the scheduling and communicating components. There is another possibility as to why these two components are seen as less important. It may be that current general ideologies place a great deal of emphasis on outcome and direct action; in other words, demonstrable work with immediate results. This almost macho approach demeans the necessary context setting, the emphasis on process, and the construction of a matrix which nurtures over a longer period and is more difficult to associate with a particular outcome.

In the RVS the Project Leader and Coordinator used the components of work analysis to re-examine roles, especially of the service deliverers. What was assumed to be a role with a majority of specialist work became more equally distributed. This in turn had implications for existing job descriptions, advertising for and recruitment of new staff, and relevant methods of management and supervision which were, and are, under discussion.

Systems design Whilst it is important to use all three components to

understand the balance of work required in a role, the fundamental purpose of any agency, including the RVS, is the eventual delivery of a service to a service user. Actually coordinating meetings and communicating with others can be really time-consuming and inefficient, even if the work is seen to be important. But each component of work can be simplified by good systems design. In specialist work this is achieved through the development of new methods and techniques which in turn become skills learnt by a practitioner.

A skill has the main function of simplifying work. Although it may be difficult to acquire a skill, once acquired it reduces the complexity of the task in hand. A system is an organisational skill. Even having a clear job description reduces complexity, since it allows the person to proceed without constant reference and negotiation. In everyday life people are always developing systems to simplify work: for example, routines - shopping on Friday, having a place for the torch and the tool kit - save time. Living in a social group like a family, however, requires that these systems are understood and followed. “Who hasn’t put the scissors back!” is perhaps a familiar cry which leads to time-wasting recriminations and searching, so delaying the task. Questions, for example, “Mum, where are my socks?”; “Dad, have I got a clean shirt?”, test assumptions about supply systems. The existence of systems is least apparent when those systems are working. They, too, can be undervalued, or seen only in terms of their restrictive properties.

For a system to work well it must not only model good and required practice, it must take into account the user (hence “user-friendly” computer systems) and anticipate problems (Macdonald, 1988). It is my experience that in most

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organisations systems are designed at too low a level or by “technocrats” (Macdonald et aL9 1987). The designer must be able to understand fully the work of the user and recipient, abstract the essential components, and then build a generalisable working model. Most people have experienced insensitive systems, such as staff rotas, ordering of supplies, and work sheets. It is tempting to import systems wholesale, for example individual programme planning systems, which then fail to work adequately and result in criticism of the system. This is an attempt to avoid the real work of re- designing a system for local needs. The RVS uses a system based on the Open University Shared Action Plan (Open University, 1986) which does allow for, indeed requires, local design.

In the RVS there are three staff in roles which, partly as a result of the analysis of levels of work, were clarified as undertaking systems design work. Although the original structure described the Coordinator as “managing” these staff, after an analysis of the level of work and of the Coordinator’s role (which is largely operational), it was clearly seen to be more appropriate for these staff to be accountable to the Project Leader (Macdonald, 1987). The work of these staff is concerned with the development of the service in terms of devising a range of systems to help working practice. Their work is to be the focus of the next area of collaborative research (Macdonald & Webb, 1987).

Although a relatively high level of work is required for good systems design, it does not have to be done at a distance. It is critical that service staff and service users are consulted and that they contribute information which can be incorporated into the design. Most practitioners do not have the time, even if they have a capability, to design their own systems. If they did it is likely that their systems would be biased towards their own practice rather than that of practitioners in general.

Conclusion This article has attempted to draw on the experience of the

RVS to make some general points. Firstly, that it is common for practitioners to undervalue the work of scheduling and communicating in comparison to specialist work. The need to pay attention to scheduling and communicating aspects is necessary in a coordinated or integrated service. It may mean receiving fewer contacts but these should be more effective. Secondly, the emphasis on scheduling and communicating aspects should not be used to justify delay in providing specialist services, or a significant reduction in service delivery, especially with regard to quality. The extent to which these two components are done well, and do not waste time, is dependent upon the systems design, which also can be underestimated.

Finally, whatever work a person is involved in should be real work. Although specialist work is more easily seen to contribute to meeting service objectives than other types of work, its effect will diminish if the context or support work is devalued. Although it may seem more exciting, it is not really in the long-term interest of service users to provide an action packed, reactive service. Members of the RVS, however, appreciate the amount of real work required to provide the alternative.

Acknowledgements

members and research colleagues. The author would like to acknowledge the work of the RVS team

REFERENCES Brown, W. Organisation. London: Heinemann Educational

Books, 1971. Jaques, E. A General Theory o f Bureaucracy. London:

Heinemann Educational Books, 1976. Macdonald, I. Assessment: a social dimension. In Barton, L.,

Tomlinson, S . (eds.). Special Educational Policy, Practices and Social Issues. London: Harper and Row, 198 1.

Macdonald, I. The Role of the Accommodation Development Officer and Relationships with Other Staff in the Rhondda Vanguard Service (Rhondda Project Paper). Uxbridge: MHSU, BIOSS, Brunel University, 1987.

Macdonald, I. Translating Policy into Action. Uxbridge: MHSU, BIOSS, Brunel University, 1988.

Macdonald, I . , Middleton, D., Notley, C. , Ovretveit, J . The Organisation and Development of the Rhondda Vanguard Service. Uxbridge: MHSU, BIOSS, Brunel University, in press.

Macdonald, I . , Palmer, T., Stewart, K . , Woffenden, M. Informaton S-vstems. Melbourne: CRA Services Ltd., 1987.

Macdonald, I . , Webb, C. Management and Development of Multidisciplinary Teams: a model for the Rhondda Vanguard Service (Rhondda Project Paper). Uxbridge: MHSU, BIOSS, Brunel University, 1987.

Open University. Mental Handicap: parterns for living. London: DHSS with MENCAP, 1986.

Rhondda Vanguard Service. Report of Progress: April 1986- March 1987. Cardiff RVS, 1987.

Welsh Office. Alf Wales Strategy for the Development of Services for Mentally Handicapped People. Cardiff: Welsh Office, 1983.

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0 1988 British Institute of Mental Handicap 67