Shaping the future for primary care education and training project. Finding the 

evidence for education and training to deliver integrated health and social care: 

the project experienceHolland, K

Title Shaping the future for primary care education and training project. Finding the evidence for education and training to deliver integrated health and social care: the project experience

Authors Holland, K

Type Monograph

URL This version is available at: http://usir.salford.ac.uk/52/

Published Date 2006

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www.pcet.org.uk

Shaping the Future for PrimaryCare Education & Training Project

Funded by the NorthWestDevelopment Agency

Authors: Karen HollandThe University of Salford

Tony WarneThe Manchester Metropolitan University

Keith LawrenceThe University of Salford

Volume 9

2006

Finding the Evidence for Education and Training to

Deliver Integrated Health and Social Care:

The Project Experience

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ContentsPage

Executive SummaryIntroduction 5Major Findings and Recommendations 5Conclusion 9

Chapter One: Education and Training in Health and Social Care 101.1 Introduction 101.2 Drivers for Change 101.3 Integrated Health and Social Care 101.4 Workforce Development and Planning 111.4.1 The Primary Care Workforce Planning Review 121.5 Education and Training of the Health and Social Care Workforce 131.6 Conclusion 15

Chapter Two: The Project Design 162.1 National and Local Context in which the Project was situated 162.2 Aims and Objectives of the Project 162.3 Project Management 172.4 Monitoring and Evaluation 182.4.1 Internal Evaluation 182.4.2 External Evaluation 182.5 Audit Compliance 182.6 Steering Group 182.7 The Project Development and Outcomes 182.7.1 Project Management (Work Package 1) 182.7.2 Stering group Contribution 182.7.3 Internal Evaluation 192.7.3.1 Effective Collaboration between Higher Education Institutions 202.7.4 The Systematic Review (Work Package 2) 222.7.5 Benchmarking of Best Practice in Integrated Health and Social Care Education

and Training (Work Package 3) 222.7.6 Mapping of Education and Training Provision from Higher and Further Education 232.7.7 Vision for the Future-Health and Social Care Workforce Perspectives 232.7.8 Visions for the Future-Service user Perspectives (Work Package 6) 232.7.9 Education and Training Needs Analysis (ETNA) Model Development (WP7)

and Piloting and Evaluation of ETNA Toolkit (WP8)2.7.10 Dissemination (Work Package 9)

2.7.8 Collaboration 242.8.1 The Collaborative Experience of the Reasearch Team 242.9 Conclusion 25

2323

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Chapter Three: Education and Training to deliver integrated Healthand Social Care: The Future

3.1 Introduction3.2 Emerging Themes3.3 Recommendations for HE/FE Organisations 273.4 Recommendations for Primary Care Trusts and Integrated Health

and Social Care Organisations 283.5 Recommendations for Service User/Carer Involvement in Education

and Training Development and Delivery3.6 Discussion3.7 Conclusion 33

References 34

Bibliography 36Appendix 1 Steering Group Membership 37Appendix 2 Steering Group Terms of Reference 38Appendix 3 Dissemination Activity of the Project Team 39Appendix 4 Knowsley Collaborative Event Report 41Appendix 5 Inter-Professional Learning in Primary Care Collaborative Event Report 45Appendix 6 Biographies of the Project Team 50

Acknowledgements 55

List of Figures, Tables and BoxesFigure 1: Project Management Communication 17Figure 2: Factors Leading to Successful Collaboration 21Figure 3: Framework of Evidence 26Figure 4: Framework of Education and Training 27Table 1: Roles of the Evaluator 19Box 1: Extract from Greater Manchester Integrated Health and Social Care 15

Workforce Strategy 2005-2010

262626

2930

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Executive Summary

Introduction Collaboration and partnership workingbetween Higher and Further Educationand the NHS and Social Care services isan essential requirement for effectivedelivery of care. The North WestUniversities Association (NWUA) and theNorth West Development Agency(NWDA) are two organisations at theforefront of creating such alliances. Theresearch project Shaping the Future forPrimary Care Education and TrainingProject was a collaborative partnershipbetween these two organisations andseven Higher Education Institutions inthe North West of England. In addition,the project brought together for the firsttime key partners in the health, socialcare and education sectors who areinvolved in supporting the delivery ofintegrated health and social care in theNorthwest Region.

The ProjectThe project had a project managementand development team and aparticipative Steering Group. For ease ofimplementation the project was dividedinto a series of Work packages, based onthe key objectives, each one led by oneof the partner Higher EducationInstitutions (HEI’s).

The main aim of the project was toidentify the evidence based for deliveryof integrated health and social care, theskills and knowledge required to deliverthis care, together with the current andfuture education and training needs ofthe North West of England Primary CareWorkforce (Work Package 1–ProjectManagement). The key objectives of theproject were:

(a) To provide a comprehensive literaturereview of the evidence base forintegrated health and social care serviceswithin the regional, national andinternational contexts (Work Package 2).

(b) To identify areas of current practice incollaborative working and integratedhealth and social care in the community,including education and traininginitiatives and develop a Benchmarkingtool for achieving best practice in

providing education and training forintegrated health and social care servicesfor Primary Care Trusts (PCT’s) setting upsuch services (Work Package 3).

(c) To map Higher Education/FurtherEducation provision of education andtraining which can support the deliveryof integrated health and social careservices, through:

n The creation of a database ofprovision of education and trainingfor health and social careprofessionals and workers availablein the North West HEI’s/FEC’s linkedto the Workforce DevelopmentConfederations and update thisdatabase annually during the lifetimeof the project. This would include thedevelopment of a Course Finder Tool(Work Package 4).

(d) To identify visions for the future forboth health and social care workforceand service users through thepreparation of a report which identifiesfor both groups:

n Perceptions of strength andweaknesses associated withintegrated health and social careeducation and training;

n Perspectives on future trainingrequirements needed to deliver thehealth and social care agenda (WorkPackage 5 and 6).

(e) To develop and pilot an Educationand Training Needs Analysis Model andTool (ETNA) for identifying the educationand training needs of the Primary CareWorkforce to meet the NHS and SocialCare agendas (this included both clinicaland health management staff) (WorkPackage 7 and 8).

(f) To disseminate, throughout thelifetime of the project, its activities andoutcomes to a range of stakeholders inthe North West, from service users toservice managers. This would include avariety of dissemination methods such asseminars, workshops, conferences andthe setting-up of a dedicated website(Work Package 9).

Major findingsand recommendations The evidence provided in the SystematicReview (Work Package 2) was central tothe development of all the other projectoutcomes and outputs. The six keythemes, namely team working, roleawareness, communication, personaland professional development, practicedevelopment and leadership andpartnership working, were seen to behelpful in providing guidance forresearch questions and thematicanalysis, together with the developmentof the final tools of the project, namelythe Benchmarking of Practice inEducation and Training for IntegratedHealth and Social Care Tool (WorkPackage 3) and the Education andTraining Needs Analysis (ETNA) Tool(Work Package 7 & 8).

In collating the evidence from all the‘sub-projects’ (Work Packages) itbecame apparent that as well as the sixkey themes which guided the researchoutcomes, that there were other majorthemes emerging. The mostpredominant was that of the centralityof inter-professional/inter-disciplinaryand inter-agency working and to someextent learning in the delivery ofeffective integrated health and socialcare services. The other themes were theneed for collaboration and the need forservice user involvement in educationand training. The overarching findings,including these themes, will bepresented through determining therecommendations made across all theresearch and development activity tothree key areas:

n Higher and Further EducationOrganisations;

n Primary Care Trusts and integratedhealth and social care organisations;

n Service user/care groups.

It is recognised, however, that in manyinstances there was an overlap across allthree areas. The main evidence will bepresented as key points collated fromthe Work Package reports.

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Recommendations for Higherand Further EducationOrganisations

Team Working n Education and training programmes

need to take cognisance of teamworking in integrated health andsocial services, not simply working ina team (WP2);

n Education and training for teamworking needs to be planned totake account of both inter-professional and inter-agencyworking (WP2);

n Pre-registration/access to health andsocial care work programmes needto place greater emphasis on teamworking in integrated health andsocial care as a core skill (WP2);

n Ensure that all educational andtraining learningobjectives/outcomes reflect nationalcompetency framework standards(WP5);

n Ensure that service managers andeducationalists work to developlearning opportunities on how todeal with the realities of teamworking across different professionsand agencies (WP5);

n Include clear models of goodpractice in integrated care in thetraining of health and social careworkers (WP6).

Communication n Pre-registration and access to health

work programmes need to ensurethat effective communication skillsfor integrated working, includinguse of technology, are core skills(WP2);

n Ensure that all education andtraining learningobjectives/outcomes reflect nationalcompetency framework standards(WP5);

n Ensure that service managers andeducationalist work to developlearning opportunities focused onhow to deal with the realities ofteam working across differentprofessions and agencies (WP5);

n Place greater emphasis in trainingon the use of basic communicationskills (especially listening skills) indirect client work (WP6).

Role Awarenessn Role awareness should become an

essential element of all programmesrelating to preparing the workforceto deliver integrated health andsocial care (WP2);

n Shared learning initiatives betweenhealth and social care workforcestudents in practice should beencouraged to develop awarenessand understanding of team roles(WP2);

n Ensure that all pre-qualifyingeducation programmes, ContinuingProfessional Developmentprogrammes and activities, moreeffectively promote role awarenessand inter-professional working(WP5);

n Ensure that where possible all CPDprogrammes aimed at increasinginter-professional working areplanned and delivered as jointenterprises (with health and socialcare, HEI’s and service users) (WP5);

n More effectively involve HEI’s inproviding empirical approaches tosupport service developments(WP5);

n More opportunities for health andsocial care workers to train togetherto enhance appreciation of differentprofessional perspectives /crossingof professional boundaries (WP6).

Practice Development andLeadership n Leadership education and training

for integrated health and social careservices needs to be built intoeducational programmes for allprofessions (WP2);

n Practice development in integratedhealth and social care requirescollaboration between educationand training organisations anddepartments to ensure skills andknowledge base meets therequirements for service useroutcomes (WP2);

n Develop multi-professional andinterdisciplinary CPD activities thatare aimed at strengtheningleadership capabilities across alllevels of the workforce (WP5);

n Continue to work collaboratively inensuring national quality assuranceprocesses for educational providersinform the development, deliveryand evaluation of educational andtraining programmes (WP5).

Personal and ProfessionalDevelopment n Flexible learning opportunities need

to exist to enable the workforce tobe able to access inter-professional/inter-agency workingprogrammes (WP2);

n Increase the awareness within PCT’sand future service providers of thescholarship role that universities canhave in supporting individualpractitioners and PCT’s (WP5);

n Ensure the development anddelivery of both educational andtraining programmes moreeffectively reflect practice needs aswell as those arising from academicinterests (WP5).

Partnership Working n Partnership and collaboration

between health and social careshould be essential in thedevelopment of curricula forintegrated health and social care(WP2);

n Education and training standardsfrom professional bodies shouldinclude core requirements forpartnership working, taking accountof team working, effectivecommunication and role awarenessas essential elements of theprogramme (WP2);

n Ensure multi–professional andinterdisciplinary CPD activities aredeveloped that are aimed atincreasing the understanding ofroles and responsibilities (WP5);

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n Ensure that future education andtraining competency standardsinclude core requirements forpartnership working (WP5).

Recommendations forPrimary Care Trusts andIntegrated Health and SocialCare Organisations

Team Workingn Develop teams with the appropriate

skills and knowledge, that are ableto liaise and work collaborativelyacross organisations and agencies(WP2);

n Ensure that any team has therequired awareness of all themember role functions andprofessional background asappropriate (WP2);

n Service planning and serviceprovision need to take account ofthe education and training requiredfor a whole team when creatingnew roles (WP2);

n Co-location of teams needs to takeinto account education and trainingfor new ways of working (WP2);

n Develop change managementknowledge and skills at all levels ofthe workforce and ensure serviceusers and carers are partners inthese processes (WP5);

n Undertake organisational cultureanalysis aimed at promoting aculture which supports greaterinvolvement of the wider workforcein decision making processes (WP5);

n Provide structured and regular‘timeout ‘sessions aimed atharnessing organisational learning(WP5);

n Develop systematic organisationalevaluative strategies that arecapable of evidencing improvedteam working (WP5).

Communication n Ensure staff working in integrated

teams have well developedcommunication skills to enable themto work within and across inter-

professional and inter-agencyboundaries (WP2);

n Ensure a common language is usedbetween health and social careorganisations to aid effective teamwork (WP2);

n Ensure that the workforce has theknowledge and skills to managechanging communication channelse.g. information technology (WP2);

n Address workload allocation ofhealth and social care workers toallow time for meaningfulinteraction with clients (WP6);

n Promote and support thedevelopment of a ‘commonlanguage’ for integrated health andsocial care, recognising theorganisational and professionalsocialisation processes that militateagainst this (WP5);

n Ensure greater transparency in theexchange and access to informationthrough further development ofnew technologies (WP5);

n Ensure the development of ITsystems that are multi-agencycapable and fit for purpose (WP5);

n Develop engagement processes thatsupport greater organisationinnovation and confidence in how ITsystems work (WP5).

Role Awarenessn When developing new roles ensure

that there has been organisationalpreparation for their introductioninto the workforce (WP2);

n A variety of innovative learningopportunities need to beconsidered, including roleshadowing, secondments to workwith multi-professional teams andinter-professional education (WP2);

n Develop more structuredapproaches to supporting andrecognising the value of informalinter-professional and organisationallearning (WP5).

Practice Development &Leadership n Leaders need to be identified and

educated to lead integrated healthand social care services (WP2);

n Practice development needs to beled by leaders who take account ofa cultural change needed to ensureeffective working in integratedhealth and social care services(WP2);

n Ensure that practice developmentactivities are facilitated by leadersskilled in cultural change processesand that these activities aresystematically evaluated (WP5);

n Ensure protected time is identifiedspecifically for multi–agency practicedevelopment and CPD activities(WP5);

n Ensure that PCT’s, future serviceproviders, educationalcommissioners and providers workcollaboratively in developing newCPD programmes which reflect thechanging nature of health and socialcare practice and the changingenvironments where such practice isundertaken (WP5).

Personal and ProfessionalDevelopmentn Compatibility needs to exist

between all the NHS and SocialCare skills and knowledgeframeworks in ensuring theworkforce is able to work inintegrated health and social careorganisations and services (WP2);

n Supportive environments needs toexist to enable personal andprofessional development inintegrated working (WP2);

n Being able to work in integratedhealth and social care situations atall levels of organisations should bebuilt into role descriptions and jobspecifications (WP2);

n Continue to develop meaningfulopportunities that promote life longlearning and the systematicidentification of training needs(WP5);

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n Regularly evaluate the impact anduse of new workers in the roles andfunctions of the existing workforce(WP5);

n Increase the opportunities to worktogether in developing moreeffective learning environmentscapable of supporting flexiblelearning within PCT’s and futureservice providers (WP5);

n Agree a joint framework agreementfor CPD that supports in-house CPDactivities being credit rated (WP5);

n Ensure that the knowledge and skillrequired to work in integratedhealth and social care services(including in education) from thebasis of job descriptions and rolespecifications (WP5);

n Ensure that integrated personal andprofessional development strategiesare explicitly linked to organisationalchange strategies and businessplanning processes (WP5);

n Develop transparent and effectivedecision making processes that arecapable of handling the personal,professional and organisationaltensions involved in determiningwhat is seen as ‘useful knowledge’(WP5).

Partnership Working n Leaders of integrated health and

social care services need to offer asupportive culture for integratedworking and delivery of care (WP2);

n Develop specific roles to facilitateinter-agency partnership working atthe Micro and Meso levels of theworkforce (WP5).

Recommendations for serviceuser/carer involvement ineducation and servicedevelopment and delivery n Ensure service users of integrated

services are integral to developingcommunication networks andlanguage (WP2);

n Role awareness education forservice users/carers should beconsidered essential to ensure

effective communication andappropriate use of services (WP2);

n Service users need to be involved inany education and trainingdevelopment which promotespartnership working (WP2);

n Role awareness education forservice users and carers should beconsidered essential to ensureeffective communication andappropriate use of services (WP2);

n Establish professional qualificationpathways for home care workers(WP6);

n Service users need to be involved inany education and trainingdevelopment which promotespartnership working (WP2);

n With service users and carersdevelop communication processesaimed at ensuring service users andcarers can better understand thedifferent roles and responsibilities ofthe workforce (WP5);

n Improve opportunities for greaterservice user and carer involvementin education and trainingprogrammes in order to increaseawareness and responses to driversfor practice development (WP5);

n With service users and carers, worktowards developing a shareddefinition of the criteria that can beused as a benchmark for systematicservice evaluation of integratedhealth and social care services(WP5);

n Ensure there is an explicitrequirement to demonstrate theinvolvement of service users ineducational and training activities incommissioning agreements (WP5);

n Proactive consultation mechanismsare needed to identify the types ofservices that users would like to seein place. Current arrangements aretoo passive–the service user has totake the initiative (WP6);

n Find ways of capitalising on obviousservice user enthusiasm for training(WP6);

n Involve service users ininterdisciplinary training sessions to

enhance workers appreciation ofuser perspectives (WP6);

n Significant increase in investment intraining for home care agencyworkers (WP6);

n Emphasise that partnership workingmeans partnership between workersand service users–not only betweenworkers (WP6);

n Raise both workers’ and serviceusers awareness of the meaning ofintegrated health and social care;that is not only integration betweenwork of different health and socialcare professionals but alsointegration between the work ofhome care staff and ‘professionals’(WP6).

Although these recommendations aregenerally self-explanatory and arethematically aligned, it was identifiedthat in many instances there wasintegration between many of them.Thus, we argue, that therecommendations should be read as arelated constellation of changes, ratherthan as single and specific items thatmight somehow require simultaneousimplementation by those concernedwith the provision of primary health andsocial care services, and thecommissioning and provision ofeducational and training programmesaimed at developing the workforce.Indeed we assert a priori that suchsimultaneous implementation would beboth impossible and undesirable.

The project outcomes, including therecommendations noted above, must beseen against the backdrop of unrelentingchange. It was clear from data collectedin developing the evidence bases thatthere were multiple versions of a visionof integrated health and social careraises the consequential possibility thatnot only might individual PCT’s beinvolved in a process of conceptualtransitions, but individuals within thesePCT’s might be involved in parallel butdifferent processes of conceptualtransitions (Warne et al 2005).

Such conceptual transitions are inthemselves, manifestations of thevarious layers of change beingexperienced by individuals and theirorganisations.

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This project has resulted in significantoutputs and recommendations. They canbe used collectively when establishingnew services or individually when forexample assessing the education andtraining needs of the workforce. Theircombined outcomes, however, will be ofvalue to all integrated health and socialcare organisations in their quest todeliver integrated services, which in turnwill benefit the local communities. It isalso anticipated that therecommendations and outputs will be ofvalue to Higher and Further EducationInstitutions in order to establish theirown strategic plans for working withhealth and social care providers toensure an effective and educatedworkforce to deliver integrated healthand social care.

Conclusion The success of this Shaping the Futurefor Primary Care Education and Trainingproject has been the result of theeffective collaboration between HigherEducation providers and theorganisations delivering and developinghealth and social care. It is our belief thatthis should be the precursor of othersuch initiatives which examine the linksbetween education and service needs inorder to ensure that the pursuit ofeffective integrated health and socialcare services becomes a reality.

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Chapter 1:Education and Training in Health and Social Care

1.1 IntroductionIn November 2001 a meeting was heldat the University of Salford to discuss thepotential for undertaking amulti–university collaborative researchproject to investigate the futureeducation and training needs of theworkforce in Primary Care Trusts (PCTs).This meeting led to a proposal that theUniversity of Salford would prepare a bidfor funds, on behalf of interested HigherEducation Institutions, to the North WestDevelopment Agency (www.nwda.co.uk). This is one of nine RegionalDevelopment Agencies, which ‘were setup by the Government to promotesustainable economic development inEngland’ (www.england srdas.com). TheNWDA has 5 key priorities, namely‘Business Development, Regeneration,Skills and Employment, Infrastructureand Image’ (http://www.nwda.co.uk). Allthe Higher Education Institutions (HEIs)involved in the collaborative initiativewere members of the North WestUniversities Association and HigherEducation North West. It was throughthis Association, as part of its strategicdirection for the health field, that thepotential for such a collaborativepartnership originated.

The Shaping the Future for PrimaryCare Education and Training project(to be known as Shaping the Futureproject) was an opportunity for anumber of key stakeholders in healthand social care and education tocollaborate in a new and unique way,both directly through the projectoutcomes and indirectly throughcreating communities of learning acrossthe North West Region. This final report,in the collection of the nine volumes thatmake up the record of the Shaping theFuture project, aims to provide an insightinto how these stakeholders experiencedthe project and what can be learnt fromhow the project was taken forward. Thestarting point is to briefly reacquaint thereader with the drivers that have led to are-focusing of the educational andtraining processes for health and socialcare professionals.

1.2 Drivers for ChangeEnsuring that the health and social careworkforce is educated and trained tomeet changing community needs isconsidered essential for current and

future health and social care serviceprovision. There is also a need to ensurethat members of that community haveopportunities to access and gainemployment, that an existing workforcecan be re-skilled whenever possiblerather than being made unemployedand that key roles are retained.Education and training is one key tosuccessful achievement of suchinitiatives.

The publication of the New NHS:Modern, Dependable White Paper set intrain the most comprehensive attempt tomodernise the United Kingdom (UK)National Health Service (NHS)(Department of Health, 1997). Greatercollaborative, interagency and inter-professional working were keyconceptual themes underpinning thestructural and functional proposals ofthis modernisation agenda. It was theNHS Plan (Department of Health, 2000)that, in setting out a ten year blue printfor the implementation of thesechanges, brought into sharp focus theoverarching policy objective ofdeveloping a primary care orientatedNHS. Such an orientation was predicatedon healthy rhetoric that sought toachieve the conceptual shift frompartnership working (represented byinter professional and interagencyworking) to integrated working (Warneet al, 2002). Howarth et al (2004)highlighted a number of ontologicallydriven issues that continue to impact onthe effective development of integratedhealth and social care services. Theseincluded:

n Increasing collaborative workingbetween health and social care, atpolicy, and practice levels;

n Creating a ‘seamless’ service forpatients based on a commitment toreduce health and social inequalitiesand protection and support ofvulnerable people in society(Howarth et al 2004: 14).

The atypical nature of these issues, inrelation to the wider modernisationagenda, belied the paucity of definitionalclarity to be found in either the empiricalliterature and/or governmentalguidance.

The atypical nature of these issues, inrelation to the wider modernisationagenda, belied the paucity of definitionalclarity to be found in either the empirical

literature and/or governmentalguidance.

1.3 Integrated health andsocial care The initial review of the literature carriedout for this project (Howarth et al 2004)highlighted a lack of clear definitions ofwhat and how integrated health andsocial care represented, and concludedthat integration was dependent on‘successful partnerships between serviceproviders, agencies and professionalgroups’. The Department of Health notethat integrated care is:

“ When both health and social careservices are combined to ensureindividuals get the right treatmentand care that they need. It helpsfrontline organisations to worktogether to deliver flexible servicesthat help people to remain incontrol and live independent lives.”(http://www.dh.gov.uk/AboutUs/DeliveringHealthAndSocialCare/fs/en)

Mur-Veerman et al (2003) envisionedintegrated care as:

“ an organisational process ofcoordination which seeks to achieveseamless and continuous care,tailored to the patients’ needs andbased on a holistic view of thepatient”. (Page 1)

In a similar definition van Raak et al(2005) proposed that integrated care as:

“ a coherent and co-ordinated set ofservices which are planned ,managed and delivered to individualservice users across a range oforganisations and by a range of co-operating professionals and informalcarers. It covers the full spectrum ofhealth and health care related socialcare” (van Raak et al 2003).

These views of integration as ‘workingtogether’ in a co-ordinated way can beseen in a number of policy decisions anddevelopments across Europe. One of themost significant areas for thedevelopment of integrated services hasbeen in the care of older people(Glendinning, 2003). An example can beseen in an international research project‘Providing Integrated Health and SocialCare for Older Persons’ (PROCARE) theresults of which suggest:

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“ that the last 20 years have broughtpartial success in integrated workingand some clear examples ofinnovative practice, yet overall thereappears to be evidence of failure tosustain cooperation between theorganisations that are involve”.(Leinchsenring 2004: 10)

Christiansen and Roberts (2005:270)note that ‘it is well recognised that poorco-ordination between health and socialcare providers can have a devastatingeffect on vulnerable old people’ whooften have ‘complex multidimensionalneeds that span the spectrum of socialcare, primary cane and secondary care’.The introduction of the singleassessment process as part of theNational Service Framework for OlderPeople (Department of Health, 2001)should in their view contributesignificantly to the success of integratedcare. They conclude, however, that thissuccess is dependent on overcomingbarriers and that most importantly:

“ This will depend on adequatesupport for the professions involved,and continuing education andtraining to bring health and socialcare providers into closer alignmentso that policy objectives aredelivered to clients and theircarers.” (Christiansen & Roberts2005:277)

To illustrate the present UKGovernment’s commitment tointegrated services, a joint White Paperwas announced in July 2005(Department of Health, 2005). Itspurpose ‘to bring together proposals forboth adult social care and all carereceived outside hospitals’. The healthminister Liam Byrne, stated in support ofthis that ‘dignity for life is our ambition.A joint White Paper will help putindividuals and their families at thecentre of care’. Alongside thiscommitment to patient led services theDepartment of Health has alsocommitted itself to ensuring that theorganisations delivering andcommissioning services should be able todo so. The publication in March 2005 of‘Creating a Patient led NHS- Deliveringthe NHS Improvement Plan’ (Departmentof Health, 2005) sets out the changesenvisioned for the future structure and

management of Strategic HealthAuthorities (SHAs) and Primary CareTrusts (PCTs).

It is clear that as these changes come tobe implemented those involved in takingthese changes forward require greaterclarity of purpose. The various teamsworking on the Shaping the Futureproject were faced with similarclarification needs. Against thisconfusing and complex plethora ofdefinitions that made up the context forthe Shaping the Future project, adecision was required in relation to whatthe team could use that would provide ashared understanding for all parties. Theteam involved in researching thesystematic review brought a number ofdefinitions, which highlightedintegration as a theme. However it wasagreed that we would use our owndeveloped term in order to ensureconsistency and simplicity. Thus, theShaping the Future working definitionof integrated health and social care usedwas:

“ Care that is determined bypartnerships between health andsocial care agencies and users/carersfor the health and well being of the(local) community.”

This definition is in keeping with some ofthe definitions of integrated health andsocial care that have continued toemerge over the life of the project. Asthese definitions and terms have begunto emerge and used in planningprocesses for the integration of services,other factors have come to the fore. Forexample, the need to ensure that theworkforce required to deliver thechanges will in turn have differenteducation and training needs.

Effective workforce development andplanning becomes essential, as does theneed for collaboration between Higherand Further Education and the NationalHealth Service (NHS). The Department ofHealth consultation report (Departmentof Health 2002:2) on the funding anddevelopment for the healthcareworkforce highlighted that futurefunding should be ‘reorganised on aninterdisciplinary basis’ and should be‘underpinned by key values oftransparency, equity, comprehensiveness,responsiveness, integration, partnershipand flexibility’. Of particular relevance to

the Shaping the Future project was thevalue of partnership whereby it wasnoted that:

“ the health and education sectors,social care and private and voluntarysectors should work together todeliver training .There should becontinuing support for learning anddevelopment from the wider NHSand more recognition of theincreasing role of further educationin the development of the NHSworkforce” (Department of Health2002:2)

1.4 Workforce Developmentand Planning

In their March 2001 report on Educationand Training the Future HealthProfessional Workforce in England, theNational Audit Office outlined thesignificant developments, which hadtaken place in relation to developing theworkforce since the early 1990s. Theyalso made recommendations for futureworkforce development in educationand training arrangements. Theseincluded the recommendation thatfuture Workforce DevelopmentConfederations would need to ensurethat they:

“ involve higher education institutionsat all levels in planning educationand training, both strategic andoperational and adopt a jointapproach including sharedresponsibility for recruitment,selection and retention”.

Workforce Development Confederationswere established in April 2001 followingthe publication and consultation of AHealth Service for All the Talents:Developing the NHS Workforce(Department of Health, 2000). Thisdocument was the direct result of theHouse of Commons Health SelectCommittee recommendations(Department of Health, 2000) for amajor review of workforce planning inthe NHS. The terms of reference for thisreview were to review workforceplanning arrangements for allprofessional groups in the NHS:

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n Considering the roles andresponsibilities for workforceplanning at all levels within the NHSand the NHS Executive;

n Exploring the opportunities andbarriers which currently exist foreffective and efficient workforceplanning within the context ofcurrent related policy initiatives andknown future changes likely toimpact on the workforce(Department of Health, 2000:3)

The underpinning philosophy to theseproposals was one predicated on theappeal that ‘caring for people is whatthe NHS is all about’ and to achieve thisrequired development and investment inthe NHS workforce. Social Services andSocial care reforms in workforcedevelopment was not at this stageincluded in the proposals, although anote was made in relation to the needfor high quality care which was‘seamless between primary, secondaryand tertiary services and care which isintegrated with other services, forexample, social services’. The proposalswere considered ‘wide ranging andradical’ and focused on the followingthemes (Department of Health, 2000):

n Team working across professionaland organisational boundaries;

n Flexible working to make the bestuse of the range of skills andknowledge which staff have;

n Streamlined workforce planning anddevelopment which stems from theneeds of patients and not ofprofessionals;

n Maximising the contribution of allstaff to patient care doing awaywith barriers which say only doctorsor nurses can provide particulartypes of care;

n Modernising education and trainingto ensure that staff are equippedwith the skills they need to work ina complex changing NHS;

n Developing new , more flexiblecareers for staff of all professions;

n Expanding the workforce to meetfuture demands (Department ofHealth, 2000:5).

Implicit within the recommendations forimproving training, education andregulation was the ‘need to build on,and develop, partnership working withthose providing training and educationfor the NHS workforce and with therelevant regulatory bodies’ (p7).Working in a multi-professional/multi-disciplinary way was also advocated aswas the need to view the workforce as‘teams of people rather than differentprofessional tribes’. The reviewrecommendations focused on ‘makingthe needs of patients central toworkforce development’. The results ofthe consultation focused on five keyareas (Department of Health, 2001):

n Modernising education and training;

n Changing working patterns;

n New systems of workforce planning;

n Modernising funding arrangementsand

n Further reviews.

The consultation responses specificallyidentified that there was adisappointment that ‘the review had notdealt with primary care workforceplanning in depth and looked forward tothe proposed primary care workforceplanning review’.

1.4.1 The Primary CareWorkforce Planning Review Thus it was that a Primary CareWorkforce Planning Framework wasdeveloped as a result of the review(Department of Health, 2002b). This hadsignificance for the Shaping the FutureProject, focusing as it did on PrimaryCare education and training. Theframework consisted of three parts:

Part 1: An introduction to why planningworkforce development was importantfor primary care and the purpose of theframework;

Part 2: Outlined the context for planningprimary care workforce developmentincluding: integrated plans; nationalcontext of Primary care workforceplanning and drivers for change; multi-professional education and trainingbudgets and the lifelong learningframework for the NHS;

Part 3: Focused on the elements of aworkforce development plan, outlining

the vision, how to identify futuredemands, mapping the existingworkforce and developing the futureworkforce, educational issues relevant toprimary care workforce planning, inter-professional education and training anda workforce action plan.

The main aim of the Framework was to‘help PCTs to shape their plans todevelop and modernise the primary careworkforce’ in order to contribute tomeeting the delivery of the NHS Plan(Department of Health, 2000a) inrelation to ‘expansion of the NHSworkforce’ and ‘for better realisation ofthe potential of the individuals whowork for it’ (Amos, 2002). It had beenthe Investment and Reform for NHSStaff: Taking Forward the NHS Plan(Department of Health, 2001c) which inrelation to workforce planning had setout the progress made in relation toincreasing the number of staff in theNHS and how any changes in the waystaff would work for the benefit ofpatient care (Department of Health,2001c:3), for example:

2500 more doctors, 6300 morenurses and 3500 more qualifiedscientific, therapeutic and technicalstaff had been employed with plansto continue this increase in order toinfluence patient care.

It concluded that for 2002 there wouldbe:

n An unprecedented £250 millionincrease in training budgets;

n 300 more specialist registrars;

n At least 150 more GP trainees;

n 1000 more nurses entering training;

n 700 more therapists and other keyprofessionals entering training.

It also stated that the reportdemonstrated how this was improvingand modernising arrangements for:

n Investing in staff by modernisingprofessional education and trainingand driving forward training for thewider NHS workforce to support ouroverall goals;

n Workforce planning to ensure wehave the right number of staff withthe right skills in the right place atthe right time (Department ofHealth, 2001c:4)

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The role of the Workforce DevelopmentConfederations was seen to be central tothe implementation of all workforceplanning and development, in particularmanaging the multi-professionaleducation and training budget andothers. They were to undertake anumber of core functions (Departmentof Health, 2002c):

n Take a leading role in visioning thefuture healthcare workforce ;

n Develop and lead an integrated

approach to workforce planning for

health and social care communities.

In particular, they were charged with

working ‘with local employers and

other agencies to ensure that local

workforce planning takes a joint

approach to health and social care’;

n Have overall responsibility fordeveloping the existing and futurehealth care workforce;

n Take a lead in developing a sharedapproach to HR policy and practice;

n Establish robust workingrelationships with the NHSUniversity and with NHS, Social careand allied learning organisations onbehalf of its constituent members;

n Will negotiate, manage and monitorperformance of contracts witheducation and training providers,including Further and Highereducation, and support themodernisation of professionalpreparation, education and training;

n Have responsibility for practiceplacements for all students on NHSand HEFCE funded health caretraining programmes;

n Will actively promote patient, carerand student input to thedevelopment and delivery ofhealthcare education and training;

n Will co-ordinate the strategicmanagement of local learning andeducation facilities in the NHS andsupport capital development plansfor those facilities and their revenueconsequences;

n Will ensure effective systems andprocedures are in place for thefinancial managements andaccountability of all funds for whichit is responsible (Department ofHealth, 2002c:3-6).

Interestingly, two years later, the AuditCommission Health Briefing (2004) inproviding an overview of the strengthsand weaknesses of the WorkforceDevelopment Confederation, failed tonote specifically how the WDC’s hadmanaged the core function of:

n Develop and lead an integratedapproach to workforce planning forhealth and social care communities.

It did report, however, that goodprogress had been made ‘in establishingthemselves and delivering their keypriorities’, in particular, partnership andstakeholder consultation. One exampleof good practice was in the North WestRegion, namely Greater Manchester,whereby in ensuring modernisation ofprofessional preparation, education andtraining:

“ The WDC’s Strategic Developmentteam is undertaking a projectentitled a ‘Radical Review ofEducation, Learning andDevelopment’. The project’selements include DevelopingLearning Organisations; EnsuringFitness for Purpose ( focused onclinical placements andcontracts);Improving Partnerships;Interdisciplinary Working ;Implementation of the MPETReview; and Providing a Vision ofHealth and Social Care Educationfor Greater Manchester”. (AuditCommission 2004)

The Workforce DevelopmentConfederations were to be fullyintegrated into Strategic Health

Authorities from April 2004. (AuditCommission, 2004)

As these changes would requiresubstantial development in relation tothe future workforce, we consideredthat the Shaping the Future project wastimely in relation to determining whatthese were. Coincidently, as with all thechanges taking place within the NHSwith regards to education and trainingthere were similar ones taking placewithin Higher and Further Educationorganisations who had a major stake inthe future health and social careworkforce.

1.5 Education and Training ofthe Health and Social CareWorkforce The Audit Commission (2001:71)posited the idea that in order for thenew Primary Care Trust (PCT’s)organisations to effectively develop jointworking processes they should:

“ increasingly deliver services throughintegrated teams whose membershave a range of professionalbackgrounds. In these organisationsclinical teams will work togetheracross professions and expect totrain together and to draw onresources from each other”.

The Audit Commission also concludedthat a ‘profession-bound model’ ofeducation and training and developmentdid not ‘sit easily with current healthpolicy which (rightly) starts with theexperience of the patient or clientseeking help, often from primary care’. Itproposed that there would be a need formore ‘co-ordinated training anddevelopment’ –for multi-professionalteams.

In the same year, the Department ofHealth set out its vision and strategy fordeveloping this future workforce in theirLifelong Learning Framework(Department of Health, 2001b) andproposed to support this with the settingup of the National Health ServiceUniversity (NHSU). However, this utopiandream was never achieved and the NHSUniversity was dissolved on July 31st2005. Although never established as alearning and teaching entity, it was'replaced’ by the NHS Institute for

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Innovation and Improvement in 2005(NHS, 2005). Learning remains one of itskey aims. Despite the failure of thesepolitically driven aspirations it is clearthat the existing Higher Education andFurther Education institutions have asignificant role to play in the educationand training of the health and social careworkforce.

For example, Further Education providesa number of different ‘access to health’programmes such as the BTEC NationalDiploma in Care, as well as in someinstitutions (in partnership with HigherEducation colleagues) the newFoundation Degrees. These are awards,which bring together institutions andemployers ‘to create a blend of academicand work based learning’(www.foundationdegrees.org.uk). In theGreater Manchester area these havebeen linked to the development of anew workforce role, that of the AssistantPractitioner (see www.gmsha.nhs.uk forfurther information). New roles such asthis is part of the drive towards changingthe skill mix of the healthcare workforce(Sibbald et al 2004) and role redesign(Hyde et al 2005). These offer newchallenges to education providers andpractice managers (Warne andMcAndrew, 2004a).

Higher Education Institutions have theresponsibility, in partnership with theNHS and Social Care organisations, toeducate and train the future health andsocial care professions, as well as fornew roles such as those described above.One of the major developmentsaffecting all these is that of inter-professional education. Loxley (1997)considered that this had ‘been long andwidely held as an essential component ofcollaboration’, an issue which was to beestablished as a central concept withinthe Shaping the Future project. D’Amouret al (2005:116) noted that ‘inter-professional collaboration is a key factorin initiatives designed to increase theeffectives of health services currentlyoffered to the public‘. However, theyoffer a new concept for consideration inrelation to inter-professional education,namely that of ‘interprofessionality’

(D’Amour and Oandasan, 2005) whichthey conclude:

“ concerns the processes anddeterminants that influence inter-professional education initiatives aswell as determinants and processesinherent within inter-professionalcollaboration. Inter-professionalityalso involves the analysis of thelinkages between these spheres ofactivity”

They also consider that ‘an attempt tobridge the gap between inter-professional education and inter-professional practice is long overdue’and that ‘the two fields of inquiry need acommon basis for analysis’. Theyproposed a new frame of reference, aninter-professional education forcollaborative patient–centred practiceframework

1.

The centrality of the service user orpatient to inter-professional education isalso influencing their increasinginvolvement in education and training ofthe health and social care workforcegenerally (Humphris and Hean 2004;Warne and McAndrew, 2004b; Porter etal 2005 ; Humphreys 2005). Indeed,Porter et al (2005:327) suggest that as‘service user /carer involvement in allaspects of health care delivery is one ofthe key target areas in the government’smodernisation agenda’ it should also be‘reflected in educational programmes’.Further information on the role of inter-professional education can be found inHowarth et al (2004) and that of serviceuser involvement in education andtraining in Reid et al (2005), both reportsfrom the overall Shaping the Futureproject .

Continuing Professional Development(CPD) for the current health and socialcare workforce is also a cornerstone tothe changes taking place in the NHS. InJuly 2002 it was announced(Department of Health, 2002e) that aproject would be commissioned todevelop a ‘Shared Framework for HealthProfessional beyond registration’. It wasanticipated that the three key outputswould better enable both education

providers and Workforce DevelopmentConfederations to gain a betterunderstanding of different issues aroundCPD and enable better planning of anycurrent and future provision. As yethowever no outcome of the project hasbeen formally published.

There is a commitment by StrategicHealth Authorities to develop theworkforce in order to ensure that these‘drivers for change’ are accommodated.We can see in Box 1 the strategicdirection adopted by GreaterManchester Strategic Health Authority inits ‘Integrated Health and Social CareWorkforce Strategy’ (GreaterManchester Strategic Health Authority,2005).

1Further detail on this model can be seen at the HealthCanada website (www.hc-sc.gc.ca)

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Greater Manchester Strategic HealthAuthority is committed to ensuring thatall health , social care, independent andvoluntary sector organisations areequipped with the skills, knowledge,competence and the tools and tech-niques to produce an organisation ornetwork integrated workforce strategyand workforce action plans to deliverworkforce capacity and enable keyorganisational objectives and targets tobe met. The SHA also recognises theimportance that an integrated strategycan play in modernising servicesthrough visioning new services, wholesystem planning of scenario’s, assessingdemand and supply, bridging and prior-itizing gaps within the system and thenimplementing action plans to deliver thevision. This strategy sets out the driversand principles that underpin the need toproduce a workforce strategy and work-force plan to enable the SHA to fullycomprehend the current reality of work-force demand and development require-ments within Greater Manchester and

the desired future for workforce. Theoverarching macro strategy producedfrom the sum of all the organisationmicro strategies will assist the SHA in anumber of key areas namely:

n Appropriate educationcommissioning and delivery of theeducation and learning strategy;

n Delivery of the e-learning strategy;

n Evidence based primary data forhuman resource and workforceintervention strategies;

n Underpinning new developmentsin the ‘delivering the workforce‘programme;

n Provide intelligence for themodernisation strategy;

n Outline priority areas fororganisational development andleadership strategic andoperational intervention;

n Substantiate our actions indelivering workforce reform as partof the productive time efficiencymeasures;

n Detail clear objectives for newprojects to enhance capacity,capability and sustainability;

n Assist in the devolution of servicesto Greater Manchesterorganisations (shifting the balanceof power).

Box 1: Extract from GreaterManchester Integrated Health andSocial Care Workforce Strategy2005-2010 Resource Pack“Modelling Your Desired Future”(GMSHA, 2005)

1.6 Conclusion

As can be seen in this brief overviewthere has been and continues to be sig-nificant change taking place within theNHS (including social care) which in turnhas had a major impact on the workundertaken by both Higher and FurtherEducation in the education and trainingof both the future and current work-force. Recommendations from theShaping the Future project as to possiblefuture developments can be seen inChapter 3.

Box 1

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Chapter 2:Project Design

2.1 National and local contextin which the Project wassituatedFor the purpose of this project PrimaryCare was viewed as encompassingsocial, community and primary care. Itwas recognised that at thecommencement of the project that theseareas were distinct and discrete ratherthan being encompassed in a genericterm.

As was seen in Chapter 1 the nationaland regional Primary Care agendarequires a workforce that is capable ofdriving through NHS policies and deliveryof integrated health and social careservices, as well being able to interfacewith the Acute Care sector. To besuccessful in achieving this will requirean investment (professional andfinancial) in staff, which is based onsound evidence of current and futureeducation and training needs.

Both the NHS and Higher EducationInstitutions are major employersnationally and regionally, as are, to alesser extent, the independent healthcare organisations and Further EducationInstitutions. Ensuring a future workforcethat is employable as well as beingemployed, with the right skills andknowledge to deliver services, is in manyways linked to how these organisationswork collaboratively for the benefit oflocal communities.

The agreements between theDepartment of Health and the HigherEducation Funding Council (Departmentof Health/HEFCE, 2002) to work closelyon developing collaborative partnershipsshould enhance this process, as long asthe evidence used in support of this isbased on both local and regional need.For example, given the rapid changetaking place with the social, communityand primary care sectors it will beessential that all stakeholders involved indelivery of health and social care andeducation and training workcollaboratively to avoid duplication ofprovision (especially when collaborationas providers would be more productivein terms of both skills and financialresources). In addition, such approachesprovide further opportunities to examinenew ways of working and share goodpractice, whilst ensuring thatcompetition in provision does not dilute

the potential for working together andwill ensure a better quality of educationand training provision.

In a parallel and illustrative process, theShaping the Future project provides agood example of this partnershipapproach. It brought together for thefirst time key partners in the Health andEducation sectors who are involved insupporting the delivery of integratedhealth and social care in the North WestRegion. These organisations include:

n The North West DevelopmentAgency who funded the project aspart of their Key Targets for Health;

n The North West UniversitiesAssociation, who initially stimulatedthe development of thecollaborative initiative;

n The 3 Strategic Health Authorities inthe North West (and prior to 2004the Workforce DevelopmentConfederations), key organisationsin ensuring education and trainingdevelopment and funding to all NHSTrusts and Primary Care Trusts forthe majority of the health careworkforce;

n The Primary Care Trusts in the NorthWest who are the local employers ofhealth and social care staff;

n All Higher Education Institutions andFurther Education Colleges bothdirectly and indirectly involved withthe Project Management;

n Social Services.

It was anticipated that the SteeringGroup, with membership from the aboveorganisations and associations, and theProject Team would be the precursor to aclose regional partnership, which couldcreate real synergies at a regional level,developing practices, which can later beapplied at national level.

2.2 Aims and Objectives ofthe Project The main aim of the project was toidentify the evidence base for delivery ofintegrated health and social care, theskills and knowledge required to deliverthis care, together with the current andfuture education and training needs ofthe North West of England Primary CareTrust workforce. This would takeaccount of the NHS modernisationagenda and the needs of the

independent sector as it interfaced withsocial, community and primary care.

The specific objectives of the projectwere:

(a) To provide a comprehensive literaturereview of the evidence base forintegrated health and social care serviceswithin the regional, national andinternational contexts. (Work Package 2)

(b) To identify areas of current practice incollaborative working and integratedhealth and social care in the community,including education and traininginitiatives and develop a Benchmarkingtool for achieving best practice inproviding education and training forintegrated health and social care servicesfor Primary Care Trusts setting up suchservices. (Work Package 3)

(c) To map Higher Education/FurtherEducation provision of education andtraining which can support the deliveryof integrated health and social careservices, through:

n The creation of a database ofprovision of education and trainingfor health and social careprofessionals and workers availablein the North West HEIs/FECs linkedto the Workforce DevelopmentConfederations and update thisdatabase annually during thelifetime of the project. This wouldinclude the development of aCourse Finder Tool. (Work Package4)

(d) To identify visions for the future forboth health and social care workforceand service users through thepreparation of a report which identifiesfor both groups:

n Perceptions of strength andweaknesses associated withintegrated health and social careeducation and training;

n Perspectives on future trainingrequirements needed to deliver thehealth and social care agenda.(Work Package 5 & 6).

(e) To develop and pilot an Educationand Training Needs Analysis Model andTool (ETNA) for identifying the educationand training needs of the Primary CareWorkforce to meet the NHS and SocialCare agendas (this included both clinicaland health management staff). (WorkPackage 7 & 8)

(f) To disseminate, throughout thelifetime of the project, its activities andoutcomes to a range of stakeholders inthe North West, from service users toservice managers. This would include avariety of dissemination methods such asseminars, workshops, conferences andthe setting-up of a dedicated website.(Work Package 9)

(g) To undertake both internal andexternal evaluation as an ongoingprocess.

(g) To produce a report, which summarisesthe outcomes of the project and makesrecommendations as to how all the keyStakeholders can collaborate to meetthe NHS agenda for Primary Care in thefuture.

2.3 Project ManagementThis was a large, complex project, whichneeded to be carefully and closelymanaged to ensure successful and timelydelivery. In order to ensure successfulmanagement of the aims and objectives,the work of the project was divided intoa number of different Work Packages(sub-projects), each being led by one ofthe partner HEI’s. A small-dedicatedteam was set up, with the aim ofmanaging the project through a ProjectManagement Group charged withdelivering inputs at an operational levelby partners. This group was able toregularly monitor the progress of theindividual ‘sub-projects’ (Work Packages)whether they were the responsibility of asingle partner or a number of partnersworking through a lead partner. Thisapproach enabled the various WorkPackage leads to develop their own smallteams and arrive at methodologies thatwere relevant to gathering the requireddata and achieve their project objectives.

Work Package 1: Overall ProjectManagement: Lead - University ofSalford

Work Package 2: Systematic Review ofthe Literature: Lead – University ofSalford

Work Package 3: Developing aBenchmarking Tool for best practice ineducation and training for integratedhealth and social care: Lead - LiverpoolJohn Moores University and fromApril 2005 the University of Salford

Work Package 4: Mapping ofEducation and Training Provision inHigher Education and Further EducationInstitutions in the North West of Englandand development of a Course FinderTool: Lead – University of Salford

Work Package 5: Vision of the Futurefor Integrated Health and Social Careeducation and training – the PrimaryCare Workforce Perspective: Lead –Manchester Metropolitan University

Work Package 6: Vision of the Futurefor Integrated Health and Social CareEducation and Training –The Service Userperspective: Lead University of CentralLancashire

Work Package 7: Development of anEducation and Training Needs Analysis(ETNA) Model and Tool for the PrimaryCare Trust Workforce: Lead - BoltonUniversity

Work Package 8: Testing andEvaluating the Education and TrainingNeeds Analysis (ETNA) Tool for thePrimary Care Trust Workforce: Lead –Lancaster University

Work Package 9: Dissemination ofProject Development, Delivery andOutcomes: Lead – University ofSalford

Although the project was divided intothese individual Work Packages it wasthe intention that in order to fulfil theaims and objectives that an iterative andintegrating process could take place,whereby the whole Project team wasinvolved in the decision making processand the development of each of theWork Package outcomes (see Figure 1-Project Management Communication).

Initially, this approach allowed for muchsharing of ideas and a great deal ofcommitment to all of the various work-packages, and latterly this solidfoundation of team working supportedthe overall team in working through themany practical issues of doing ‘real life’research.

Figure 1: Project Management Communication

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2.4 Monitoring andEvaluationEach Work Package had its own internalmonitoring and evaluation criteria.However, there was a need to ensurethat progress was monitored across theproject and that the project work planwas both realistic and achievable. Withthis in mind monitoring and evaluationalso took place in a collaborative way bythe evaluation team.

2.4.1 Internal EvaluationAn internal evaluator from the Universityof Salford was appointed to the Projectto monitor the project’s overall progressand identify issues that requiredattention by the Project ManagementTeam. The intention was that theevaluator would act as a ‘critical friend’to the Project Manager over the life ofthe project and ensure that ongoingreports on the project’s progress wereproduced to inform project managementstrategy and development.

2.4.2 External Evaluation An External Evaluation team was alsoappointed to the project from theUniversity of Chester. This team were toensure that there was an independentanalysis of the project direction andoutcome, in particular, in relation to therole and function of the Steering Groupand dissemination activity. Their findingsare provided independently of this reportto the funding body.

2.5 Audit ComplianceThe University of Salford had systems inplace which ensured the monitoring andrecording of project spend and outputdelivery and also ensured the project metthe requirements of the project auditors.Membership of the Project ManagementTeam included a Finance Manager. Thisappointment was instrumental inassuring good financial management ofthe project which was essential given thenumber of project partners and theindividual finance arrangementspertinent to each HEI involved.

2.6 Steering Group The Steering Group was to provide astrategic steer for the project and act onreports from the Project Director over thelength of the project as well as offeringguidance and advice, in particular inrelation to the way external influencessuch as new national policies in health

and social care or education and trainingcould affect the direction of the projectand the Work Packages themselves (seeAppendix for Terms of Reference andmembership) Membership included twolay members of the public.

2.7 The Project Developmentand Outcomes This section will outline the progress ofthe project as proposed in the ProjectPlan. The organisation of the Project intoindividual Work Packages precludes thediscussion of an overarching projectmethodology. However a brief overviewis identified in the different WorkPackage summaries.

2.7.1 Project Management(WP1) Effective project management isdependent on a number of issuesincluding communication, team workingand effective planning (NCTeam, 2002).To facilitate this the Project team andexternal evaluators attended a two-dayresidential to get to know one anotherand also to discuss and understand therequirements of each Work Packageaims and objectives. It was agreed atthat event that the Project ManagementTeam meetings would take place on amonthly basis.

At the end of the first 6 months ofmeeting it was apparent that there wasa need for development meetings as wellas the more formal team meetings. Itwas agreed that the latter would onlyoccur every 3rd month and that theother two meetings would then beavailable for development work. Thisproved to be one of the most positivesteps in the management of the project,in particular, given the number ofpartner organisations and also the inter-relationship of the individual WorkPackages.

Effective communication was consideredvital to the success of the project. As wellas the monthly meetings the projectteam made use of the project intranet,which proved invaluable in thedevelopment of the project outputs.Newsletters had been considered butthis idea was discarded in favour of theintranet and the main web site, whichwas linked to a number of searchengines. Regular data as to the use ofthe web-site to communicate and

disseminate project activities wasprovided by the web-design team.

One of the key determinants of asuccessful project is also effectiveadministration and given the complexityof the project it had been agreed toinclude within the funding bid sufficientfunding for an Executive Officer Grade 2post. The collaborative working betweenthe Project Administrator, the Directorand Chair of the Steering Group haswithout doubt added to the success ofthe project’s management strategy.

During the proposal development it hadbeen recognised that one of the keydeterminants for successful projectcommencement and continuation wasthe obtaining of Ethical approval from aMulti-site Research Ethics Committee(MREC). Given previous experience wehad built in additional time for theapproval process but even this wasinsufficient. As noted in Warne et al(2005) this was a major hindrance to thecommencement of data collectingactivity. Eventually approval wasobtained in June 2003, some six monthsafter commencement of the project.However, even though we had approvalfrom MREC our progress overall was stillhampered by the requirements of manyof the NHS Trusts Research GovernanceCommittees, which required anadditional process of approval (Warne etal, 2005). There is a clear need to ensurethat such arrangements are robustenough to ensure effective researchgovernance, but flexible inimplementation so as not to become anadditional burden for researchersworking in the field. This aspect, in itselfprovides further opportunities toconsider the educational and trainingneeds of managers and researchers interms of how to work more effectively inintegrated research and evaluationprojects. This might be work best left toSteering Groups and their like, but theremight also be a case for a more proactiveresponse being adopted.

2.7.2 The Steering GroupcontributionThe first task of the Steering Group hadbeen to establish agreed Terms ofReference and pattern of meetings tomeet the funding body (NWDA)requirements (Four times a year). It hadbeen agreed at the project managementmeetings that the proposal for theSteering Group to have a ‘hands on’approach to the project development

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would be discussed at the first meeting.The agreement to be involved in thedevelopment of project by the Steeringgroup proved to be of immense value, inparticular, given the breadth of expertiseand knowledge that the memberscontributed on an individual andorganisational level. The project teamwas kept updated on ongoing and newdevelopments, which over the period ofthe project turned out to be continualand often extensive. In terms of thehealth and social care workforce thesehappened to be very significant e.g.implementation of the Agenda forChange policies (Department of Health,1999), the introduction of new rolessuch as Assistant and AdvancedPractitioners and the drive for inter-professional education. Although it hadbeen the intention at the onset of theproject that another regional groupwould evolve from the Steering Group(see 2.2) to date this has not occurred.The regional picture with regards tohealth and social care has changedconsiderably, in particular, with theDepartment of Health’s commitment tomake integrated health and social care areality. The publication of the recentWhite Paper – ‘Our health, our care, oursay’ (Department of Health, 2006)demonstrates the commitment toensuring this integration.

2.7.3 Internal EvaluationTwo levels of evaluation were consideredto be helpful to the project: namelystrategic (External) and operational(Internal). The internal evaluation wasprimarily formative, i.e. it was aimed atsupporting project improvementthroughout the delivery period, whereasthe external evaluation was aimed atassessing the impact of the project, andthus had much more of a summativeemphasis. The nature of formativeevaluation means that the distribution ofeffort during a project tends not to beuniform, with the majority of the lessonsbeing learnt during the earlydevelopmental stages. The use of theinternal evaluator is a relatively newapproach in the UK, so it is worthsummarising the sorts of role that willand will not work (Patton, 1997) (SeeTable 1).

During this project the main rolesundertaken by the internal evaluatorwere Management Consultant, Planner,Decision Support and Systems

Generalist. Internal evaluation reportswere made directly to the ProjectDirector. These were sometimes formal(written), but more often informal(verbal).

The Project Director and Internalevaluator agreed a number of questionsto be considered in the ongoingevaluation:

1. What lessons for future multi-partnerprojects can be learnt from the projectdevelopment process?

It was clear from the earliest discussionswith the funding agency (NWDA) thatthe project to be developed should becollaboration between a range of NorthWest Higher Education Institutions(HEIs), with the University of Salford asthe lead organisation. The projectdevelopment process, therefore, had tokeep a delicate balance between:

n Offering the Region’s HEIs theopportunity to participate; and

n Creating a project plan that wasboth realistic and achievable withinbudget and time constraints.

The process was initiated by holding ameeting to which all the North West’sHEIs were invited in order to present theproject idea and identify whichorganisations wished to participate. Allthose attending indicated that theywanted to participate. A follow-up withthose not attending confirmed that theyeither were not able or did not wish tobe involved. However, a key problemwith developing projects involving asignificant number of partners is increating a project plan, which balances anumber of factors:

n Each partner should feel satisfiedthat they have a sufficiently largepart to play in the project;

n Partners should have the availableexpertise to perform their tasks;

n Partners should be clear about, andsign up to, their tasks;

n Partners should understand thedependencies between their tasks

and those of other partners;n Sufficient resource is allocated to

project management andcoordination.

As was noted above, the chosenapproach of using a series of workpackages helped ensure these issueswere addressed at the planning stage,and developed further as the activitiesrequired to reach the desired outcomeswere separated into discrete groups foreach Work Package (See Section 2.4). Asecond meeting was then held wherethe work package approach wasdiscussed and agreed with partners.Partners were then asked to identifywhich Work Packages they felt best ableto deliver given their research interestsand areas of expertise. The WorkPackages were then allocated topartners on this basis, with one-to-oneconversations taking place to ensure thateach partner was satisfied with the resultof this process.

The Work Packages were thendeveloped in detail, identifyingobjectives, specific activities, milestonesand outputs. Overall, there was anominal budget allocated to the projectand this was then split between theWork Packages in as fair a way aspossible, with each partner being askedto confirm their acceptance not only ofthe Work Package detail but also thebudget allocated to it.

Running in parallel with the aboveprocess was the continuous involvementof the NWDA’s Project Champion. Thisperson was an NWDA employee whoserole it was not only to ensure that theproject developed as originally intendedby the Agency, but also to act as thepromoter of the project when itunderwent assessment. It was,therefore, seen to be critical that theChampion be involved and consulted asmuch as possible during thedevelopment process.

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Table 1: Roles of Evaluator (Patton, 1997)

1. Spy2. Hatchet carrier3. Number cruncher4. Organisational conscience5. Public relations officer

1. Management consultant2. Planner3. Decision support4. Management information resource5. Systems generalist6. Expert trouble-shooter

Successful roles Unsuccessful roles

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2. What lessons for other multi-partnerprojects can be learnt from the projectinitiation process?

Experience shows that even whensignificant time and effort is spentinvolving partners in the developmentphase it is often the case that only thelead (or contracting) organisation has afull grasp of the project, the proposedactivities and its intended outcomes. Theproblem is often compounded when, asin this case, some of the partnerschanged the personnel involved whenmoving from the planning to the deliveryphase. This meant that the projectstarted with a team of deliverers, not allof whom, necessarily knew each otherand had varying levels of understandingabout the project and its goals.

It was, therefore, important to start theproject with activities which:

n Started the process of building theteam;

n Brought all the team to the samelevel of understanding of not onlythe role of their organisation, butalso of the roles of the otherpartners and the interdependenciesbetween them; and

n Clarified the process of projectmanagement and administration.

The catalyst for addressing these issueswas a two-day meeting at a hotel in thecentre of the Region. This opportunitywas important not only from theperspective of developing a commonunderstanding of the aims of the project,but also for developing the creation of amutually supportive team. It is likely thatthe good relationships developed bythose working with the project wouldnot have been as successful as it hasbeen if this event had not taken place.

The issue of project management andadministration was an important aspectof this two-day meeting for two reasons:

a) Projects like this need good leaders.Everyone involved in the project deliverywas working part time on the project.This meant that meeting the needs ofthe project was not necessarily at the topof everyone’s ‘to do’ list. Effectivedevelopment of a good relationshipbetween the Project Director and the restof the team early on was important in

ensuring that the team responded to theneeds of the project as and when asked.The Director realised this and putconsiderable efforts into earlyrelationship development. This wassupported by a leadership style which,while giving the team members a voicein decision-making, neverthelessrecognised when to take the lead toensure the project kept on track indelivering outcomes against the agreedschedule. Partners appreciated thisapproach and were both flexible andresponsive to the changing needs of theproject, particularly when one WP haddelivery problems.

b) The project was to be subject to auditon behalf of the NWDA. This meant thateach partner had to put systems intoplace that provided the evidencerequired by audit. This was a newconcept to a number of the partners’staff delivering the project and an earlydiscussion of the requirements wasessential to ensure that major problemswould not be encountered later on. Italso gave a human face to the personresponsible for collating claims and auditevidence, which also aided latercompliance with requests foradditional/clarifying information frompartners.

3. How was the progress of each WorkPackage measured?

With the delivery of each Work Packagebeing the responsibility of differentpartners, it was important that theProject Director had regular updates onthe progress of each Work Package. Inorder to give a uniform approach toreporting, the project proposal wasanalysed in detail and a work plan wasproduced for each Work Packageshowing planned activities, milestonesand outputs. In advance of eachquarterly Steering Group meeting WorkPackage leads were asked to report tothe Project Director indicating the % rateof progress towards delivering eachactivity and the obstacles to progress.The Director was then able to take anynecessary corrective action, eitherdirectly or through the regular progressreporting mechanism to the SteeringGroup.

The value of having an internal evaluatorwho was in fact a ‘critical friend’ to theproject team proved invaluablethroughout the project but in particular

during the first 12 months, as the teamsought to establish itself and learn towork together. For example, one of thetasks he undertook was to determinewhat each of the Project team membershoped to gain from being part of thislarge multi–partner project. Thisprovided the Project Director withinformation which was then used toassist in achieving their individual aims.One of the key ones was to be involvedin disseminating the ongoing projectdevelopment and outcomes. All theWork Package Leads achieved this to alesser or greater degree (see Appendix 3for Project Dissemination outputs).

2.7.3.1 Effective Collaborationbetween Higher EducationInstitutions One of the aims of the evaluationprocess was to identify the factors whichcan lead to a successful collaborationbetween HEIs. These factors aresummarised in the Factors Leading toSuccessful Collaboration given in Figure2. An examination of these factorsillustrates that the foundations for thecreation of a successful collaboration arelaid during the planning and projectinitiation phases, where effectiveleadership is also relevant. This is coveredin Section 2.8.3.

Other factors of relevance are:

Effective team working Creating an effective team was not just aquestion of developing good individualrelationships, but also ensuring that theteam were clear about how their WorkPackages contributed towards theoverall aim of the project and whatoutputs their Work Packages werecommitted to deliver. Linked to this wasa need for all members of the team tounderstand how others depended ontheir activities in order to deliver theirroles, and vice versa.

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Figure 2: factors Leading to Successful Collaboration

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There was a shared view that this was avery complex project in which most ofthe Work Packages were linked to eachother. Initially, these linkages were notfully appreciated and efforts were madeto reach a common understanding.

Sound project managementand administrationWith each Work Package having adifferent lead individual, it wasimportant that all activities weremonitored and a good communicationssystem was put into place.

Only in this way could issues beidentified early and remedial actiontaken. Having a full time member of staffwith responsibility for this was critical tothe success of the project.

Effective financial proceduresThe contract with the NWDA requiredthat the project be subject to externalaudit upon its completion. This meantthat systems had to be put in placewhich ensured that the contract holder(University of Salford) was able tosuccessfully pass this audit. Thesesystems were based on the assumptionthat the audit requirements would besimilar to those for other NWDA fundingprogrammes, such as the SkillsDevelopment Fund (SDF). It was,therefore, important that the financesystems used by the project, particularlythose required for grant claims, wereclearly explained to all partners, with asignificant part of the project initiationmeeting being given over to this process.This was only partly successful and it wasfound necessary to directly involve theFinance Departments of some partnersto ensure that the claims process workedsmoothly.

Another key issue was that the NWDAdoes not allow grant to be transferredbetween financial years (which run fromApril to March). Consequently, any grantunclaimed at the end of each financialyear would be lost to the project. Allpartners were made aware of thisrequirement, as were their FinanceDepartments.

In the end most partners, while notenjoying the process, recognised theneed to provide the level of detail andevidence of expenditure required by theaudit procedures. Despite certain

problems the entire grant allocated forthe project was drawn down.

Clarity over the expectedbenefits to both partnerorganisations and individualteam membersSuccessful delivery of any projectrequires there to be clarity over theanticipated benefits for both the partnerorganisations and the individualsinvolved in its delivery. Data for boththese areas was gathered by eitherquestionnaire or interview in the earlystages of the project. This then enabledthe Director to support not only thedelivery of the project and its outcomes,but also those of the partners and theirrepresentatives.

At a personal level there were two keythemes with respect to what individualswanted from the project:

n Networking and collaborating withother HEIs and the Health and SocialCare sector; and

n Gaining experience, improvingreputation and developing an areaof academic interest, for bothteaching and research.

This was a positive outcome as itdemonstrated that the delivery team notonly understood the value of the projectto themselves, but also the potential forworking together in the future. It wasapparent that the delivery team had aclear view as to “what’s in it for me” andthat those personal benefits coincidedwell with what the project is trying toachieve.

The perceived benefits to theorganisation (i.e. the HEI) showed agood correlation to the desired personalbenefits:

n Creating networks for futurecollaboration;

n Academic enhancement eitherthrough research or improvedcourse provision and delivery; and

n Raising institutional profile.

Progress towards achieving theseaspirations was monitored and itbecame clear that the project enabledconsiderable networking to take placeand created opportunities for the projectteam and its HEIs that would nototherwise occurred. These opportunitiesranged from writing/presenting papers

in journals and conferences, to thedevelopment of new project ideas andfinally to some consultancy work.

2.8.4 The systematic review(WP2) This early piece of work was influentialto the successful development andcompletion of the project as a whole.The team’s responsibility was to identifykey literature and provide themes onwhich the other Work Packages couldbase their development and endoutcomes. An iterative search strategywas used and the review ‘took accountof the importance andinterconnectedness of policy, practice,population and workforce needs withinan integrated health and social careservice’ (Howarth et al 2004).

Six key themes emerged from thefindings: team working, communication,role awareness, practice developmentand leadership, personal andprofessional development andpartnership working. The teamconsidered that a combination of allthemes were ‘essential requirements ofeducation and training to delivereffective integrated health and socialcare’ (See Chapter 3).

2.8.5 Benchmarking of BestPractice in Integrated Healthand Social Care Educationand Training (WP3) This element of the overall project led tothe development of a BenchmarkingTool to identify good practice inintegrated health and social careeducation and training. An expert groupestablished the framework for the tool,which was then refined and evaluated bya number of key focus groups across theNorth West Region. The definition ofintegrated care was used to guide thedevelopment. Unfortunately, due to anumber of factors we were unable topilot the tool in practice once it had beenamended. This was considered alimitation on its value across health andsocial care services (see Howarth et al2006). However, what has emerged is atool for benchmarking current practicein education and training inorganisations, focusing on integratedhealth and social care (see Howarth,Holland, Hardiker & Lunt 2006).

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2.8.6 Mapping of Educationand Training Provision fromHigher and Further Education(WP4) This Work Package focused on themapping of education and trainingprovision in Higher and FurtherEducation organisations across the NorthWest of England and culminated in theproduction of a web-based CourseFinder Tool. These organisations‘provided the source material used topopulate the database of courses’ andthe tool ‘in contrast to other similartools, focuses specifically on courses thatcan support the delivery of integratedhealth and social care’ (Hardiker, 2005).It was discovered that there were gaps inthe provision of programmes considerednecessary to educate and train theworkforce to deliver integrated healthand social care. However, prospectusesand course information did notnecessarily provide adequateinformation as to what was actuallyincluded in the programmes’ content.The recommendations of this arediscussed in Chapter 3.

2.8.7 Visions for the Future –Health and Social CareWorkforceperspectives (WP5) A multi-methods approach to theresearch design was adopted in order toexplore the views of current primaryhealth and social care workforce. Datawere collected that illustrated the natureof integrated health and social care asthey experienced it. This approach, usinga survey questionnaire, semi–structuredinterviews, participant and non-participant observation and a series ofworkshop case studies and involvedparticipants from three different levels oforganisational responsibility and role.This Macro, meso, micro cross sectionalapproach to data collection was alsoused in the initial stage of analysis(Warne et al 2005). Findings noted theeffects that continual change withinPCTs had on the workforce and howindividuals and groups within theseorganisations responded. A great deal ofrhetorical agreement was evident overthe need for integrated working, butlittle evidence as to how this wastranslated into organisational,educational, and professional practices(see Chapter 3 for recommendations).

2.8.8 Visions for the Future –Service User perspectives(WP6) The aim of this study was to exploreservice users ‘perspectives concerningintegrated health and social care, and toidentify the perceived strengths andweaknesses associated with the currentworkforce and services provided’ (Reid etal 2005). A mixed methods approachincluded the use of focus groups,questionnaires and in-depth interviews.Findings were mixed, from examples ofgood practice to what the research teamdescribe as ‘disintegrated care’ (seeChapter 3 for recommendations).

2.8.9 Education and TrainingNeeds Analysis (ETNA) ModelDevelopment (WP7) andPiloting and evaluation ofETNA Toolkit (WP8) According to Stead and Nettleton (2005)‘three methodological commitmentsunderpinned the development of theETNA Toolkit‘, namely collaboration,learning and interaction. It wasdeveloped in three phases: (1) thecreation of a prototype tool; (2) testingthis and; (3) the final production of theToolkit. The identification of workforceeducation and training needs is essentialif the delivery of policy objectives such asthose described in Chapter 1 are to beimplemented with any degree ofsuccess. A feature of the tool is thepotential to include users and carers inany skills and knowledge gap analysisundertaken.

2.8.10 Dissemination The dissemination strategy considered anumber of options. The maindissemination route was via the projectweb-site (www.pcet.org.uk) whichensures ongoing information for twelvemonths past the end of the project date.All project reports and other outputs aremade available on this site.

Given that it was essential that allstakeholder groups were to beencouraged to participate in the projectdevelopment as well as being madefamiliar with the anticipated outputswhich they could use within theirorganisations a number of briefingevents took place within year one. Theseproved immensely valuable as

networking events and for directcontacts to participate in the expertgroups.

As the project progressed it becameapparent that it was essential that theproject teams became aware of thedevelopments taking place within thePrimary Care organisations themselves aswell as gaining an understanding of thepolitical and care contexts in which thehealth and social care workforce foundthemselves. A small number of thesevolunteered to host events, which wouldnot only benefit the project but alsothemselves. An example of the eventheld with Knowsley can be found inAppendix 4.

In terms of integrated health and socialcare Knowsley was an excellent exampleof the changing face of integratedhealth and social care. It was unique inthe North West region at the time, inthat the Chief Executive of the PCT wasalso the Director of Social Services. Thisinter-relationship of roles permeated theduality of the organisations and theensuing structure of health and socialcare services. As with other trusts in theNorth West of England, Knowlsey hasmany examples of developing integratedhealth and social care services, e.g. GoIntegral Project for Older People Services.

One other key event took place at theUniversity of Salford, which involved thefuture health and social care workforce.This was a joint event between theproject and the University of ManchesterSchool of Primary Care, and focused on‘Interprofessional learning in PrimaryCare: The student experience.’ (seeAppendix 5 for full details). The focus ofthe day was deliberately chosen, as wewere discovering that alongside the drivefor integrated health and social care wasthat of the drive for inter-professionallearning. We determined that an insightinto any inter-relationship between thetwo was essential if we were to providerecommendations as to the futureeducation and training needs of thefuture health and social care workforce.Issues raised by the students included:

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n The need to understand eachother’s professional roles andresponsibilities. One studenthighlighted the problem with lack ofunderstanding from a patient’sperspective, in that ‘if we don’tunderstand each others roles howdo we expect a patient to do so?’and ‘if they come into a HealthCentre and are faced with lots ofdifferent professions looking afterthem how do they know who doeswhat in their care?’

n The wish that they could ‘follow thepatient journey‘ in practice in orderto understand all their care not justthe part that their professionalgroup played (The centrality of thepatient within their learningexperience was evident throughoutthe discussions).

A second student event took place 12months later, when similar themesregarding the lack of practice experienceof inter-professional working andlearning became evident. The studentsagreed at both events that there weresignificant benefits to working inter-professionally and inter-agency.

The Project Team had agreed at theonset of the project that it would takeevery opportunity to disseminate thework of each project team and theoverall project and a number of the teamhave presented their work atconferences and to date through a smallnumber of publications. It wasrecognised that the majority ofpublications would be attained postproject completion (see Appendix 3 forlist of dissemination outputs). Many ofthese would be collaborative, in keepingwith the overall delivery of the project.

2.9 CollaborationAccording to Sullivan (1998) the‘literature is replete with myriad andvaried descriptors that are snippets ofdefinition’s of collaboration and is opento many interpretations’. For thepurpose of this project we choseSullivan’s own definition, developedfrom a concept analysis, whereby:

“ Collaboration is defined as adynamic process of creating apower sharing partnership forpervasive application in health carepractice, education, research and

organisational settings for thepurposeful attention to needs andproblems in order to achieve likelysuccessful outcomes” (1998:6)

2.9.1 The CollaborativeExperience of the ResearchTeamThe Project was what Hardy et al (2003)define as an inter-organisationalcollaboration. It was a researchcollaboration, a term which Smith & Katz(2000) in their study of collaborativeapproaches to research in HigherEducation, found difficult to define for avariety of reasons. They did, however,identify ideal types or models ofcollaboration, namely a) Corporatepartnership b) team collaboration and c)inter-personal collaboration. This projectinvolved all three types to a lesser orgreater degree.

a. Corporate PartnershipIt was a corporate partnership betweenseven HEI’s in the North West, led by theUniversity of Salford who wereresponsible for the overall ProjectManagement and Dissemination ofproject activity. As Smith & Katz (2000)identified, there are a number of benefitsto such partnerships, which were alsorealised in this project. Examples are:

n Identification of institutionalcomplementarities and pooling ofresources – through both theSteering Group and Research Teamwhich enabled access to a widerange of human and physicalresources;

n Promote cultural transformation andnew synergies among partners withpotential spin offs – through, forexample, new insights intodevelopment of education andtraining programmes in differentorganisations and bringing togethera wide range of stakeholderorganisations who are activeparticipants in the project learningcommunity. Potential ‘spin-offs’included future collaborative biddingby the team and others in theirrespective organisations anddevelopment of new programmesto meet local and regional needthrough creating new partnerships

between previously ‘un-connected’stakeholders.

b. Team collaboration: TheProject Team as a LearningCommunity It was a team collaboration and inaddition there were similarities to a‘learning community’. Defining what ismeant however by a ‘community oflearning’ proved a challenge. Its use ismost predominant in the use ofelectronic media for remotecollaboration (Calvani et al 1997, Hall2003). Three themes, however, emergedfrom the literature as to this concept: (1)Communities of learning arecollaborative (Thomas et al 2002); (2)transformative (Macdonald, 2002) and(3) emancipatory (Lleras, 2003). Further,Eraut (2002) offers a challengingeditorial on many of the new terms toemerge that ‘attempt to capture thesocial and collaborative dimensions oflearning’. One definition of community is‘the people who live, work or learnwithin a particular boundary’ (Eraut,2002). It was anticipated that within theShaping the Future project there wouldbe many such ‘communities of learning’but working across organisational andprofessional boundaries and interactingwith each other and not just individually.The closest relationship to such a‘community of learning’ was evidencedwithin the overarching projectmanagement team. Examples of teamcollaboration and therefore communitiesof learning were:

n Research focused collaborationinvolving teams of researchers basedin various departmental, researchcentres or other units at two ormore institutions. There were sevenin this project;

n Teams involving universities, industryor professional practice: theseinclude the Project Team and two‘expert’ development groups as wellas a number of smaller focus groupsand expert reference groups in thewider consultation exercise.

Benefits of such collaborative teamsinclude the development of appropriateskills and expertise and high University –user inter-facing (Smith & Katz 2000:11). Team collaboration was consideredthe key to successful completion of theproject aims.

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C. Inter-professionalCollaborationSmith & Katz (2000:11) note that‘collaboration is intellectually driven anddiscipline based and sometimes, in largercollaborations, discipline organised.However, it is dependent on essentiallypersonal relationships between two ormore university based individuals,sometimes groups.’ Examples of keyfeatures of inter-professionalcollaboration found in the Shaping theFuture project are:

n It was based on personalrelationships, trust and ability towork together;

n It was facilitated by regular –face toface contact but can be substitutedby the development of other formsof contact e.g. e-mail or intranet.

The benefits of such collaborationsaccording to Smith and Katz (2000)include:

n A key to disciplinarydevelopment/intellectual curiosity;

n Enhancement of personal and jointcapacity;

n The social basis of collaboration i.e.collaboration is fun;

n Benefits for teaching and researchtraining.

In terms of collaboration the projectproved instrumental in creatingnetworks and stimulating dialoguebetween local, regional and nationalgroups. It also acted as a catalyst forbringing people and organisationstogether in a variety of ways – forexample, as groups which can beconsidered communities of learning e.g.Education and Training Needs AnalysisTool Development group and also theProject Development Team itself. It alsoacted as a vehicle for developingresearch skills (as per Smith & Katz,2000) of sub-project team members e.g.a doctoral student who had theopportunity to work with a team ofexperienced academics and researchersand enjoy team support and supervisionof this expert team. It created a wealthof knowledge and practice incollaborative working, team buildingand those activities that Sullivan (1998)has defined in her definition ofcollaboration. It also demonstrated whatD’Amour et al (2005) in their review of

the literature, identified as fiveunderlying concepts to collaboration,namely sharing, partnership, power,interdependency and process.

It was the responsibility of the ProjectDirector to pull together the differentfacets of the project. Key factorsemerging that appear to contribute tosuccessful development of the projectwork included:

n Internal evaluator role – acting ascritical friend to the project teamand supporting the Director inlearning to manage a project of thissize and complexity;

n Skills and experience needed to leadthis project and for the research anddevelopment elements of it, inparticular, the need for experiencedteam members to lead sub-projects;

n Recognition of the contribution ofthe Steering Group and its expertisein shaping the project;

n The need for an effectivecommunication strategy and toolse.g. Project intranet site;

n The expertise and skills of all of theProject Management team towardsthe development of the wholeproject and recognition of thiscontribution;

n Networking and collaboration withthe external world, especially ineducation and health and social careorganisations that are involved witheducation and training of theirrespective workforce.

2.10 Conclusion The Shaping the Future for Primary CareEducation and Training Project achievedall its main project outcomes. At timesthis appeared to be an ambitious plan,given the size of the overall projectteams and the number of organisationsinvolved. However, with an ongoingdevelopmental approach to projectmanagement and excellent collaborationfrom those who led and participated inthe individual studies we have succeededin producing end of project material thatwill be of value to organisations andindividuals as they participate in thecontinual ongoing changes occurringwithin Primary Care services.

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Chapter 3:Education and Training to Deliver IntegratedHealth and Social Care: The Future3.1 Introduction Warne et al (2005) highlight theoverarching context in which this studytook place, in particular the continuedturbulence, which appears as a result ofpolicy change. The results of this theypoint out ‘has resulted in disjunctionsand tensions between managerial,educational, political and professionaldiscourses, theories and practice’ (Warneet al 2005:6). The implications of this foreducation, service and service users arefar reaching but we concluded that theevidence from the project wouldilluminate ways of managing thesewhilst ensuring effective delivery ofintegrated health and social careservices.

3.2 Emerging themes As seen in Chapter 2 the evidenceprovided in the Systematic Review (WorkPackage 2) was central to thedevelopment of all the other projectoutcomes and outputs. The six keythemes which emerged were seen to behelpful in providing guidance forresearch questions and thematicanalysis, together with the developmentof the final tools of the project, namelythe Benchmarking of Practice ineducation and training for integratedhealth and social care tool (WorkPackage 3) and the Education andTraining Needs Analysis (ETNA) Tool(Work Package 7 & 8). Theinterconnectedness of the six key themesof team working, role awareness,communication, personal andprofessional development, practicedevelopment and leadership andpartnership working with policy,practice, population and workforceneeds can be seen in Figure 3, TheFramework of Evidence.

In collating the evidence from all the‘sub-projects’ (Work Packages) it becameapparent that as well as the six keythemes which guided the researchoutcomes, there were other majorthemes emerging. The mostpredominant was that of the centralityof inter-professional/inter-disciplinaryand inter-agency working and to someextent learning in the delivery ofeffective integrated health and socialcare services. The other themes were theneed for collaboration and the need forservice user involvement in education

and training (see Figure 4: Frameworkfor Education and Training).

Figure 3: Framework of Evidence

Service User

Working

Policy Practice

Work ForceNeeds

Population Needs

Team Working

Role Awareness

CommunicationPersonal &Professional

Development

Practice Development& Leadership

Integr

ated

Hea

lth& Social Care

&So

cialCare

The overarching findings, including thesethemes, will be presented throughdetermining the recommendations madeacross all the research and developmentactivity to three key areas:

n Higher and Further EducationOrganisations;

n Primary Care Trusts and integratedhealth and social care organisations;

n Service user/carer groups.

It is recognised, however, that in manyinstances there was an overlap across allthree areas. The main evidence will bepresented as key points collated from theWork Package reports.

3.3 Recommendations forHE/FE organisations

Team working n Education and training programmes

need to take cognisance of teamworking in integrated health andsocial services, not simply working ina team (WP2);

n Education and training for teamworking needs to be planned totake account of both inter-professional and inter-agencyworking (WP2);

n Pre-registration/access to healthand social care work programmesneed to place greater emphasis onteam working in integrated healthand social care as a core skill (WP2);

n Ensure that all educational andtraining learning

objectives/outcomes reflect nationalcompetency framework standards(WP5);

n Ensure that service managers andeducationalists work to developlearning opportunities on how todeal with the realities of teamworking across different professionsand agencies (WP5);

n Include clear models of goodpractice in integrated care in thetraining of health and social careworkers (WP6).

Collaborationbetween

Educationand Service

Inter-professionalWorking and

Learning

Inter-Agency and Organisational

Working

ServiceUser

Involvement

Team WorkingPartnership Working

Role Awareness

CommunicationPersonal &

ProfessionalDevelopment

Practice Development& Leadership

Education &

Training

Integr

ate

dH

ealth

& Social Care&

SocialCare

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Figure 4: Framework for Education and Training

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Communication n Pre-registration and access to health

work programmes need to ensurethat effective communication skillsfor integrated working, includinguse of technology, are core skills(WP2);

n Ensure that all education andtraining learning objectives/outcomes reflect nationalcompetency framework standards(WP5);

n Ensure that service managers andeducationalist work to developlearning opportunities focused onhow to deal with the realities ofteam working across differentprofessions and agencies (WP5);

n Place greater emphasis in trainingon the use of basic communicationskills (especially listening skills) indirect client work.

Role Awarenessn Role awareness should become an

essential element of all programmesrelating to preparing the workforceto deliver integrated health andsocial care (WP2);

n Shared learning initiatives betweenhealth and social care workforcestudents in practice should beencouraged to develop awarenessand understanding of team roles(WP2);

n Ensure that all pre-qualifyingeducation programmes, ContinuingProfessional Developmentprogrammes and activities, moreeffectively promote role awarenessand inter-professional working(WP5);

n Ensure that where possible all CPDprogrammes aimed at increasinginter-professional working areplanned and delivered as jointenterprises (with health and socialcare, HEIs and service users) (WP5);

n More effectively involve HEIs inproviding empirical approaches tosupport service developments(WP5);

n More opportunities for health andsocial care workers to train togetherto enhance appreciation of differentprofessional perspectives/crossing ofprofessional boundaries (WP6).

Practice Development andLeadershipn Leadership education and training

for integrated health and social careservices needs to be built intoeducational programmes for allprofessions (WP2);

n Practice development in integratedhealth and social care requirescollaboration between educationand training organisations anddepartments to ensure skills andknowledge base meets therequirements for service useroutcomes (WP2);

n Develop multi-professional andinterdisciplinary CPD activities thatare aimed at strengtheningleadership capabilities across alllevels of the workforce (WP5);

n Continue to work collaboratively inensuring national quality assuranceprocesses for educational providersinform the development, deliveryand evaluation of educational andtraining programmes (WP5).

Personal and ProfessionalDevelopment n Flexible learning opportunities need

to exist to enable the workforce tobe able to access inter-professional/inter-agency workingprogrammes (WP2);

n Increase the awareness within PCTsand future service providers of thescholarship role that universities canhave in supporting individualpractitioners and PCTs (WP5);

n Ensure the development anddelivery of both educational andtraining programmes moreeffectively reflect practice needs aswell as those arising from academicinterests (WP5).

Partnership Working n Partnership and collaboration

between health and social careshould be essential in thedevelopment of curricula forintegrated health and social care(WP2);

n Education and training standardsfrom professional bodies shouldinclude core requirements forpartnership working, taking accountof team working, effectivecommunication and role awareness

as essential elements of theprogramme (WP2);

n Ensure multi–professional andinterdisciplinary CPD activities aredeveloped that are aimed atincreasing the understanding ofroles and responsibilities (WP5);

n Develop curricula that explicitlyprovide learning opportunities forpartnership working (WP5);

n Ensure that future education andtraining competency standardsinclude core requirements forpartnership working (WP5).

3.4 Recommendations forPrimary Care Trusts andIntegrated Health and SocialCare Organisations

Team working n Develop teams with the appropriate

skills and knowledge, that are ableto liaise and work collaborativelyacross organisations and agencies(WP2);

n Ensure that any team has therequired awareness of all themember role functions andprofessional background asappropriate (WP2);

n Service planning and serviceprovision need to take account ofthe education and training requiredfor a whole team when creatingnew roles (WP2);

n Co-location of teams needs to takeinto account education and trainingfor new ways of working (WP2);

n Develop change managementknowledge and skills at all levels ofthe workforce and ensure serviceusers and carers are partners inthese processes (WP5);

n Undertake organisational cultureanalysis aimed at promoting aculture which supports greaterinvolvement of the wider workforcein decision making processes (WP5);

n Provide structured and regular‘timeout’ sessions aimed atharnessing organisational learning(WP5);

n Develop systematic organisationalevaluative strategies that arecapable of evidencing improvedteam working (WP5).

Communication n Ensure staff working in integrated

teams have well developedcommunication skills to enable themto work within and across inter-professional and inter-agencyboundaries (WP2);

n Ensure a common language is usedbetween health and social careorganisations to aid effective teamwork (WP2);

n Ensure that the workforce has theknowledge and skills to managechanging communication channelse.g. information technology (WP2);

n Address workload allocation ofhealth and social care workers toallow time for meaningfulinteraction with clients (WP6);

n Promote and support thedevelopment of a ‘commonlanguage’ for integrated health andsocial care, recognising theorganisational and professionalsocialisation processes that militateagainst this (WP5);

n Ensure greater transparency in theexchange and access to informationthrough further development ofnew technologies (WP5);

n Ensure the development of ITsystems that are multi-agencycapable and fit for purpose (WP5);

n Develop engagement processes thatsupport greater organisationinnovation and confidence in how ITsystems work (WP5).

Role Awarenessn When developing new roles ensure

that there has been organisationalpreparation for their introductioninto the workforce (WP2);

n A variety of innovative learningopportunities need to beconsidered, including roleshadowing, secondments to workwith multi- professional teams andinter-professional education (WP2);

n Develop more structuredapproaches to supporting andrecognising the value of informalinter-professional and organisationallearning (WP5).

Practice Development &Leadershipn eaders need to be identified and

educated to lead integrated healthand social care services (WP2);

n Practice development needs to beled by leaders who take account ofa cultural change needed to ensureeffective working in integratedhealth and social care services(WP2);

n Ensure that practice developmentactivities are facilitated by leadersskilled in cultural change processesand that these activities aresystematically evaluated (WP5);

n Ensure protected time is identifiedspecifically for multi–agency practicedevelopment and CPD activities(WP5);

n Ensure that PCTs, future serviceproviders, educationalcommissioners and providers workcollaboratively in developing newCPD programmes which reflect thechanging nature of health and socialcare practice and the changingenvironments where such practice isundertaken (WP5).

Personal and ProfessionalDevelopmentn Compatibility needs to exist

between all the NHS and SocialCare skills and knowledgeframeworks in ensuring theworkforce is able to work inintegrated health and social careorganisations and services (WP2);

n Supportive environments need toexist to enable personal andprofessional development inintegrated working (WP2);

n Being able to work in integratedhealth and social care situations atall levels of organisations should bebuilt into role descriptions and jobspecifications (WP2);

n Continue to develop meaningfulopportunities that promote life longlearning and the systematicidentification of training needs(WP5);

n Regularly evaluate the impact anduse of new workers in the roles andfunctions of the existing workforce(WP5);

n Increase the opportunities to work

together in developing moreeffective learning environmentscapable of supporting flexiblelearning within PCTs and futureservice providers (WP5);

n Agree a joint framework agreementfor CPD that supports in-house CPDactivities being credit rated (WP5);

n Ensure that the knowledge and skillrequired to work in integratedhealth and social care services(including in education) from thebasis of job descriptions and rolespecifications (WP5);

n Ensure that integrated personal andprofessional development strategiesare explicitly linked to organisationalchange strategies and businessplanning processes (WP5);

n Develop transparent and effectivedecision making processes that arecapable of handling the personal,professional and organisationaltensions involved in determiningwhat is seen as ‘useful knowledge’(WP5).

Partnership working n Leaders of integrated health and

social care services need to offer asupportive culture for integratedworking and delivery of care (WP2);

n Develop specific roles to facilitateinter-agency partnership working atthe Micro and Meso levels of theworkforce (WP5).

3.5 Recommendations forService User/CarerInvolvement in Education andService Development andDelivery n Ensure service users of integrated

services are integral to developingcommunication networks andlanguage (WP2);

n Role awareness education forservice users/carers should beconsidered essential to ensureeffective communication andappropriate use of services (WP2);

n Service users need to be involved inany education and trainingdevelopment which promotespartnership working (WP2);

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n Role awareness education forservice users and carers should beconsidered essential to ensureeffective communication andappropriate use of services (WP2);

n Establish professional qualificationpathways for home care workers(WP6);

n Service users need to be involved inany education and trainingdevelopment which promotespartnership working (WP2);

n With service users and carersdevelop communication processesaimed at ensuring service users andcarers can better understand thedifferent roles and responsibilities ofthe workforce (WP5);

n Improve opportunities for greaterservice user and carer involvementin education and trainingprogrammes in order to increaseawareness and responses to driversfor practice development (WP5);

n With service users and carers, worktowards developing a shareddefinition of the criteria that can beused as a benchmark for systematicservice evaluation of integratedhealth and social care services(WP5);

n Ensure there is an explicitrequirement to demonstrate theinvolvement of service users ineducational and training activities incommissioning agreements (WP5);

n Proactive consultation mechanismsare needed to identify the types ofservices that users would like to seein place. Current arrangements aretoo passive –the service user has totake the initiative (WP6);

n Find ways of capitalising on obviousservice user enthusiasm for training(WP6);

n Involve service users ininterdisciplinary training sessions toenhance workers appreciation ofuser perspectives (WP6);

n Significant increase in investment intraining for home care agencyworkers (WP6);

n Emphasise that partnership workingmeans partnership between workersand service users –not only betweenworkers (WP6);

n Raise both workers’ and serviceusers awareness of the meaning of

integrated health and social care;that is not only integration betweenwork of different health and socialcare professionals but alsointegration between the work ofhome care staff and ‘professionals’(WP6).

Although these recommendations aregenerally self-explanatory and arethematically aligned, it was identifiedthat in many instances there wasintegration between many of them. Thuswe argue that the recommendationsshould be read as a related constellationof changes, rather than as single andspecific items that might somehowrequire simultaneous implementation bythose concerned with the provision ofprimary health and social care services,and the commissioning and provision ofeducational and training programmesaimed at developing the workforce.Indeed, we assert a priori that suchsimultaneous implementation would beboth impossible and undesirable.

The project outcomes, including therecommendations noted above, must beseen against the backdrop of unrelentingchange. It was clear from data collectedin developing the evidence bases thatthere were multiple versions of a visionof integrated health and social careraises the consequential possibility thatnot only might individual PCTs beinvolved in a process of conceptualtransitions, but individuals within thesePCTs might be involved in parallel butdifferent processes of conceptualtransitions (Warne et al, 2005). Suchconceptual transitions are in themselves,manifestations of the various layers ofchange being experienced by individualsand their organisations.

This project has resulted in significantoutputs and recommendations. They canbe used collectively when establishingnew services or individually when forexample assessing the education andtraining needs of the workforce. Theircombined outcomes, however, will be ofvalue to all integrated health and socialcare organisations in their quest todeliver integrated services, which in turnwill benefit the local communities. It is also anticipated that therecommendations and outputs will be ofvalue to Higher and Further EducationInstitutions in order to establish theirown strategic plans for working withhealth and social care providers to

ensure an effective and educatedworkforce to deliver integrated healthand social care.

3.6 DiscussionThe collective outputs of the Shaping theFuture project represent how the feltexperiences of individuals working in thecurrent PCT system were first captured,interpreted and, in some instances usedto build models, tools and guides forfuture thinking. Overall, these accountsrepresent a valid evidence base that hasbeen constructed from data collected invarious ways. Where this has involvedparticipants describing their experiences,we argue that while such data isauthentic, there can be no guaranteethat this data are representative of allthose working in primary health andsocial care. However, the various teamshave, in their reports, been able to revealthe extent of the generally high level ofshared awareness of the need to developmore integrated ways of working inprimary health and social care.

It was interesting for us that when weembarked on this project the types ofintegrated health and social careconcepts now being proposed in theWhite Paper – Our health, our care, oursay (Department of Health, 2006) werestill in its infancy. Given that Primary CareTrusts were also still in the early stages ofdevelopment it could be considered arisky decision by the project team toexamine the implications of suchintegration for the future health andsocial care workforce. However, itappears that our ‘reading of the runes’ inmany respects, has become a newreality.

There has been over the life of this projecta move from a position where conceptsaround multi-professional working, multiagency working, partnership working andcollaborative working, were oftenpreviously conflated, used inter-changeably by participants to a place thatis conceptually more stable. It is if the term‘integration’ is being used a verb, not anoun as is more usual. For example, theevidence base points to a vision of thefuture that is of a primary health andsocial care service characterised byintegrative working practices. We arguethat this vision is not the same as thevision of developing integrated healthand social care services and points to thedifficulties that might result from similar

examples of conflation and reductionismas these new futures begin to takeshape. Thus, we argue, that thepublication of this latest White Paper(Department of Health, 2006) isopportune in the context of therecommendations arising from thisproject, in particular, in relation topreparation of the workforce to deliverthe proposed changes. For example,there are explicit policy indicators settingout the shift in focus and methods ofworking for those involved in currentprimary health and social care servicesand the consequential impact this shiftwill have upon staff ‘it will meanchanges for all staff, whether they arefocusing more on prevention or workingin new settings‘ (Department of Health,2006: 185). One of the fundamentalchanges being proposed is ‘betterintegration between those working inthe NHS and those working in socialcare’ and states that:

“ A better integrated workforce–designed around the needs ofpeople who use services andsupported by common educationframeworks, information systems,career frameworks and rewards–can deliver more personalised care,more effectively”. (Department ofHealth, 2006:185)

Such appeals to popular professionalrhetoric’s are not new however. It hasbeen argued that these rhetoric’s allowindividuals and groups to unconsciouslyrecognise and respond to the link madebetween an often remote, yet widelyknown, context, and the immediatesituation they find themselves in (Warneet al, 2005). Likewise, how thesepolitically driven objectives aimed at‘reshaping’ future services are to beachieved is still to be agreed. Indeed, weargue that there is no reason to assumethat the different interests of the manydiverse stakeholders involved in healthand social care education, training andservice provision coincide. There is aneed to keep in view the whole systemsapproach to planning and facilitatingresponses to the educational andorganisational implications of developingintegrated health and social care firstoutlined by Howarth et al (2004) andfurther developed by Warne et al, 2005and Reid et al, 2005 in their analysis of

the workforce and service userexperiences.

The Systematic Review of the literature(Howarth et al 2004) highlighted sixthemes that facilitated criticalexploration of factors involved in thesuccessful integration of health servicesthrough effective education and trainingof the workforce. These themes werethen used throughout the project teams’work to determine their value andusefulness in attempting to capture theneeds of the workforce and other keystakeholders in the care process. Such aprocess was inevitably context driven.

The overarching context, represented inthe achievement of integrated healthand social care services, was in itself, partof a wider and more complex context. Sofor example, whilst some PCTs involvedin the Shaping the Future project, wereclearly able to demonstrateorganisational activity that supportedthe realisation of the currentgovernmental vision ‘of increasingpartnership working and collaborativeapproaches’, this often appeared to bethe consequence of a continuing debatearound whether to provide a wide rangeof general services or move to theprovision of more specialist services.There was evidence to suggest that suchdebates often occurred at the macrolevel of planning and decision-making.However, there was also evidence in theform of parallel operational processes,for example, the assimilation processesmany participants were involved in aspart of the implementation of Agendafor Change for example (Department ofHealth, 1999).

However, even where morespecialisation replaces genericism interms of future working, greaterinnovative integration, per se will berequired to ensure that more effectiveoutcomes are achieved for professions,organisations and patients. The PCTs ofthe future will have greater responsibilityfor ensuring such integration throughthe proposed new commissioningarrangements.

Given that integration implies bringingtogether different health and social careworkers in new ways of working it willbe essential that purposefulconsideration is given to the way thatteams are affected by the introduction ofnew and sometimes different individuals.

The skills of team working in any contextcan not always been be considered asbeing simply transferable into any healthand social care settings, particularlywhere there is a systematic attemptbeing made to ensure such services areintegrated. Effective team working reliesheavily on the level of understanding ofeach others’ roles each team memberhas, as indicated in therecommendations arising from the roleawareness theme. This approach isclearly linked to the inter-professionaland inter-agency working agenda whereunderstanding one another’s roles isessential for effective team working(Freeman et al 2000). We argue that thisis a particularly important factor forthose educational and trainingprogrammes that involve pre-qualification programmes. In theseprogrammes, the first step in acquiringknowledge and skills for practice,integrated working should be seen as acore skill and be embedded in theprocesses involved in ‘becoming’ aprofessional.

In this context we also argue that ratherthan teaching about team working perse, the emphasis needs to shift to anapproach that includes learning abouthow to deal with the realities of teamworking. The importance of effectivecommunication skills for integratedworking is seen in the ‘Statement ofGuiding Principles relating to thecommissioning and provision ofcommunication skills in pre-registrationand undergraduate education for Healthcare professionals’ (Department ofHealth, 2003). Ineffective communicationbetween health and social careprofessions can result in far reachingoutcomes as for example was evidencedin the report from the Victoria Climbieenquiry (Laming, 2003).

Our recommendations for serviceusers/carer involvement in education andtraining also has a resonance with thenew White Paper (Department of Health,2006) in particular as it relates toinformal carers. Two of therecommendations of Reid et al (2005),for example:

n 3.5 Significant investment intraining for home care agency(WP6)

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n Establish professional pathways forhome care workers (WP6)

are reflective of the White Paperrecommendations:

“ We must ensure that informal carerscan move in and out of the paidworkforce” (Department of Health,2006:189)

and

“ We envisage a much greater role forinformal carers and people who useservices in training staff - with‘expert’ carers running courses fornurses, doctors, allied healthprofessionals, social workers andother staff” (Department of Health,2006:188)

The change to more community basedcare, including community basedhospitals, where health and social carewill merge, will also require that thefuture workforce, in particular, pre-registration health and social carestudents, gain experience of this. Thiswill require Education and Serviceproviders to work closely together inorder to ensure that this futureworkforce more effectively developslearning and teaching approaches thatprepare staff to meet patient and carerneeds in the new and emergent servicecontexts. The pursuit of inter-professional learning will need tocontinue, but not without a parallelprocess of inter-professional working inpractice. However, it is not easy to movefrom the rhetoric to a new reality. Forexample, in the feedback from the Inter-professional Study day (see Appendix 5)it was clear that not all students haveexperienced this. In our view the drivetowards inter-professional learning willbe counter productive unless there isalso new investment to support thedevelopment of this within practice.

Much of what is stated in the variousrecommendations arising form thisproject will also require continued andnew investment in education andtraining of staff and as indicated, theservice user and their carers. However,there is a real danger that in theheadlong pursuit of integrated working,educational experiences will be replacedby competency based and skills basedtraining programmes. For example, theearly experience of many Assistant

Practitioners point to the dangers of notensuring training for new workers in thehealth and social care workforce that isappropriately underpinned by effectiveeducational experiences. It can beargued that every aspect of health andsocial care service provision ultimatelydepends on the knowledge and skills ofindividual staff. Education and trainingfor the workforce is a major industry initself. The large scale of educational andtraining processes is increasinglymatched by a corresponding complexityin the commissioning processes.

Health and social care generally, andprimary and community health andsocial care in particular, haveexperienced a period of rapid and oftenunpredictable change. These changesare set to continue as the future PCTsrole changes to reflect a role morearound service commissioning than thatof direct provider of services. It is likelythat these commissioning processes willcontinue to grow in complexity as neworganisational forms for primary healthand social care services continue todevelop.

Likewise, if PCTs are not providingservices in the future, they will not needto directly employ many of the clinicalworkforce currently on their payrolls. It ispossible to envision a future that, interms of career pathways for individualprimary health care practitioners andprofessions, would appear morefragmented than integrated.

There are implications also foreducationalists and those responsible forensuring individuals are competent andfit to practice. For example, given thedifficulties that there might be inensuring coherent CPD, re-registration,personal and professional developmentprocesses exist, the creation of a newprimary health and social care workerwould appear to be a desirabledevelopment. Additionally, developing anew primary care workforce would notentail having to deal with the transfer ofemployment of the current workforce tonon-NHS organisations. For example,pension rights, and equality of nationalterms and conditions of employment.

Likewise, the process of creating apatient-led NHS, which uses newcommissioning approaches, payment byresults and money following patients islikely to add to the already turbulent

environment of the NHS. If individualpractitioners increasingly feel at risk andvulnerable to such processes, they maychose to opt out of the health and socialcare workforce completely. It is clearfrom the evidence that theorganisational demands made of staff(for example, in meeting governmenttargets) often result in a practice beingcharacterised by a sustained sense ofbusy-ness which works againstcollaborative practice being developed(Warne et al, 2005). Against theseorganisational demands, educationalone is unlikely to lead to bettercollaborative practice. Indeed, ‘intra-institutional’ (such as imbalances instudent numbers; finding suitableaccommodation for both large and smallgroup teaching, timetabling problemsacross groups with discrete discipline-specific curricula) and ‘extra-institutional’inhibitors (such as disparate professionalbodies; unsynchronised validation cycles;separate funding streams) often workagainst the successful implementation ofinter-professional educationprogrammes. Similar issues aretransposable to health and social careorganisations.

The UK health and social care field ispopulated by large organisations ratherthan single entrepreneurs or small free-standing units. Although these variousorganisations have long been exhortedto work together in a more interrelatedway, achieving this or even inter-organisation co-ordination remainsdifficult and problematic. Partly, thereason for this is a consequence of twodifferent relationship concepts (1)vertical relationships (usually involving atop down approach to servicedevelopment and management); and (2)lateral relationships (usually involvingpartnerships between agencies or acrossnetworks) resulting in countervailingprocesses of collaboration and/orconflict. The way in which individualsand groups within and betweenorganisations behave in response tothese countervailing processes is alsoimportant to consider. The collectiveaccounts represented in the ninevolumes of reports stress the need tolocate the health and social careworkforce and educational preparationwithin a broad understanding both ofthe changing nature of who make upthis workforce, and of the turbulentnature of the context

3.7 ConclusionPrimary health and social care workersaim to provide services against a policybackdrop, which calls for an increasingfocus on integrative, multi-professionaland multi agency working, in order toprovide seamless and effective servicesto patients. This requires a more effectiveinvolvement of a much wider workforcethan that traditionally involved (medical,nursing, allied health professionals andother health and social care supportworkers). There are new roles beingdeveloped that will need to beaccommodated and assimilated into thetraditional workforce. Alongside theseshifts, requiring greater diversityamongst primary care workers is theneed for greater flexibility, inemployment practices. Individuals withthe workforce will increasingly faceservice and practice developments thatchallenge traditional many aspects ofprofessional practice. The emergentpolicy guidance on the development of apatient-led NHS, provides bothchallenges and concerns for the futurehealth and social care workforce. Thesechanges, in policy and practice, havesignificant implications for the educationand training of future health and socialcare workers, necessitating equalmeasures of flexibility and innovationfrom educational institutions as will beexpected from primary care staff.

Given the unrelenting level of changetaking place in health and social carethere needs to be some stability inrelation to education and training anddevelopment of the workforce. With thepublication of the White Paper(Department of Health, 2006) this is notyet likely to occur. If its proposals forintegration of health and social care areto occur there will of necessity need tocloser working relationships andcollaboration between Education andService providers in particular throughthe work of the new Regional StrategicHealth Authorities. Such work is crucial ifthose that can provide education are notdisenfranchised by the increasing pursuitof skills based training programmes.

Holland (2004:229) concluded that:

“ To achieve fully integrated servicessupported by inter-professional andinter-agency working will require asignificant cultural change for anumber of organisations at all levels

of service management and delivery.Central to this will be the need foreffective leadership and mostimportantly effective partnershipsand collaboration between healthand social care services and theirrespective education partners toensure that any future workforcewill have the skills and knowledgeto deliver the care that users of thisservice require”.

The success of this Shaping the Futurefor Primary Care Education and Trainingproject has been the result of theeffective collaboration between HigherEducation providers and theorganisations delivering and developinghealth and social care. It is our belief thatthis should be the precursor of othersuch initiatives which examine the linksbetween education and service needs inorder to ensure that the pursuit ofeffective integrated health and socialcare services becomes a reality.

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34

Amos D 2002 Primary Care workforceplanning framework (letter), Dept ofHealth, London

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Together, Learning Together – AFramework for Lifelong learning,Department of Health, London

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Department of Health 2002a FundingLearning and Development for theHealthcare Workforce, Consultation onthe review of NHS Education andTraining Funding and the Review ofContract benchmarking for NHS FundedEducation and Training, Department ofHealth, London

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Department of Health 2005b Creating apatient led NHS – Delivering the NHSImprovement Plan, Department ofHealth, London

Department of Health 2006 The WhitePaper: Our Health, our care, our say,Department of Health, London

Eraut M 2002 Editorial, Learning inHealth and Social Care,1, 4, 177-179

Freeman M,Miller C & Ross N 2000 Theimpact of individual philosophies ofteamwork on multi-professional practiceand the implication for education,Journal of Inter-professional Care,Vol.14, No.3, 237-247

Glenndinning C 2003 Breaking downbarriers: Integrating health and socialcare services for older people inEngland, Health Policy, 65, 139-151

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Hall R 2003 Forging a LearningCommunity? A pragmatic approach toco-operative learning, Arts andHumanities in Higher Education, Vol. 2,2, 155-172

Hardiker N 2006 Course Finder, Shapingthe Future for Primary Care Education &Training Project, University of Salford,Volume 2, www.pcet.org.uk

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Holland K 2004 Inter-professionalworking and learning for integratedhealth and social care services, Editorial,Nurse Education in Practice, 4, 228-229

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37

Steering Group membership

Sue Lightup

Richard Jones

Bernard Walker

Eileen Martin

Dr Janine Talley

Jean Llewellyn (from 06/03 – 10/04)

Jane Flanagan (from 10/04 – Present)

Prof. Norma Raynes

Dr Keith Lawrence

Karen Holland

Andy Duffin

Chris Jeffries

Tony Watmaugh

Jo Reeve

Maria Thornton

Tina Egan

Prof David Pilgrim

Prof Valerie Wass

Pat Sandiford

Prof Godfrey Mazhindhu

Terry Roche

Gaye Jackson

Celia Granell

Dave Jones

Jacky Knapman

Director, Social Services

Director, Social Services

Director, Social Services

Dean of Health & Chair, NWUA Health Sub-Group

Staff Tutor

Project Champion

Project Champion

Chair, Project Steering Group

Project, Internal Evaluator

Project Director

Project Administrator

Assoc Dir, Education & Learning Resources

Director, North West Region

Honorary Lecturer - Primary Care

Deputy Director, Teaching & Learning

Principal Officer (Ops)

Clinical Dean

Professor of Community Based Medical Ed.

Manager of Community Based Medical Ed.

Dean of Health

Acting Regional Director

Project Manager

Development Manager

Project Manager, (CMSHA Post Reg. Framework)

Education Director

St Helen's MBC

Lancashire County Council

Wigan MBC

UCLAN

Open University

NWDA

NWDA

University of Salford

University of Salford

University of Salford

University of Salford

GMSHA (Gtr Manchester Strat Health Authority)

Association of Colleges

Cheshire & Merseyside tPCT

Salford PCT

NWUA

Blackburn with Darwen PCT

University of Manchester

University of Manchester

Liverpool John Moores University

NHSU

GMSHA (Gtr Manchester Strat Health Authority)

CLSHA (Cumbria & Lancs Strat Health Authority)

CMSHA (Cheshire & Merseyside Strat Health Auth)

Cheshire & Merseyside tPCT

Appendix 1

38

Steering Group Meetings-Terms of Reference

1. To actively shape and influence theProject and its progress, includingcommunicating and liasing with theProject Team and relevant organisations

2. To advise the NWDA (as the fundingbody) on the progress of the projectand its monitoring

3. To monitor financial management ofthe project in collaboration with theProject Director

4. To develop a sustainable collaborativepartnership between key organisationsand individuals involved in the deliveryand development of integrated healthand social care, education and trainingand workforce development in the NWRegion. This includes actively pursuingother opportunities for collaborativeinitiatives as a result of the projectobjectives and outcomes.

5. To assist in the dissemination processthrough networking activities andattendance at local, regional andnational events and forums.

6. To receive regular reports on projectprogress from Project Director inaccordance with the Project Plan.

7. To attend quarterly meetings as peragreed annual calendar

Appendix 2

Dissemination Activity of Project Team

ConferencepresentationsHardiker N 2004: The PCET CourseFinder Tool presentation, ProjectRegional Conference, Reebok StadiumConference Centre, Bolton

Holland K 2003: Shaping the Future forPrimary Care Education and TrainingProject: A collaborative experience.Paper presented at 4th AnnualInternational Research Conference,Transforming Healthcare throughResearch, Education & Technology,Trinity College, Dublin

Holland K 2004: Collaboration inEducational Research: Finding theevidence to develop the workforce insocial, community and primary careintegrated services. Paper presented at15th Annual International ParticipativeConference–Nurse Education Tomorrow’Education in Health Care, DurhamUniversity

Holland K 2004: Working inPartnership: Shaping the Future forPrimary Care Education and Training.Paper presented as part of a symposiumof three papers at ‘Unlocking thepotential–partnerships in health andsocial care Conference’, North WalesInstitute of Higher Education, Wrexham,North Wales

Holland K 2004: Shaping the Future foreducation and training project, ProjectRegional Conference, Reebok StadiumConference Centre, Bolton

Holland K 2005 Key Note Paper:Partnerships and Collaboration inEducation, 3rd Annual Developments inNurse Education Conference, Universityof Salford

Howarth M & Grant M 2004: Reviewingthe evidence base for integrated healthand social care: Challenges andopportunities, Project RegionalConference, Reebok StadiumConference Centre, Bolton

Howarth M, Grant MJ 2003: Reviewingthe evidence base for integrated healthand social care: challenges andopportunities, Transforming HealthcareThrough Research, Education and

Technology, Dublin. 5-7 November 2003

Howarth M 2004: Collaboration,cooperation or compromise,Collaboration, Cooperation orCompromise conference, Brighton, April2004

Lunt H 2004: Draft Benchmarking Toolfor Best Practice in Education andTraining Strategies for Integrated Healthand Social Care, Project RegionalConference , Reebok StadiumConference Centre , Bolton

Nettleton R & Stead V 2004:Developing and piloting the ETNA Tool,Project Regional Conference , ReebokStadium Conference Centre , Bolton

Nettleton R 2004 Developing a tool foreducation and training needs analysisfor integrated health and social care:Work in progress. Paper presented aspart of a symposium of three papers at‘Unlocking the potential–partnerships inhealth and social care conference’,North Wales Institute of HigherEducation, Wrexham, North Wales

Reid P et al 2004: Service UserPerspectives on Integrated Health andSocial Care, Project RegionalConference , Reebok StadiumConference Centre, Bolton

Reid P et al 2005: Service UserPerspectives on Integrated Health andSocial Care, Comensus Service UserInvolvement Conference, Harris BusinessPark, University of Central Lancashire,Preston

Warne T 2003: Integrated health andsocial care: Implications for educationand training the future workforce.Paper presented at 4th AnnualInternational Research Conference,Transforming Healthcare throughResearch, Education & Technology,Trinity College, Dublin

Warne T 2005: Educating Nurse Rita towork in health and social care. Paperpresented at 6th International NursingConference, Comenius University,Martin, Slovakia

Warne T 2005: Loitering with intent:Soliciting the views of the primarymental health care workforce. Paper

presented at the 2005 University ofSwansea Research Seminar series,University of Swansea, Wales

Warne T 2005: Taking time out to learn:The views of the primary health andsocial care workforce. Paper presentedat 16th Annual InternationalParticipative Conference–‘NurseEducation Tomorrow’, Education inHealth Care, Durham University

Warne T 2005: Abandoningegocentricity in the search of the HolyGrail of integrated health and socialcare. Paper presented at 3rd AnnualConference on Community HealthNursing Research, Tokyo, Japan

Warne T 2005: Current difficulties inthe UK primary care nursing practice(invited speaker) Hungarian ScientificSociety of Nursing, 10th InternationalConference, Pec’s, Hungary

Warne T, King M, Street C, McAlonanC, 2006: From fragmentation tointegration in health and social careservices. 1st Nurse EducationInternational Conference "Developingcollaborative practice in health andsocial care education" Vancouver,Canada

Poster Presentations Howarth M, Grant MJ & Holland K2005: Finding the evidence to developthe workforce in social, community andprimary care integrated services. Posterpresentation at Royal College ofNursing 2005 Annual InternationalNursing Research Conference, Belfast

Project Reports Hardiker N 2006: Shaping the Futurefor Primary Care Education and TrainingProject: Education and Trainingprovision to deliver integrated healthand social care: A Course Finder Tool,Shaping the Future Project, University ofSalford

Holland K, Warne T & Lawrence K2006: Shaping the Future for PrimaryCare Education and Training Project:Finding the evidence for education andtraining to deliver integrated health andsocial care: The Project Experience,Shaping the Future Project, University ofSalford

Appendix 3

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40

Howarth M, Grant M & Holland K2004: Shaping the Future for PrimaryCare Education and Training Project:Finding the evidence for education andtraining to deliver integrated health andsocial care – A systematic review,Shaping the Future Project, University ofSalford, www.pcet.org.uk

Howarth M, Holland K, Lunt H &Cosgrove P 2006: Shaping the Futurefor Primary Care Education and TrainingProject: Best Practice in Education andTraining Strategies for Integrated Healthand Social Care, Development of theBenchmarking Tool, Shaping the FutureProject , University of Salford

Howarth M, Holland K, Hardiker N andLunt H 2006: Shaping the Future forPrimary Care Education and TrainingProject: Best Practice in Education andTraining Strategies for Integrated Healthand Social Care, A Benchmarking Tool,Shaping the Future Project , Universityof Salford

Reid P, Nicholson G, Martin J & RatinckxL 2006: Shaping the Future for PrimaryCare Education and Training Project:Integrated Health and Social Care: thePerspectives of People using theservices: A mixed method analysis,Shaping the Future Project, University ofSalford

Stead V & Nettleton R 2006: Shapingthe Future for Primary Care Educationand Training Project: Integrated Healthand Social Care: Developing theEducation and Training Needs Analysis(ETNA) Toolkit, Shaping the FutureProject, University of Salford

Warne T, King M, Street C & McAlonanC 2006: Shaping the Future for PrimaryCare Education and Training Project:Finding the evidence for education andtraining to deliver integrated health andsocial care – The Primary CareWorkforce Perspective, Shaping theFuture Project, University of Salford

Published papersHolland K 2004: Editorial: Inter-professional working and learning forintegrated health and social careservices, Nurse Education in Practice,4,228-229

Holland K & Raynes N V 2005: Shapingthe Future for Primary Care Educationand Training: A collaborativeexperience, Journal of InterprofessionalCare, Vol 19, No 2, 176-177. A ShortReport

Holland K 2005: Shaping the Future forPrimary Care Education and Training.Innovative Learning in Action, Issue 3,Employability, Enterprise andEntrepreneurship, EducationDevelopment Unit, University of Salford

Tools Hardiker N 2006: Course Finder Tool,Shaping the Future for Primary CareEducation and Training Project:Education and Training provision todeliver integrated health and socialcare, University of Salford,http://www.pcet.org.uk/coursefinder/index.asp

Howarth M, Holland K, Hardiker N &Lunt H 2006: Shaping the Future forPrimary Care Education and TrainingProject: Best Practice in Education andTraining Strategies for Integrated Healthand Social Care, A Benchmarking Tool,Shaping the Future Project, University ofSalford

Nettleton R & Stead V 2006: Shapingthe Future for Primary Care Educationand Training Project: Education andTraining Needs Analysis (ETNA): Toolkit– A resource kit and user’s guide,Shaping the Future Project, University ofSalford

41

Appendix 4

A Collaborative Event

Shaping the Future for Primary CareEducation and Training Project

&Knowsley

Tuesday May 11th 2004

Venue: European SuiteLiverpool Football Club, Anfield, Liverpool

‘Education and training to deliver integrated health and social care’

A Conference to share good practice in integrated health and social care

Report from the Event

Website: www.pcet.org.uk

42

Introduction The event itself was the outcome ofdiscussions between Karen Holland,Project Director, Shaping the Future forPrimary Care Education and TrainingProject, University of Salford and AnitaMarsland, Chief Executive of KnowsleyPrimary Care Trust/Director of SocialServices and Wendy Pickard, DeputyDirector of Service Provision, KnowsleyPCT.

The key aims of the day were to:

1. Establish the perspective of health andsocial services workforce as to what theyconsidered to be essential knowledgeand skills necessary to deliver integratedhealth and social care services;

2. Establish how Knowsley could beinvolved in the Shaping the FutureProject;

3. Enable the Shaping the Future Projectteam to gain a better understanding ofissues related to working and learning inan organisation that was identified as anintegrated health and social care service;

4. To enable Knowsley to establish abaseline evaluation of the workforceperspective of its current position withregards to an integrated health andsocial care organisation;

5. To enable a way forward to beplanned for the future education andtraining needs of the workforce inKnowsley.

Delegates47 delegates attended the day, with 40from Knowsley and 7 from the Shapingthe Future Project Team (A Full list ofdelegates in Appendix 1).

Programme of the Day Following registration and coffee the daybegan with a welcome from CouncillorKen Keith, Knowsley Borough Council.He spoke highly of the collaborativepartnership between the Primary CareTrust and social services, in particular thework of the Older People Services. Hethanked all the staff present and theircolleagues for their hard work anddedication in caring for the people ofKnowsley. He was thanked for hiswelcome by Wendy Pickard, KnowsleyPCT.

Following this Wendy Pickard gave anoverview of integrated health and socialcare nationally and locally – entitled‘Better Together’ (Copy of fullpresentation in the Publications Menuon the www.pcet.org.uk websiteentitled ‘Better Together’). This providedan excellent background for thedelegates and highlighted in particularthe health and social care issues ofKnowsley. It also highlighted theexcellent achievements that had alreadybeen implemented in integratingservices for the benefit of the localcommunities.

Karen Holland, Project Director ofShaping the Future for Primary CareEducation and Training Project thenpresented an overview of the projectaims and progress (Copy of fullpresentation in the Publications Menuon the www.pcet.org.uk websiteentitled ‘Overview and Project Aims’).This generated discussion and offers ofsupport to become involved in elementsof the project. It was anticipated thatmany of the issues would be revisitedduring the remainder of the day.

Following a coffee break the delegatesreturned to the main area where Karenoutlined the Group Activity for the firstsession.

The delegates were all allocated to agroup with a facilitator from eitherKnowsley or the Shaping the Futureproject.

Morning session

Group Activity 1 Identify knowledge and skills to deliverintegrated health and social care.

The aim of this session is:

To identify (in broad terms) what areconsidered to be the essential skills andknowledge for the workforce to be ableto deliver an integrated approach tohealth and social care. (This is notspecific to Knowsley).

Consider for the feedback session:

1. What determines the knowledge andskills required to deliver integratedhealth and social care services?

2. How would organisations determinetheir specific workforce needs withregards to this knowledge and skills?

3. What essential knowledge and skillsare considered essential to delivereffective integrated health and socialcare services?

4. How would you ensure that theworkforce would gain essentialknowledge and skills?

Please identify a member of the group togive a brief feedback on these points.Flip chart paper/pens are available tomake notes for this exercise.

Feedback from the morningdiscussion Prior to the group feedback AnitaMarsland the Chief Executive ofKnowsley PCT/Director of Social Servicesaddressed the delegates. She gave abrief update on developments andprogress in relation to collaboration andpartnership activities, the uniqueness ofher role and also the issues she faced inher day to day work because of this. Thiswas a very enlightening insight. Shethanked Karen, the project team andWendy for making the day possible andall the staff for making a commitment totake things forward. Delegates had anopportunity to talk with Anita during thelunch break that followed.

The facilitated sessions had provided anopportunity for the groups to get toknow each other on both a social andprofessional basis. There was a livelydiscussion in all the groups.

The morning activity focused onknowledge and skills in general to deliverintegrated health and social care. Theissues raised highlighted both nationaland local drivers influencing workforceneeds.

Summary of key issues Q1) What determines the knowledgeand skills required to deliver integratedhealth and social care services?

Key issues identified were:

n The needs of the community – inparticular, users and caresneeds/experiences/ feedback andchanging population needs in shiftfrom secondary to primary care;

n Professional role needs;

n National drivers and legalframeworks;

n Health promotion , education anddisease management;

n Organisation vision.

Although there was variation in howviews were expressed it was clear thatdelegates understood the external andinternal drivers determiningorganisational strategy.

Q2) How would organisations determinetheir specific workforce needs withregards to knowledge and skills?

Key issues were:

n Consultation process within theorganisation and users/carers;

n Training needs analysis linked tobusiness planning;

n Strategic planning and sharingacross organisations;

n Respecting diversity;

n Identifying skills mix and gapanalysis;

n Appraisal systems.

There was a significant similarity inresponses to this question between allfive groups.

Q3) What essential knowledge and skillsare considered essential to delivereffective integrated health and socialcare?

Key issues were:

n Good strategic planning and clarityof vision (all levels of staff);

n Good leadership skills- innovation,creativity and vision;

n Organisational development,workforce development and teamdevelopment;

n Robust communications;

n Organisational vision;

n Knowledge of local needs;

n A range of skills – customer care,effective team working, finance,evidence based practice and IT andcommunication skills.

There was again significant similarity andagreement between the groups as toessential knowledge and skills. Inparticular in was also apparent that thedelegates were raising similar themes to

those already being identified in theShaping the Future project –SystematicReview.

Q4) How would you ensure that theworkforce would gain essentialknowledge and skills?

Key issues were:

n Team working and networking;

n Better understanding of each othersroles across health and social care;

n Commitment to developing staffand reducing barriers;

n Career mapping;

n Partnership working with academia;

n Role redesign;

n Defined goals–keep focus onintegrated working not just inter-agency working;

n Make protected learning time andresources (including trainingfacilities) available – learningbecomes a part of the culture.

The overall themes from all the feedbackappear to focus on having an initialStrategic vision and planning, clearvisionary leadership, taking account ofuser/carer needs and views, togetherwith having robust training need analysisstrategies linked to appraisal andsupported by resources and protectedtime. All this in an environment whichsupports and promotes collaborativeworking and partnerships across andwith communities.

Afternoon Session Delegates returned from an excellentlunch and the afternoon session wasoutlined. There was some negotiation atthis point from some supporters ofLiverpool Football Club to be given theopportunity to undertake group activityin the Executive boxes overlooking theground itself. This provided some lighthearted discussion on the issue offavourite football teams! It alsodemonstrated excellent negotiation skillsand collaboration between delegates!

The groups again worked hard toachieve the session outcomes.

Group Activity 2

Knowledge and skills forKnowsley The aim of this session is:

To explore education and training needsof the workforce to be able to deliver anintegrated approach to health and socialcare in Knowsley.

Consider for the feedback session

1. What are the local determinantswhich will influence what skills andknowledge are required by the healthand social care workforce in Knowsley?

2. Do you consider that Knowsley has anintegrated approach to health and socialcare and what leads you to believe that(or not)?

3. What education and training needs doyou consider essential if you are to workin an integrated health and social careorganisation of the future?

4. How do you envisage that youreducation and training needs will be metby the organisation?

5. What would the group expect tohappen in relation to this event, withregards to their future education andtraining needs?

Following the feedback Michelle Taylor,Life Long Learning Co-ordinator brieflyoutlined some of the plans for the futurelifelong learning strategy and asked forany volunteers to be involved in thedevelopment groups. There was anexcellent support for this and nameswere offered at the end of theafternoon.

We were very pleased to welcomeRosemary Hawley, Chair of KnowsleyPCT who gave a short closing address tothe day. She then thanked the delegatesfor their hard work in providingKnowsley community with suchexcellent service and also Karen and theProject team for making the daypossible.

It had been a very successful day –indicating the trust commitment to itsphilosophy and strategy for integratedhealth and social care. There are manychallenges to be faced within the next

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12 months, in particular those related tochanging services for Children, andcloser working links with the Educationservice. Given its current positionKnowsley will be at the forefront ofthese challenges and its workforceprepared to get involved in ensuring itssuccess.

Links would continue with the trustthrough the project and Karen proposedthat a similar event took place in 12months time to evaluate progress anddevelopments.

Karen HollandProfessorial FellowAssociate Dean (Research)Faculty of Health and Social Care University of Salford

Project Director –Shaping the Future forPrimary Care Education and TrainingProject

and

Wendy Pickard Deputy Director of Service ProvisionKnowsley PCT

Report preparation:-

Andy DuffinProject Administrator

Shaping the Future for Primary CareEducation and Training ProjectUniversity of Salford

11th May 2004

45

Appendix 5

A Collaborative Event

Shaping the Future for Primary Care Education and Training Project

&University of Manchester, School of Primary Care

Hosted by the University of Salford

February 18th 2004

Sponsored by:

“Inter-professional learning in Primary Care: Exploring the student experience”

A Conference for North West Region Health and Social Care Students

Report from the Event

Website: www.pcet.org.uk

46

Introduction The Conference itself was the outcomeof discussions between Karen Holland,Project Director, Shaping the Future forPrimary Care Education and TrainingProject, University of Salford andProfessor Val Wass, Professor ofCommunity Based Medical Education,School of Primary Care, University ofManchester. The key aims of the daywere to:

1. Identify what makes a good learningenvironment in the community forhealth and social care students;

2. Identify ways in which inter-professional learning and working couldbe promoted in the community setting;

3. Identify the skills, knowledge andattitudes needed to work effectivelywithin an inter-professional team inPrimary Care/community setting;

4. Identify ways in which theirprogrammes of learning could bestructured to enable them to achievethis.

DelegatesUndergraduate students and their tutorshad been invited from all the North WestHigher Education Institutions, withanticipated attendees from all healthand social care groups. Twentyundergraduate students took part in theday’s events, from the University ofManchester, Salford, Liverpool & CentralLancashire and Edge Hill College ofHigher Education, together with atrainee assistant practitioner fromSalford Primary Care Trust. Theserepresented nursing – adult, child andmental health branches, medicine andpodiatry.

In addition, there were an additionaltwelve attendees, which included clinicaltutors, Primary Care Trust representativesfrom Salford and East LancashireTeaching PCT’s and Cumbria andLancashire Workforce DevelopmentConfederation. All students hadexperienced a community clinicalplacement and were nearly all in the finalyear of their programmes of study.Length of time in a communityplacement varied from a day/two daysper week to longer blocks of time of 8weeks and more.

Programme of the Day Following registration and coffee the daybegan with a welcome and introductionto the day by Karen Holland and ValWass, both giving an overview of theirwork in relation to education andtraining issues facing the Primary Caresector. The aims of the day were outlinedand participation through discussion wasencouraged. All delegates would receivea summary of the day’s discussions.

The delegates were all allocated to agroup, three student groups and onemixed tutor/service group. There was aset focus to both morning and afternoonsessions:

Morning session

Group Activity 1: Futureworking in a communitysetting Given that you have all experiencedclinical placements within a communityenvironment we are interested to know,from your perspective, what it is thatwould attract you to working there oncequalified. In your groups, consider someof the following issues:

n How were you prepared for thelearning experience within thecommunity?

n What do you consider to be a goodlearning environment?

n What contact did you have withother students from differentcourses/professions?

n What learning and teaching tookplace in an inter-professional way?

n What benefits do you think inter-professional teaching and learninghas for patient care?

n What would you like to see in yourcurriculum that would help you tolearn and to work inter-professionally/inter-agency?

With your facilitator identify:n 3 key factors that would facilitate

learning in a communityenvironment;

n 3 key issues arising from yourdiscussion that would help you todecide to work in a communitysetting, once qualified.

Karen Holland, Professor Val Wass andDr Tony Warne (ManchesterMetropolitan University, member ofShaping the Future Project Team)facilitated the three student groups.

Group Activity 1:Tutor/service delegate Group You are asked to develop a programmefor a group of students from differenthealth and social care backgrounds toenable them to experience ‘working inthe community’.

Key issues n What do you consider would make

a good learning environment forcommunity based learning?

n How would you prepare them towork inter-professionally/inter-agency?

n What are the benefits of preparingthem for working in such anenvironment?

n Do you feel that you are preparedfor delivery of an inter-professionallearning and working curriculum?

Please identify:

n 3 key factors that you would includein a curriculum to supportcommunity based inter-professionallearning and working;

n 3 key factors that you consider as agroup would be essential in thepreparation of lecturers and mentorsin practice to deliver this curriculum.

Feedback from the morningdiscussion The facilitated sessions provided anopportunity for the groups (mixedprofessional backgrounds) to get toknow each other on both a social andprofessional basis. There was a livelydiscussion in all the groups, and it wasespecially pleasing to see the confidentand articulate way in which the studentsconducted themselves. They were acredit to their respective Institutions. Thenotes from the discussions only illustratea fragment of what went on in eachgroup but give an overall flavour of keyissues.

In terms of what they considered wouldmake a good learning environment it

was clear from both notes anddiscussion that being valued as a studentand person was high on their list of

priorities. During the feedback sessionand open discussion it was apparent thatall the students had experienced clinicalplacements where this was not the casebut they reported that where they werevalued, their learning experience hadbeen excellent. Other positives in theseparticular placements were holisticpatient centred care, wide variety of skillsfor good patient care and workingtogether collaboratively. Student GroupA illustrated their ideas of a goodlearning environment with a map –many of which had also been raised indiscussion in the other two groups. Oneinteresting issue was their perceptions ofhierarchy, in that it existed more in theAcute Care placements than in thecommunity – where there was more of afocus on team work and peer support.

The key factors identified that wouldfacilitate learning in a communityenvironment illustrated a major issuethat arose in the discussions, in thatthere was a need to understand eachothers professional roles andresponsibilities. For example, there was alack of awareness of role of podiatristsand that student nurses actually pursueddifferent branches which led to differentwork roles on qualifying. One student inthe feedback session highlighted theproblem with this as well from a patient’sperspective, in that “if we don’tunderstand each others roles, how dowe expect a patient do so?” “If theycome into a Health Centre and are facedwith lots of different professions lookingafter them how do they know who doeswhat in their care?”

Many of the students would have likedto follow the ‘patient journey’ in order tounderstand all their care not just the partthat their professional group played. Thecentrality of the patient within theirlearning experience was evidentthroughout their discussions andfeedback. For example, taking accountof the patient’s life story and the way inwhich they managed their illnesses i.e.‘Learning from the patient’ and seeing‘the patent as a person’.

As can be seen from the discussions thesame themes appeared across the threegroups, giving some indication that,even if we had had larger numbers of

students present, there were clearindicators of sameness in relation to theirclinical experience and what theyconsidered important to them. Aninnovative idea from a student in GroupB was that of ‘peer mentoring’, i.e.mentoring by other students in clinicalplacements, and they also felt that beingsupervised by someone from a differentprofession was a good learningexperience. In terms of what would helpthem decide if they wanted to work in acommunity setting once qualified it wasapparent that their student experiencewould determine this if it was a positiveone, together with issues such asworking flexible hours.

The tutor/service group interestinglypicked up on similar issues re learningenvironment in the community inrelation to multi-professionalopportunities, but also the need formentors not just for the students butalso the practitioners. In terms of a goodlearning environment the issue of beinga supportive one was noted plusensuring availability of resources forlearning.

They concluded that the benefits ofworking inter-professionally/inter-agencywere numerous none more so than thebenefits to the patients and increasedunderstanding of roles which was amajor theme with the students.

Lunch provided an opportunity forfurther lively discussion and theircommitment to the day was evident inthat everyone returned for the afternoonsession!

Afternoon Session

Group Activity 2: Integratedhealth and social care You are a group of students undertakinga clinical placement within a large Healthcentre in an inner city area. As part ofmajor re-organisation there is a plan toset up within this Centre a newintegrated health and social care servicefor rehabilitation of older people whohave experienced a stroke. There is alsoa plan to integrate the service with theAcute Hospitals Trust through thedevelopment of an integrated carepathway for this illness.

You are invited as a group to identify thefollowing:

n Who would you envisage would bethe team in this new service?

n What skills, knowledge andattitudes would the team need todeliver this new service?

n How would you ensure that theteam worked together?

n How would you determine whetherthis new service was a success ofnot?

With your facilitator identify:

n 3 key points in each of the abovesections;

n 3 key issues that you would expectto see in your curriculum that wouldenable you to both learn and workin such an integrated health andsocial care service.

For the tutor/service group:

Consider the student activity anddetermine your own responses to thesame scenario (from the perspective ofpreparing practitioners to work in thisenvironment).

The students facilitated their own groupsfor this session. They were all veryconfident with this approach and giventhat most of them had not met beforethis event it was pleasing to see theircollaborative working. There were verylively discussions in all the groups andtheir conclusions reflected the veryfocused approach they had all taken tothe scenario they had been given. Inrelation to the team required it wasevident that on the whole the studentsconsidered roles already known to themin relation to delivery of care. However,as they begun to look at the ‘patientjourney’ approach they began to realisethat not all the roles were possibly inplace to meet patient needs. Forexample, one group identified the needfor a ‘Needs Assessor‘, and linked this toan assessment tool used in nursing,based on a Daily living model of care. Itwas evident that they saw the need alsofor input from agencies other than thecaring ones, for example, transport,benefits and housing. The importance ofbeing able to educate patients, takingaccount of their environment and socialcircumstances were consideredimportant skills and knowledge in

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delivering an integrated health andsocial care service. The term ‘patientcentred care’ encapsulates theunderlying theme throughout the day.

As in the morning discussion the issue ofappreciation of everyone’s role in thecare of the patient was noted.

Once group identified six key skills thatwere essential to the team – includingcommunication and basic care. Regardfor other health care colleagues wasagain noted as an attitude to be held inrelation to working in the team.Innovative answers were provided forensuring that the team worked together,including the need for effectiveleadership of the team and a removal ofany hierarchy.

They acknowledged the importance ofevaluation using different means in theirdetermination of whether this newservice was a success or not. Thetutor/service group noted a number ofissues for inclusion in a curriculum thatwould enable students to learn andwork in an integrated health and socialcare service, many of which linked to thestudent groups conclusions. Crosstraining and better knowledge ofprofessions and practice were noted.

Following the feedback from theafternoon discussions the delegateswere asked to highlight what they hadgained from the day and what theyconsidered could be improved upon.

The key positive issues: n They have learnt something about

other professions;

n The variety of different students thatattended was very good;

n The small group work wasstimulating;

n The event was not led by lecturers;

n The quality of discussion was verygood.

Noted for future (from the students):

n Perhaps mixing up the studentattendees with qualified staff insimilar professions as both partiescould benefit more in this situationby sharing experiences;

n Mixing students with practitioners ina similar student–led event may beuseful.

Conclusions The event far exceeded our expectationsin relation to the participation bystudents in all the activities. It was clear,even with a small representative ofprofessional groups that they had similarexperiences in clinical practice within acommunity setting and that they wereagreed on a number of issues thatneeded to be addressed within bothpractice and within their curriculum toenhance their learning experience. Beingvalued as students and individuals was amajor theme throughout the day, as wasthe need for a better workingunderstanding of otherprofessions/agencies roles andresponsibilities in the care of patients.This was not only from a theoreticalviewpoint but a practical one, as many ofthe students identified the value ofworking alongside otherprofessions/health and social careworkers within the practice setting.Although the focus of the day wasPrimary Care experience, the studentsraised the same issues in relation toworking within the Acute Care sector.When asked if they would choose towork in Primary Care/Community whenqualified, a number of them said theywould consider it and two or three hadalready made a commitment to this aim.Some of them, however, indicated thatthe service did not make it easy foremployment on qualifying, with some ofthe nursing students indicating they hadbeen told to gain experience in a hospitalbefore looking for work in a health carecentre. The medical students were alsoaware of the changes taking place intheir post–qualifying rotation, whereby acommunity placement was to becomecompulsory.

They were unsure of how this wouldimpact on doctors choosing to thenwork as General Practitioners.

From a Higher Education point of viewthe day held lessons for how we preparehealth and social care students to learnin practice as students and also for theirfuture work. Currently there is a drive forinter-professional learning within the HEclassroom. However, based on this eventit would appear that it requires morethan ‘learning in the same classroom’ to

ensure that they learn to work inter-professionally. They also need to beexperiencing inter-professional/ inter-agency working within their clinicalplacements and also be able to have theskills to work collaboratively withinteams and the attitude of valuing othersin those teams for the contribution theymake to patient care. This hasimplications, not only for how thestudents are prepared for this but alsothe lecturers/clinical tutors and otherswho have to facilitate inter-professionalworking and learning experiences.

Recommendations from theday n To host another joint event with

qualified practitioners from healthand social care professions – alongsimilar lines but the perspective ofeducation and training of studentsin clinical practice to deliverintegrated health and social care;

n To host small workshops with healthand social care students to explorein more detail some of the issuesarising from this event;

n To continue to work collaborativelyon issues related to education andtraining issues in a communitysetting – University of Manchester,School of Primary Care and theShaping the Future Project,including a collaborative paper oninter-professional working andlearning.

Karen Holland

Professorial Fellow

Associate Dean (Research)

Faculty of Health and Social Care

University of Salford

Project Director –Shaping the Future forPrimary Care Education and TrainingProject

Professor Val Wass

Professor of Community Based MedicalEducation

School of Primary Care

University of Manchester

Dr Tony Warne

Lecturer

Manchester Metropolitan University

Work Package 5 Lead –Shaping theFuture Project

Andy Duffin

Project Administrator

Shaping the Future for Primary CareEducation and Training Project

University of Salford

15th March 2004

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Appendix 6

Work Package 1: Karen Holland

Biography: Karen Holland

Karen Holland is a Professorial Fellow in the School of Nursing and Institute of Health and Social Care atthe University of Salford.

Karen has extensive experience in both nursing practice and nursing education and her main area ofexpertise has been in curriculum development and research. She has a specific interest in practicedevelopment and inter-professional working and has undertaken activities in a number of NHS Trustswhich focuses on these areas.

She is a subject advisor (nursing) with the Learning and Teaching Support Network (LTSN) Health Sciencesand Practice Centre, King’s College, London and actively promotes the linking of teaching and researchboth internally within the University of Salford and through her activities with the LTSN.

She is editor of an international nurse education journal Nurse Education in Practice and is a member ofthe editorial board of Work Based Learning in Primary Care. She has also co-authored and edited twobooks: Cultural Issues in Nursing and Health Care & Application of the Roper Logan & Tierney Model ofNursing in Practice.

Work Package 2: Michelle Howarth & Maria J Grant Biography: Michelle Howarth RGN, MSc, PGCE (Dist) & Lecturer

Karen Holland is a Professorial Fellow in the School of Nursing and Institute of Health and Social Care atthe University of Salford.

Karen has extensive experience in both nursing practice and nursing education and her main area ofexpertise has been in curriculum development and research. She has a specific interest in practicedevelopment and inter-professional working and has undertaken activities in a number of NHS Trustswhich focuses on these areas.

She is a subject advisor (nursing) with the Learning and Teaching Support Network (LTSN) Health Sciencesand Practice Centre, King’s College, London and actively promotes the linking of teaching and researchboth internally within the University of Salford and through her activities with the LTSN.

She is editor of an international nurse education journal Nurse Education in Practice and is a member ofthe editorial board of Work Based Learning in Primary Care. She has also co-authored and edited twobooks: Cultural Issues in Nursing and Health Care & Application of the Roper Logan & Tierney Model ofNursing in Practice.

Biographies of Project Team

51

Biography: Maria J Grant

Maria is a Research Fellow (Information) at the Salford Centre for Nursing, Midwifery and CollaborativeResearch (SCMNCR), University of Salford. She has a background in information science and hascontributed to a range of health and social care systematic reviews. These activities have included bothfinding and appraising the research evidence.

Maria has an extensive background in information service provision, having previously worked at theCentre for Health Information Quality (providing a national information service to self help groups and theNHS on producing high quality evidence based consumer information) and the UK Clearing House onHealth Outcomes.

Her research interests include enhancing practice through the investigation of optimal database searching– particularly in relation to qualitative research evidence – and investigating the effectiveness of literaturesearching training provision.

Maria is Chair of IFM Healthcare, a charitable organisation committed to improving the provision ofinformation in enhancing healthcare management and delivery. She is also Chair of the 2003/4 Researchin the Workplace Award, an initiative seeking to contribute to the development of the library andinformation community evidence base.

Work Package 3: Helena LuntBiography: Helena M Lunt

Helena Lunt is a Senior Lecturer in Public Health and Primary Care at the Centre for Public Health, LiverpoolJohn Moore’s University. Her Public Health career has been underpinned by many years extensiveexperience in Primary Care. Before deciding to return to full-time study on the Masters in Public Healthat Liverpool University, Helena was employed in clinical and managerial positions within General Practice,the Health Authorities and the Primary Care Trusts.

In 2004 she was appointed Senior Lecturer at JMU, and more recently, was given the opportunity todevelop her research portfolio by working for Prof John Ashton, Regional Director of Public Health.

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Work Package 4: Nick HardikerBiography: Nicholas Hardiker

Nicholas Hardiker is a Senior Research Fellow within the University of Salford’s Centre for Nursing,Midwifery and Collaborative Research. He has been a registered nurse since 1987 and completed in 2002a ‘Return to nursing practice’ course at the University of Manchester. He has been employed in HigherEducation since 1993 with a research focus on health informatics.

Shortly after graduating with a BSc (Hons) in Computing (he also holds a Masters degree and a Doctoratein Computer Science) he received the 1993 British Computer Society Nursing Specialist Group Dame PhyllisFriend Award. In 2001, he received the American Medical Informatics Association Nursing InformaticsWorking Group Award.

His current research interests include: health and nursing informatics, representing health care knowledge,facilitating the integration of research evidence into clinical practice, supporting clinical research throughinformatics, supporting the user-terminology system/knowledge source dialogue and mediating betweenheterogeneous health care terminology systems. He has published and presented widely on these andother topics.

In addition to undertaking diverse research projects, he runs postgraduate modules for several institutionsincluding the University of Colorado (on-line), Trinity College, Dublin and the University of Wales, Swansea.He is a former member of the ICNP® Strategic Advisory Group at the International Council of Nurses, amember of the Steering Committee of the US Nursing Terminology Summit and a member of standardsbodies at national, European and international levels.

Work Package 5: Tony WarneBiography: Dr Tony Warne

Dr Warne has worked as both a clinical practitioner and latterly as a manager responsible for a wide rangeof specialist mental health services, before moving to Manchester Metropolitan University, Department ofHealth Care Studies, in 1995. He is currently the Principal Lecturer for the Division of ContinuingProfessional Development and Postgraduate Studies.

His professional background is in mental health nursing. The focus for his research interests is inter-personal relationships. This has involved a long term working partnership that seeks to explore the impactof such relationships on nursing practice, policy, organisation and education using psychodynamic andmanagerialist analytical discourses. He gained his PhD in 1999, which looked at intra and inter-professional, organisational and economic relationships within the GP Fundholding system.

He has undertaken several large research projects, including a national study looking at mental healthnurses preparation for multi-professional, multi-agency team working; workforce planning for nursing staffworking in primary care; and a number of local evaluations for organisations within the North West. Hehas published widely in this area. He has also recently published a book on using patient experience innurse education.

He is a visiting lecturer to universities in Finland and Kenya. He is a Magistrate with a special interest in thementally disordered offender and was formerly a nurse reviewer for the Commission for HealthImprovement.

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Work Package 6: Paul ReidBiography: Paul Reid

Paul has worked have worked at the University of Central Lancashire for seven years. He is a Senior Lecturerin the Lancashire School of Health and Postgraduate Medicine and Course Leader for our BA/BSc (Hons)Public Health. His areas of teaching are: substance misuse, health psychology, health communication andmental health.

Much of his research activity has focused on aspects of substance misuse. For example: the health andservice implications of polydrug misuse; peer intervention concerning harm reduction and amphetaminemisuse; and the evaluation of drug prevention strategies which target Black and minority ethnic groups.

He also has a strong research interest in homelessness, having carried out research into self medication andsubstance misuse amongst homeless young people, and having completed a PhD focusing on homelessyoung people’s ways of coping with harassment. His research career has mainly focused upon the ways inwhich the perspectives of current and potential service users can be used to enhance service provision.

Prior to coming to the University of Central Lancashire he worked for several years as a Research Fellow atManchester Metropolitan University, and prior to that as a Residential Social Worker with Mencap andother non-statutory organizations providing services to people with learning disabilities.

Work Package 6: Geraldine NicholsonBiography: Geraldine Nicholson

Geraldine has been a researcher in the Lancashire School of Health & Postgraduate Medicine at theUniversity of Central Lancashire in Preston for approximately eight years working on various projects.

She has recently had the opportunity of working within the NHS as Research Governance Coordinator forEast Lancashire Teaching PCT.

She has a Masters degree in Medical Ethics and Law, and has a wide range of interests and experience ofworking in an unpaid capacity with vulnerable members of society including youth groups, people withlearning difficulties and people from differing ethnic backgrounds. This work has incorporated fundraisingactivities, organising and encouraging outdoor pursuits activities and teaching and advocate.

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Work Package 7: Rob NettletonBiography: Robert Nettleton

Robert Nettleton led this work package from The University of Bolton where he is Director of Health andSocial Care Programmes. His professional background is in health visiting and community nursingpractice and education. He has experience of integrated working in child protection services, integratednursing teams in primary care and the development of the skills escalator across boundaries betweenhealth and social care through Greater Manchester Workforce Development Confederation’s ‘Deliveringthe Workforce’ Project.

Work Package 8: Valerie Stead Biography: Dr Valerie Stead

Valerie Stead is an Honorary Fellow of the Department of Management Learning in the ManagementSchool at Lancaster University and a Fellow of the Chartered Institute for Personnel and Development.

Valerie’s background includes management and development in the voluntary, health and public sectors.Valerie’s experience within Lancaster University has included a particular focus on qualitative evaluationresearch and action research, and the design and development of new initiatives and accreditedprogrammes.

Her current research interests include the evaluation of learning programmes, mentoring asmanagement development and the experiences of women leaders. Valerie also teaches on the LancasterMA in Human Resource Development and Consulting, and is co-director on The Health FoundationLeaders for Change programme based at Lancaster University.

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Acknowledgements

We wish to thank everyone who has contributed to the success of this projectand its achievements. In particular all those who cannot be named due to theirinvolvement in the research elements, the students involved in the inter-professional workshops we held and all those who attended the briefingdays. We particularly wish to thank the following organisations:

The North West Development Agency

The North West Universities Association

Greater Manchester Strategic Health Authority

Cheshire and Merseyside Strategic Health Authority

Cumbria and Lancashire Strategic Health Authority

Knowsley Primary Care Trust and Social Services

Salford Primary Care Trust

Bebington and West Wirral Primary Care Trust