Rethinking specialist services: The "two triangle" model
Many of us will be familiar with a triangle model of public services. In this model, universal services are the biggest chunk at the bottom of the triangle working with most of the population, there is a middle layer of targeted support, and at the top, there is a small section representing specialist services. Specialist services can include professionals such as speech and language therapists; clinical psychologists, psychotherapists; or health visitors or midwives with a particular specialism in an issue such as perinatal mental health. According to this model, specialist services work only with the babies, children and families with the highest levels of need, or experiencing rare and complex issues. They sit at a hard-to-attain peak beyond a particular threshold. Like scaling a mountain, it takes time for families to reach this peak and they have often had difficult experiences on the way.
The traditional triangle model of public services
In recent years, the mountain has got taller for many, as specialist services have become harder to attain. Needs have grown, and frequently services have also been cut back, leading to increasing waiting lists and greater rationing of the most expert support. For example, over 65,000 children in England on the waiting list for speech and language therapy, with 20,000 waiting over a year.
In some local systems high thresholds and long waiting lists mean that specialist services, such mental health, can feel unattainable for families. At Isos Partnership, we regularly speak to professionals in universal and targeted services who feel overwhelmed working with families whose needs are more complex than they feel able to deal with, while children spend months, sometimes years, on waiting lists for specialist support during vital developmental periods. Time waiting for support is time wasted, when children’s problems can escalate, become entrenched and have knock-on impacts on other areas of their lives.
The traditional triangle model of services illustrates a system stuck in the mindset of late intervention, where the most expensive, specialist services are reserved only for those whose needs are already the greatest.
But without the resources to increase the number of specialists in our systems, what can be done?
An alternative model is being implemented across different sectors and in different places.
This model moves specialists away from the top of the triangle to give them a role across the system. It separates out our understanding of population need, from the deployment of specialist expertise. In this model, specialist expertise is deployed across the whole system to benefit all families, although it is most intensively used where need is highest.
This alternative approach comes, in part, from the creativity that arises when resources are scarce, and needs are high. More positively, it is driven from a desire to deploy valuable resources in more equitable ways and to enable systems to act earlier to address children’s needs more quickly and effectively. It is becoming increasingly common across range of sectors including mental health, speech and language therapy, family support and occupational therapy.
We can illustrate this model using a pair of triangles facing in opposite directions:
The triangle on the left represents needs in the population, with smaller number of families having higher levels of need.
The triangle on the right represents where specialist expertise is working across the system. Specialists are working most intensively and directly with families with most need, but they are not solely located there. They work right across the system, building capacity and bringing their expertise to benefit families with low and medium levels of need.
I have seen this way of working exemplified in areas of mental health services such as perinatal and infant mental health. Specialised parent-infant relationship teams are small teams of multi-disciplinary professionals with specific expertise in supporting the early relationships between parents and their babies, led by a psychologist or psychotherapist. They offer specialist therapeutic care to a small number of families with the most complex needs, but also spend a significant proportion of their time providing training, consultancy and supervision to other professionals such as midwives, health visitors and family support workers so that all babies in a local area might benefit from their expertise.
In this “two triangle” model, families with lower levels of need may not have direct contact with specialists, but specialists provide training and support to universal practitioners to build their capacity to promote good outcomes; prevent problems emerging and identify and act on any issues that do arise. Specialists might also provide strategic support, informing the development of local care pathways and service specifications.
Specialists provide more support, such as supervision and consultation, to professionals working with families with increasing levels of need. They might also provide some joint appointments, or offer families some time-limited additional support, such as group interventions. Like the triangle model, direct, intensive specialist support is still only provided to families with more complex or severe needs, but in this case, this is not the only work that specialist professionals do.
The two-triangle model has multiple benefits
It is less deficit-focussed than the traditional triangle: It does not concentrate resources only where there are significant problems but recognises that all families benefit from some specialist input. The quality of universal and targeted services should improve as a result of receiving additional support and input from specialists, and this should, in turn, reduce demand for direct specialist support because children get timely support before issues become entrenched or escalate. And, if families still do need direct specialist support, they will not be left with no help while on waiting lists– universal services will be better able to support their needs during any wait.
It can reduce the number of services that families need to build relationships with: If families’ needs can be addressed by an existing professional being upskilled and supported by a specialist, the number of services that families need to see and to build relationships with could be reduced. I remember a social worker in specialised parent-infant relationship team in Leeds describing to me how she was supporting a foster carer “behind the scenes” through calls and supervision so that a baby boy who already had experienced trauma and many adults coming in and out of his life, did not have to have direct contact with another professional.
We often hear how vulnerable families can feel that they are passed around systems, repeatedly having to tell their story to different people. If specialist services support universal professionals, rather than requiring families to “step up” to specialist care for a short period and then be discharged again, it helps families receive continuity in their care and to embed support into an ongoing, longer-term relationship.
It supports a “progressive universal” approach, with the intensity of support provided to each family commensurate with their needs. Compared to a model where families move between universal, targeted and specialist support, progressive universalism secures continuity of relationships for families, and enables professionals to provide more dynamic, timely responses to families’ need as they fluctuate over time. It also reduces any stigma for families which might be associated with accessing different services.
It helps embed shared understanding across different services: When specialists work across local systems it helps to embed shared understanding and common approaches across different services. If specialist professionals train and support universal and targeted professionals in a local area, families are more likely to interact with professionals who have similar approaches and speak the same language, making it easier for those who are moving around the system or working with multiple services.
In short, if we are looking for a model of public services that is efficient; supports integration; improves families’ experiences and better enables early intervention, then two triangles are better than one!