This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information

Section one: Users and carers - definitions and perceptions

By completing this section of the module you should be able to:

  • to discuss users and carers, and related concepts
  • to consider the rights and obligations of health and social service users
  • to identify and analyse the interrelationships between parties to the caring process

Family as service user

For the last twenty years, there has been an increasing emphasis on the family-centred approach to health care. Ironically, during this period, the traditional notion of family has undergone metamorphosis. Demographic data demonstrates that more people are now living alone as the number of cohabiting couples and marriages continues to reduce. However, conceptualizing and defining a family-centred approach has presented a number of difficulties (Hutchfield 1999). Indeed, family centred care as a theoretical concept is thought to be more clearly demarcated in the American literature (Hutchfield 1999). In the British literature, Darbyshire (1993) describes family-centred care as an amorphous term and notes that such vagueness can lead to a rather loose application to the context of care. From a multi-cultural perspective, the sheer variation in forms and perceptions of family can throw notions of family care into disarray. Hutchfield, in a concept analysis of family-centred care, concedes that it may not be a concept but, with reference to the American literature, suggests there are two key attributes; firstly that a lay / professional partnership is evident, and secondly, that normalised patterns of family living are emphasised (Shelton and Smith-Stephanek 1995).

Shelton and Smith-Stepanek (1995) offer one of the earliest published frameworks for family-centred care in relation to the care of children with learning disabilities; family-centred care is seen as a philosophy that drives the implementation of a lay-professional partnership that promotes a normalised pattern of living for the patient or client. Central to the philosophy is that the approach should support parents in their role as 'carers'. Hutchfield's concept analysis, whilst not drawing a clear conclusion, underlines a number of key points. Family centred care may be inappropriate in some care situations, resources may not allow its implementation; and in other cases - professionals may be reluctant to take a partnership approach as it may not be in the best interests of the patient/client. For example, in the former case, professionals may not have the necessary skills to provide parental teaching and support. In the latter case, a parent who is displaying signs of Munchausen's by proxy , may not be an appropriate partner for the health professional.

The context of family-centred care for some minority ethnic people will be inevitably influenced by majority ethnic notions of family. Kinship, for example can be focused upon extended rather than nuclear family. Ahmad (1996) argues that the extended family, although much talked about with reference to families from India, Pakistan and Bangladesh, is by no means, the universally dominant mode of family living within the national groups referred to above. Ahmad accepts that Punjabi culture promotes the corporate and co-operative greater family unit of perhaps three generations living together under one roof, inclusive of the sons; their wives and any unmarried daughters (Ballard 1990). However, Ahmad also adds that in many urban areas, such family structures may have been replaced by independently residing siblings (and their wives and children). Nevertheless, one particular attribute is apparent in South Asian concepts of family, that of 'Biraderi'. Biraderi exemplifies the way in which the extended family should behave; it is perhaps best summed up by Wakil (1970) who suggests: 'it is an individual's bank, police force and psychiatrist'

There is though, what amounts to a theory-practice gap with Biraderi - some families recognise the theory but do not actively participate in the reciprocal relationships and obligations that define it. Others do; providing an almost systematic care package of practical; and social support. Notably, Anwar (1979) identified a range of tasks that might translate the theory of Biraderi into practice and these included looking after a relative's child - who could be for example - in hospital. Of course the way in which society has changed has impacted upon all cultures - the equivalent of Biraderi is then somewhat difficult to implement in the 21st century. Social mobility can spread a group of siblings across the nation and would decrease their chances of sharing the care of one of their sick children in order to give mum an opportunity to meet the rest of her family's needs. Ahmad also adds a note of caution to Biraderi; the defining relationships are not always harmonious. He further asserts that disputes between mothers and daughters-in-law are not uncommon and sometimes competition will be the dominant factor amongst siblings to gain extra status. It is then, no surprise that there is now thought to be less emphasis on the extended family and more in the immediate family (Modood 1994), nevertheless the change in emphasis often results in an adaptation to circumstances rather than a wholesale rejection of previous life ways (Ahmad 1996).

See the discussion of the myth of the extended family in the section - 'Support for Carers' in the module Ethnicity and Learning Difficulties by Ghazala Mir.


Exercise 1.1 Self reflection activity

Consider a child that you have recently cared for whose culture is different to your own. Which family members were important in the care of this client? How did you use this information to construct a plan of care?

Furthermore, and in relation to child care, Dosnajh & Ghuman (1997) in their comparative study of child rearing practices across two generations of Punjabi parents in the United Kingdom, claimed parental involvement is changing. Second generation mothers are throwing off the majority of their traditional customs and practices and moving closer to British ways. It is perhaps consequential that fathers are now playing a more significant part in raising their children. However, this is not solely attributable to being part of a British culture, significant changes in attitude and behaviour of present day, indigenous, families from the Indian sub-continent have also played a leading part in driving change (Dosnajh & Ghuman 1997). It is accepted that social norms, attitudes and behaviours of an identifiable ethnic group cannot be pigeonholed; realities are both complex and ambiguous. Families are therefore often users and carers.

Memo

  • the shape and structure of the family has changed in recent times
  • family centred care is an ambiguous concept
  • notions of family and family centred care can differ across cultures and over time

Users and carers - definitions

Users

The Collins English Dictionary (1982) defines a user in terms of law through 'the continued exercise, use or enjoyment of a right, especially in property' or in combination with the item being used by the person e.g. 'a road-user'. Both these concepts can be applied to health services when an individual becomes involved with health care through using the service that is provided as a right to citizens. However, terminology has varied when referring to users of health services from patient or client, to consumer or user often influenced by Department of Health strategic policy. These two aspects of user involvement with health care will be explored in more depth; using the service and rights of users.

Using the service

The traditional view of service users as patients stems from the construction of the NHS as a public service to cure illness and disease. Hence the medical model of care dominated the service provided to patients, rather than for patients. Due to increasing demand associated with limited resources and rising costs, the health service was reviewed resulting in the introduction of general management principles for the NHS during the 1980's (Fatchett 1998).

Fatchett (1998 Chapter 2) outlines the NHS reforms from the construction of the welfare state through the introduction and dismantling of the internal health care market to current service provision. These organisational changes in health care form a background to the rise of user demand for the service, with increasing levels of involvement from users as consumers of the service, rather than the more passive role of patients receiving services.

Government policy has supported the notion of consumer empowerment, 'Instead of users and carers being subordinate to the wishes of service-providers, the roles will be progressively adjusted. In this way, users and carers will be enabled to exercise the same power as consumers of other services' (Department of Health, 1991a p7). This would depend on a consumer ideology that there is a range of products to choose from where consumers have access and information about services and can choose the most suitable service to meet their needs. Braye (2000) voices a common argument, that inequalities in service provision and resource shortages limit the relevance of consumerism in health and social care, which may give the illusion of participation to individual users.

Certainly the views of users are sought about services, as customer satisfaction within health care is an important component of the clinical governance agenda, which continues to inform standards of care (Department of Health, 1998). Methods of obtaining user feedback on services can be through satisfaction surveys and questionnaires, which may be problematic for children as users and with families from minority ethnic backgrounds that require translated documentation.

Refer to the module Race Equality Management, by Karen Chouhan and Dave Weaver for further discussion of this subject.

Exercise 1.2 Self reflection activity

Imagine you are a community professional whose service is being audited. You visit one of the families on your caseload and find they have been sent a questionnaire about your service. They ask for your help to complete it because they do not understand English very well.

  • how could this family be assisted in giving their view of the service?
  • what issues are raised if you help this family to complete the questionnaire?

Children as service users are usually dependent upon parents to contact services on their behalf, therefore parents become users, which both necessitates and supports a family centred approach for service delivery. However child health policy encourages child health surveillance and health promotion, therefore users may not have sought the service, conflicting with the consumer notion of service user. The subsequent existence of services can be divided into health promotion services e.g. child health clinics, Health Visitor, School Nurse, or services that provide nursing or medical treatment e.g. hospital services, General Practitioner, or Community Children's Nurse.

Often several of these services may overlap and one user may require care from more than one service, in this case collaboration between services is required to ensure quality and effectiveness of the service to the user. Thornes (1993) found in her study of children with complex health needs, that families could receive multiple visits and conflicting advice when several agencies or professional groups were involved in delivering care. The government has recognised the diversity of services that exist in the community for children (Department of Health, 1997) and in their response to the Report of the House of Commons Health Committee would like to encourage team working and co-ordination between primary care and other health care services. Inter-agency collaboration will be considered from the perspective of users and carers in the next section.

Rights of users

The law provides guidance in the shape of the Children Act (1989) and the NHS and Community Care Act (1990) to inform, consult and involve the people who use services in their own care. Furthermore local authorities are required to make strategic plans to meet the individual needs of all service users. Therefore families from minority ethnic cultures who may have particular health needs have a right to have their needs addressed both from a strategic and individual perspective.

The formation of the 'Patients Charter' (Department of Health, 1991d) intended to protect the rights of users through a set of standards, which could be used to assess the performance of the service. One of the standards within the Charter is to 'respect religious and cultural beliefs of users', however critics have commented upon the inability of users to enforce standards of care, as ultimately resources influence circumstances of care (Fatchett, 1998). The Human Rights Act (1998) contributes to the rights of users by encouraging them to question and challenge agency and professional decisions regarding service provision.

Exercise 1.3 Self reflection activity

Consider how the Human Rights Act (1998) can help a user to question a particular aspect of care provision. Illustrate your thinking with reference to three particular rights.
See the Race Equality Management Module: Chapter 1, page 13.

Carers

'Carers' have been defined in the 1995 General Household Survey as 'people who were looking after, or providing some regular service for a sick, handicapped or elderly person living in their own or another household'. The main point is, that care is provided on an informal basis by families, or friends which distinguishes it from formal care provided on an organised and paid basis. Informal care is commonly associated with feelings of love, obligation and duty, and can refer to a range of caring activities and relationships. The term has become more common during the 1980's due to research examining the experience of carers (Glendinning, 1983, Lewis & Meredith, 1988) and the feminist critique of community care (Finch & Groves, 1983, Ungerson, 1987) which examined the role of women as unpaid carers and the subsequent impact in both public and family policy. Community Care Policy (Department of Health, 1991d) has encouraged dependent people to be cared for at home, with the role of statutory services being to support informal carers to continue in their caring role. When considering children, two main groups of carers emerge, children as young carers of family members and parents as carers of sick or dependent children.

Young carers

For agencies to provide support for carers, it is necessary to collect data about people with care needs and also gather information about the population of people who are meeting these needs on an informal basis. The Office of Population Censuses and Surveys (OPCS) is the main source of official statistics, and has generated regular Household Surveys to gain more detailed information about the activities of the population and caring in particular.

It is estimated there are about 6 million carers in Great Britain who can be categorised either by the caring activities they perform (Parker & Lawton, 1994, Twigg & Atkin, 1994) or by the relationship between carer and the person requiring care. Glendinning (1983) concentrated on parents caring for children with disabilities; Lewis and Meredith (1988) considered specifically daughters caring for mothers, while Parker (1992) studied spouses caring for partners. There is also a growing body of literature looking at the needs of young carers (Aldridge & Becker, 1996, Becker, Aldridge & Dearden, 1998) defined as children under the age of 16 years who are giving some form of care to family members who are sick or disabled. However information about young carers is limited as there has been little analysis or consideration of factors such as class, income, gender or race upon caring activities, which could mean that some groups of children may not be recognised as carers. Most health and lifestyle studies concentrate on the White population (Blaxter, 1990) so inadequate national data is available on the morbidity and lifestyle of Black and minority ethnic communities. Although more recent research is now addressing this issue (Rudat, 1994) there remains little consideration of minority ethnic children as carers, which could add another dimension to the issue generally and to services who support carers.

Children may therefore require support from formal services to ensure that their needs as children are protected when there is conflict between their role as a child and their role as a carer. Aldridge & Becker (1996) in their study of young carers found 3 basic needs identified by children, these were information, someone to talk to and practical support. This sort of research has raised nationally the issue of the needs of young carers and has resulted in changes to health and social services planning to ensure that services include provision for young carers. Young carers are now entitled to an assessment of their own needs as carers under the Carers Act and as children under the Children Act. The National Carers Strategy (Department of Health 1999a) highlights the importance of services to meet the needs of young carers.

Collaboration between services can be problematic. The House of Commons Select Committee Report (1997) emphasises the importance of integrating services for children in response to their findings of poor communication from lack of co-ordination between services. Health and Social Service agencies have been encouraged to have closer links through combined Health Improvement Plans that identify the needs of the population in the local area. Discharge planning of patients with continuing health needs from secondary care back into the community is often based on joint planning between health and social services, however the focus of the agencies is usually the patient rather than the carer.

Parents as carers

Parents are naturally carers of their own children, but there is an implied difference in the notion of care as being more than the natural parental role. Parents become carers through association with health and social services where they are defined through their relationship to the service user - the child. Parents of children with complex health care needs or technology dependent children are an increasing group who require nursing support in the community. Some research has been carried out to compare with North American literature, which suggests that parents are subjected to immense stress looking after these children at home (Kirk and Glendinning, 1999). This study found that although parents wanted to care for their children at home, often there was a lack of choice about alternatives; therefore parents were potentially exploited as carers.

A technology dependent child may be a child discharged from hospital who requires ventilatory support, tracheostomy care, has oxygen dependency or requires equipment to maintain nutrition. Needs may vary from 24 hour nursing support to minimal supervision and support from community services. Community children's nursing services are developing across the country to meet the needs of families who require nursing support at home. They have direct involvement with children either at home or in school and can assist parents to provide treatment and nursing care to their children. Collaboration is therefore necessary between Children's Community Nurses and other agencies e.g. School Nurses, Health Visitors, General Practitioner's and Social Services. This is to avoid duplicating information or services to parents but also to avoid gaps in care that can result from one service anticipating incorrectly that another service is giving care. Health Visitors working from a primary care service could avoid visiting children receiving care from Community Children's Nurses who are providing an acute secondary service.

Exercise 1.4 Self reflection activity

Abdul aged 8 months has been discharged from the paediatric ward. He has a tracheostomy tube to assist with breathing. His parents can change the tube and give suction as necessary. The rest of the family do not want to be left alone with Abdul, as they feel frightened of caring for him. What support could be offered to these parents from health and social services, which could assist all the family? What, if any, would be the 'ethnic' aspects in planning this care?

Richardson and Edwards (1993) see the division between the needs of the 'sick' child and the 'healthy' child as an artificial distinction that fragments health services in the community, they argue that this is the basis for professional territoriality that impedes integration of services. This is supported by Perkins and Billingham (1997) who feel the sick aspect of the child should not be separated from the well aspect, a child with a chronic illness would still require immunisation and screening services that are normally provided by the primary health care team.

A key worker role is advocated by the National Health Service Executive (1998) to improve liaison between services and co-ordinate information and services to individual families. This may involve co-ordinating home visits, ensuring continuity of contact with the most appropriate service for the family and ensuring relevant equipment and resources are available as required. For families from minority ethnic groups there can be added problems of interpreting services, and ensuring respite care services, which are based in the home are culturally appropriate to the family. Although nationally, minority ethnic groups comprise 5-6% of population, this can be much higher in particular areas e.g. 50-80% in some areas, 100% in some schools. Thus an ethnic group of Bangladeshi's could, in one area of the United Kingdom, be a majority rather than a minority. This will have an impact on professionals working with child health services in these areas due to uneven distribution of needs for primary health care services and for nursing care of children with specific illnesses that are defined by cultural group e.g. thalasaemia, sickle cell disease. The role of users and carers is often influenced by perceptions of professionals and government policy/ legislation and this prompts the inclusion of users and carers in planning as well as receiving services.

See the section - 'Communication and Information' in the module Ethnicity and Learning Difficulties by Ghazala Mir which provides valuable insights into the role of adequate communication in linking users' and carers' needs.

Memo

  • Definitions of users and carers have developed from government policy
  • Changes in health care provision have occurred alongside increasing demands for users' and carers' views
  • Vulnerable carers in the form of young people or parents, who may be from minority groups are becoming more apparent, and as a consequence their needs are being recognised by professionals.

Health professional's perceptions of their relationship with informal carers

As we have already defined the key terms, it is now appropriate to consider the various perceptions of informal carers held by health and other care professionals. There is a generous amount of literature on the relationship between parents as informal carers and children's nurses. The most detailed analysis of the parent-nurse relationship is to be found in the work of Philip Darbyshire (1993), yet Darbyshire's work does not address the impact of cultural difference on the parent-nurse relationship.

Before proceeding read the discussion of 'Communities of practice' in the module Transcultural Communication and Health Care Practice by Charles Husband and Edwin Hoffman. Whilst this will take a little time it will aid your understanding of how each professional agency, and work team, develop their own, shared perspective.

There is a considerable weight of literature on health professional's interactions with users from minority ethnic groups (Homans 1981, Kanneh 1991, Bowler 1993, Woolet et al 1995). Furthermore, there is also evidence of categorising and labelling patients based upon particular characteristics (Hughes 1977, Kelly and May 1982, Stockwell 1984, Bowler 1993, Johnson and Webb 1995). Of specific relevance is the research of Bowler, and Woolet et al (1995), whose focus was the relationship between midwives and their clients which is to some extent, comparable to the nurse-parent relationship, but here the client is user and when they have delivered their baby, the user and the carer.

Bowler's study focused upon the maternal care of Asian women. Data were collected through non-participant observation and interviews in ante-natal clinics, maternity wards, and the women's homes. In addition, twenty five interviews were held with their midwives. In relation to communication, the midwives held that Asian women were rude and unintelligent largely due to their inability to speak English - in fact two midwives felt this was a moral failing believing 'immigrants' should speak the language of their adopted country. However, what was thought to be rudeness was sometimes attributable to the differing language structure, in Urdu, please and thank you are built into the verb and not as in European languages - separate and consequently relatively easily identified. Bowler argues that linguistic competence is often seen as a mark of intellect and this argument was supported by the findings - many of the Asian women realised their midwives thought they were stupid.

Bowler also revealed that Asian women were sometimes classified as ineffective mothers, principally due to their having large families (quantity of children was perceived as more influential in making a judgement about parental competence than the quality of a mother-child relationship). Nevertheless, notions of mothering will in part, differ dependent upon cultural norms, the dominant mode of mothering in this country is based upon white middle class behaviours - consequently such different notions serve to consolidate the 'them and us' phenomenon noted by Mason (1995). Two years later, Woolet et al (1995) undertook a comprehensive study of 100 Asian and 43 non-Asian women's experiences of pregnancy and childbirth. Using both qualitative and quantitative methods, they found that health professionals cannot assume knowing a woman is Asian is a reliable guide to culturally appropriate health care, bearing out the view that there is no guarantee of homogeneity within or between minority ethnic groups.

Government perspectives: policy and statute

Government policy and legislation is also influential in promoting the involvement of informal carers in patient or client care. An example of this legislation is the Children Act (1989) that is structured around a fundamental maxim - the development and maintenance of a working partnership with parents, seen as essential in the proper care of children. The Department of Health's guidance on the matter also asserts that approaches that do not reflect this maxim are 'counterproductive' (Department of Health 1989). In a study which attempts to evaluate the success of translating the partnership approach into practice, Sinclair and Grimshaw (1997) conducted a national survey of all local authorities in England and Wales, examined care planning practice in three of these authorities, and interviewed children, parents, social workers and carers in relation to looked after children. They found that the longer a child existed in the 'system', the less his parents were involved in his future plans. Whilst this may seem inevitable, Sinclair and Grimshaw point out that the statistics demonstrate a significant number of looked after children do return to their parents or at least maintain contact with their original families (Bullock, Little and Millham 1993). Notably, parents and in particular, fathers were not encouraged or enabled to engage in care planning and this sometimes led to 'self-exclusion'. It was also apparent that parents were not uncommonly in vulnerable situations - for example at a case conference - but without any independent support person to increase the parent's confidence in such a potentially threatening arena. Of further concern was the situation of those parents for whom English was not a first language. It was acknowledged by the researchers that the quality of interpreters was not consistent and whilst they could be found for review meetings, establishing a continuous link with an interpreter for ongoing communication was a notable challenge. Sinclair and Grimshaw also add that the attitude of social workers to parents was sometimes less than helpful in encouraging parents to retain control, however, professional carers such as social workers often find themselves in the extremely difficult position of trying to balance a child's needs against his parents' needs. This can, arguably, be more challenging because of the way in which a statute such as the Children Act is constructed and implemented, an argument that is articulated by Speight and Wynne (2000). They suggest the Act is flawed and does not adequately protect children at risk by declaring: 'children are best looked after within the family' (Children Act 1989).

Speight and Wynne are critical of what they understand to be an unhealthy bias towards natural families and the 'reinvention of the blood link', which has left some social workers in a particularly invidious position. Moreover, the Children Act does not explicitly recognise that cultural difference may impact upon parental behaviours; and whilst such behaviours may be construed by health professionals as unusual or deviant, they may not be harmful to the child or his development. The Race Relations (Amendment) Act (2000) attempts to restore the rights of all cultural groups through demanding that all public authorities must consider the implications for racial equality in all of their policies and procedures. This could apply to the way in which a given authority interprets and acts upon a statute such as the Children Act and could mean a philosophical clash between differing pieces of legislation.

Exercise 1.5 Self reflection activity

  • how can you use legislation to inform your practice in working with families? Choose a specific piece of legislation to illustrate your ideas
  • comment on the implications of the chosen legislation for different cultural groups.

Service delivery

Professional health care is an organised system of health care delivery that can involve many different professionals and agencies. Each agency will have their own system of management, regulation and policies often with prescribed rules and codes of conduct for individual practitioners. Friedson (1986) provides a critical analysis of professional power considering institutional power and health service professionals. Some of the key issues relate to autonomy of professionals in defining their service and power; and the specialist knowledge of individual professions, which are, not uncommonly, self-regulatory. These sorts of issues have influenced how professions work together and also how professionals interact with patients.

In the past this has traditionally meant that patients had very little say in what services were available to them. However, more recently patients as consumers of health services have developed a stronger position in power relationships with health professionals, supported by charters and standards of expected care (Department of Health, 1996), and patient involvement is seen as instrumental in the process of self-regulation (Department of Health 1998). Moreover, the NHS Plan (2000) will serve as a framework to encourage public involvement. Further support for user involvement in health care has arisen from the Bristol Inquiry into children's heart surgery, which investigated a number of deaths related to inadequate service provision. The Kennedy Report (2001) recommends more collaboration between professionals and the public particularly in relation to decision-making and giving patients more access to relevant information.

Communication is therefore a cornerstone of the collaborative process between professionals and users of services, which may be problematic for users and carers from minority ethnic backgrounds. Armitage (1998), in a qualitative study of the experiences of Indian and Pakistani parents, hospitalised with their sick children, found that those who spoke English generally felt well able to participate in their children's care, but voiced particular concern about their counterparts who could not speak English:

'it's a good job I knew how to speak English, to read and write…otherwise I would have felt really out of it' (011 p.41)

The consequences were spelled out by another participant:

'there's a lot of Asian people, English people think they don't want to approach them with any problem because they might not be able to reply' (014 p41).

The themes in Armitage's study (1998) are not dissimilar to the findings of Casey (1995). In a survey of over 200 child inpatients' parents, Casey concluded that these parents from different cultures who were unable to speak English were less likely to be involved in care. Additionally, Callery (1997), established that mothers whose first language was not English were less likely to be judged as having credible knowledge about the care of their sick children and this reduced their ability to gain access to care. This has far reaching implications, Mayall (1986) has demonstrated that whatever the cultural difference between mothers; there are great similarities between their aims and means of childcare.

More recently, and not surprisingly in light of the above, Gerrish (2000) has carried out research in community nursing settings which identify that acceptance of constraints to services, such as a lack of interpreters, can disadvantage minority ethnic users. This is still apparent even within a philosophy of individualised nursing, which promotes principles of equity and negotiation of care.

Varying terms have been used to help describe the collaboration of services provided to individuals and communities, which also offer some interpretation of the work. For example multidisciplinary teams may include members of different disciplines, employed by the same organisation working to common goals, while multi-agency refers to different organisations collaborating to provide a service. Biggs (1997) refers to interprofessional collaboration, which retains the notion of professional cultures and identity that may exist within or outside of one organisation. He considers social policy, which supports interprofessional collaboration as a better way of delivering services, and debates whether in fact choice is limited for service users, through one single entry and assessment of care. However, the contrasting argument is that inter-professional service delivery is fraught with difficulty for service users who have to repeat their stories to various professionals (Thornes 1993). Murphy (2001) refers to the lack of privacy that some families caring for technology dependent children at home experience due to visits from a wide range of professionals.

Exercise 1.6 Self reflection activity

Using a SWOT analysis (strengths, weaknesses, opportunities and threats), identify how a multi-disciplinary health care team you have known could develop guidelines to inform a particular aspect of service delivery. E.g., Home Visiting, with specific reference to ethnic diversity.

Primary care reforms have encouraged inter-professional collaboration both as a quality initiative and as an organisational necessity to ensure that seamless care can be delivered in reality instead of rhetoric. However, research such as that by Elston and Holloway (2001) suggests that 'it will take a new generation of health professionals to bring about an inter-professional culture in the NHS' (p.19), due to barriers of power between different professional groups. The recommendations made are that inter-professional education may improve understanding and collaborative practice between professions. This is apparent in some multi-agency training for child protection, which was recommended, by the Children Act (1989) and Working Together to Safeguard Children (Department of Health, 2000c). The government in the NHS plan supports the notion of multidisciplinary, inter-agency and intra-professional working and the Children's Task Force and National Service Framework sees this as a key factor in the development in children's services in England.

Service delivery to minority ethnic groups in the community is therefore supported by policy and organisational structures such as primary care trusts, but is still hampered by the traditional attitudes and approaches of some professionals.

Memo

  • health professional interactions with clients and families from minority backgrounds can be tainted by stereotypical attitudes
  • legislation such as the Children Act, may not necessarily meet the needs of clients, families or health professionals
  • effective communication between users, carers and professionals relies upon collaboration to define mutual goals and share the decision making process