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14th June 2013

Joined-up Care

The Department of Health recently issued a Press Release, headed – “People will see health and social care fully joined-up by 2018”.

In writing about this, I am qualified to have an opinion as I have experience of working within a healthcare service which started out with the same wonderful aim in 2004 and actually achieved this in 2010 after a number of years of uncertainty and hard work.  In Scotland, `Health and Care Partnerships` and `Community Health Partnerships` have been a goal for the last decade.   Now a number of these actually exist, the largest cluster around Glasgow and the Clyde, with some smaller Health boards achieving joined-up care in more rural areas of the country.  The barrier which was hardest to shift in order to bring about change was one of `ownership` of service.  People involved in care on both sides of the fence, from upper management to hands-on jobs, found it difficult to make the paradigm shift from `health` or `social` to just `care`.  Each service had cultural and procedural traditions which they did not want to give up.  It did eventually happen, but it took financial pressure within both services to bring about a huge cultural shift.  By that, I mean budgets were so tight that `no change` was not an option!  In order to appreciate the press release we should look North of the border at existing examples.

To write about why these changes need to happen from a person-centred perspective, I can use my experiences of working in Scotland as a member of a `Clinical Incident Investigation Group`.  Collating incidents from a number of different investigations I`ll create a single story about one person, Mrs H, who was caught in the gap between two organisations.  The story starts when Social Services made a complaint alleging that an elderly person was denied a Place of Safety bed in a local hospital during an acute phase in management of their mental health .  Unfortunately, one thing led to another and the end result was a fatality.  An investigation led to the realisation that there was virtually no communication between the medical and social care services.  Notes and records concerning care by the two organisations responsible were kept in geographically different locations and were not accessible by the other `side`.  The records were in different formats, one side being mostly digital, the other side holding paper folders written by several individuals, which were not collated in a central depository.

Specialists from both sides saw Mrs H but reported only to those who had made a referral, and joint case conferences only occurred after the event.  This meant that her medical, psychiatric and social care was not coordinated.  Furthermore, Mrs H`s GP practice visited her during the day and an Out-of-Hours service visited at night after being called by the Nursing Home , with the result that prescriptions were duplicated.  In the meantime, drugs were dispensed from an unofficial central store of collected medications without prescription.  On one occasion, drugs were withdrawn by staff who disagreed with `an ethos` of medication.  Eventually, this unhappy and confused person/patient/client, whichever term you feel is appropriate, was found wandering in the street and neither service wanted to take responsibility.  Unfortunately, her general health deteriorated rapidly and she died soon after.

This story, I hope, illustrates a degree of chaos which can exist when care is disjointed.  Now, within the new partnership organisations in Scotland, stories such as that of Mrs H are less likely to happen.  At the moment, in England, Clinical Commissioning Groups and Social Services have completely separate management structures.  There is quite often a tenuous link at the lower levels between GP practices and Community services, but this is only as good as the communication skills and motivations of individuals involved.  Hospitals remain separate to either service and the threesome rarely work collaboratively.  As a result we have a large number of very skilled and caring staff all trying to work in the best interests of the people they care for but locked in separate organisations.

The vision now is for a joined up service in which people don`t have to keep re-telling their story whenever they encounter a new service.  A service where people have appropriate facilities at home after discharge from hospital so that they don`t deteriorate and fall back into acute care.  A cynical view is that the fiscal savings gained from combining services will take the pressure off healthcare budgets.  However, this could be a win/win situation in which people gain a better level of service and health, whilst cutting out duplication of management and reduction of costs.  The Government`s vision goes wider still, with the integration of the NHS, social care, education, housing services and Public Health under one umbrella.

The plan is to provide support and tools for this process through a new agency called the Integrated Care and Support Exchange.  This will collate examples of `best practice` in the joining up process and share information and expertise in the field.  Dr Sam Bennett of `Think Local, Act Personal` says

“We welcome this important collaboration.  Through our shared commitment we will support the focus on joining up services at the level of the individual.”

Finally, I`d like to ask you to put yourself in the place of Mrs H`s relatives.  How do feel knowing her story?  How much better would you feel if her care had been coordinated from the beginning and a single specialist had recommended a treatment regime that was performed by a joint team with a single line management reporting to one commissioning entity?  Even when something went wrong there would be only one complaints procedure to follow and one reporting organisation to say sorry.

Dr John Shapter

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