INTEGRATED CARE
use them – the community nurses, personal care assistants, social workers, care managers, occupational therapists and the myriad of other professionals who traipse through the houses of people with complex needs and add, unintentionally, to the confusion.
Patient wishes vs patient outcomes?
Primary care has been identified as the key player in integrated services and the health service of the future, but primary care, for all its links with public health and the health of communities, is still strongly associated with meeting (clinical) needs, and doing so in the best interests of the patient. Acting in the best interests of patients is deeply rooted in the working practices of NHS staff, and ironically means that sometimes the expressed wishes of those patients are difficult to hear when these run counter to what is considered to be good care.
1990s, I can remember situations when these two different approaches – working in the best interest of patients and promoting the rights of the individuals to live as they wished – led to stalemate, and these stalemates did nothing to reduce the need for future interventions.
Without a careful exploration of the different cultures that exist on the ground in the services that we want to work together, therefore, there is a real risk integrated approaches will fail at the coal face.
“Acute trusts, it seems, view the Better Care Fund as a problem, whereas directors of social services see it as an opportunity.”
Why is this an issue for integrated care? It’s an issue because there is a risk that those actually delivering care to individuals may be talking different languages, or at least may be uncomfortable with or unable to hear a different perspective.
Differences in underlying values between social workers and clinicians
Social workers, for example, see their underlying values as respect for persons and promoting self-determination. They see themselves as autonomous practitioners, an approach which was given the seal of approval by the Department of Health in 2011 in the ‘Enabling Excellence: Autonomy and Accountability for Healthcare Workers, Social Workers and Social Care Workers’ command paper. From my own experience as a community nurse in the
That this continues to be an issue (my experience is somewhat dated, after all) was evident in an innovative series of workshops delivered four years ago by myself and Open University colleagues, in collaboration with a department of adult social services and an NHS trust in the north west of England. The theme of the
workshops was the culture change needed for personalisation to work, and they had been instigated by a very insightful training officer in the social services team. Over a number of workshops, we worked with the participants to explore what personalised care really looked like, and what would get in the way of success. Social workers, service users, occupational therapists, carers, community nurses and others worked together to unpack and explore the issues. It was exciting and inspiring, but it was too much for the community nurses, who felt that their perspective was too different for them to be comfortable, and who concluded that this approach just wouldn’t work for them.
This was genuine discomfort, and it is entirely likely that the same kind of discomfort would be felt in situations where social care staff are in a minority, and the context is more clinical, and it highlights an issue that has to be addressed if integrated care is to work on the ground. And it has to work on the ground if it is to produce
the efficiencies in care that are needed, let alone improve the experience of those who use services.
One obvious place to start is in the training and education of future practitioners, and the continuing development of those currently practising. I was pleased, recently, to attend a workshop organised by Health Education England and the Centre for the Advancement of Inter-professional Education (CAIPE) to explore opportunities for future healthcare professionals to learn together, but my enthusiasm was dented somewhat when I realised that much of the inter- professional learning that is currently going on remains firmly in the clinical sphere. So nurses, occupational therapists, pharmacists and physiotherapists are learning together sometimes; but where are the future social workers, administrators and care managers?
The King’s Fund held an event earlier this year prior to the deadline for initial submissions to the Better Care Fund, and reported a relative absence of representatives from acute trusts. Acute trusts, it seems, view the Better Care Fund as a problem, whereas directors of social services see it as an opportunity – just as in our workshops where social care providers saw personalisation as an opportunity but healthcare staff saw only obstacles. These conflicting approaches will continue if we don’t create effective opportunities for staff from across the sectors to learn together in order to work together, and grapple with the culture change that will either make or break integrated care.
Mary Twomey FOR MORE INFORMATION
References for this article are available at the NHE website. T: 01908 858815 E:
mary.twomey@
open.ac.uk W:
www.open.ac.uk
national health executive Nov/Dec 14 | 55
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