the swampy ground research project
a resource about partnership working for managers & educators in health & social care
Case Study - 'Everybody wants it, it’s just getting there'
'Everybody wants it, it’s just getting there' Intermediate care
This story is about Intermediate Care (IC) provided to clients/ service users to support them when they come out of hospital, or to prevent admission. It is free to all and lasts around 6 weeks only. It is jointly managed by the local authority Social and Community Services (SCS) Department and 5 PCTs.
The Intermediate Care manager’s remit was to integrate three existing services: These services were:
The Rapid Response Re-enablement Service (RRR) funded by Social and Community Services, and aiming to ‘re-enable’ patients /clients in their own homes.
Intensive Community Support Services (ICSS), a nursing service to offer care and provide care in the homes, sometimes to people lat the end of their life.
The Community Rehabilitation Service (CRS), jointly employed by Health, and Social and Community Services, who are Occupational and Physiotherapists. They work both in people’s homes and in day and community hospitals. The aim is that each person is provided with the support they need from any of these services, in an integrated way. This phase of IC follows from government directives in the NHS plan, the NSF for older people. In this county however, the struggle to create a coherent integrated care service has been going on since 1996, through many different ‘morphs’ [Amanda]. The context is one of many different phases of restructuring, and the integration must now be carried out at ‘nil cost’ [Katie].
People in this case
Mrs S and Mr and Mrs A – clients/users of Intermediate Care
Valerie: Intermediate Care provider, S& CS
Edwina – locality team manager for Intermediate Care, S& CS
Imogen - locality team manager ( joint post between PCT and S & CS; a therapist by profession)
Brenda – Service manager for Intermediate Care, S & CS
Amanda - Service manager, Intermediate Care, PCT
Katie - Intermediate Care Manager, jointly employed, one of three in each area who make up ‘the mix’
Read or download a PDF of all the stories in this case study.
researchers' Commentary
Views of users
The users we hear from are very satisfied, particularly Mr and Mrs. A who contrasted it with the absence of support when Mr. A first came out of hospital. They are also very grateful, though Mrs S noted her own determination to recover. Mr. A said ‘they decided to take me on’: he clearly did not feel his choice was over-riding the professionals.
Consultation and involvement
Notably, users were not consulted at any stage. There were different views on how far staff were consulted. [Edward : only managers were consulted, and that was about the management structure. Brenda :formal consultation with unions, and was very aware of the amount of time she needed to set aside for this. ]
Layers of integration
There are a number of different ways in which the term ‘integration’ is used in this story.
1. Through behaviour or through re-structuring [Amanda ]. Structural integration can be carried out through joint management with shared leads, as in this case; or through single line management which could either in the PCT or in social services. [Edward and Amanda]; or through a Care Trust to work with older people as a separate organisation.
2. Through co –location for example a residential care home which houses a NHS day hospital care home and social day centre run by Age concern. [Amanda]
3. Through a new generic role eg Care Provider, combining the roles of therapy assistant, care assistant, and some elements of Home Care [Valerie]
4. Through integrated training: Care Providers need integrated training and changed expectations so that they can work with all types of clients, from those who will return to active life to those who are at in the last phase of their lives.[Amanda]
5. Through good access to all other professionals [Valerie care provider]
6. Through combined referral procedures: in this story however, the integrated IC desk is not open at weekends.
Professionals and professionalism
There are positive approaches to broadening concepts of professionalism: ‘multi-professional’ managers’ [Imogen] . However, senior professionals are ‘playing silly buggers’ [Edward] There is a fear of joint management, [Brenda]; and anxiety about clinical supervision which ‘failed to materialise’. Edward, Valerie the Care Provider is a generic staff member [Valerie] .Registered professionals do not need to work with all patients [Amanda] Valerie mused on whether she was a clinician herself: [‘I wouldn’t call myself a clinician. I am in one sense. In another I'm just a provider of care.’]
History
There are different approaches to history: Brenda and Imogen say they have been doing integrated care for years. [Amanda : ten years ago in inter-disciplinary care, with a hospital social worker involved and joint records, though it is not clear if those too cross all groups]. Katie focuses clearly on the present task. We wondered how selectively people remember the past. What is striking is the length of time and the difficulty it has taken to reach this level of integration and the problems that still remain. .[Brenda ‘This is where we wanted to get to a few years ago’] Autonomy over budget Health as ‘more free and easy’; Social Services’ can’t sneeze without filling in a form’.[Imogen, physiotherapy background];
Outcomes and drivers
On the continuum from those clients who can do well with re enablement, to care and support for those at the end of their life.
Real changes in people Valerie worked with.[Valerie]
Meeting performance indicators for star ratings and increased budget [Edward]
Pressure from the government IC targets to achieve hospital discharges over-riding the use of the appropriate services [Amanda]..
Performance review
Opposing views on whether health or social services have more performance indicators. [Imogen and Brenda (both therapists).
Cultural difference in the type of indicators: health deals with outcomes and outputs and finished episodes, S&CS have process measures, reflecting the ongoing relationship that social care may have with clients.
Forms/ data management
All except the clients saw different records as problematic, with 12 different systems [Katie].i Initial records are different for each staff group and in hard copy; work review form faxed [Valerie].Data bases are quite separate for health and social care [Edward] Pay Differential health/social care mentioned by all the managers; discrepancies even for managers doing the same job.Pay reflects how far people feel valued [Imogen]
Language
The term ‘re-enablement’ seen as invented in this county; preferable to ‘rehabilitation’ seen as clinical [ Amanda and Brenda] ‘Patients’ /‘clients’ ‘winning’; ‘bread and butter cases’ ‘PC world’
Leadership
A gap in strategic leadership, and operational managers were left to get on with it [Edward]. ‘Not how to do it, just do it’ ‘determined’ to carry through the integration, in spite of the difficulties she was very aware of. [Katie] Positives experienced by those in this story
What was going well in this story includes the following:
The users’ good experience of the service New generic worker role provides a career development path for unqualified staff Integrated care has a value in itself. Some experienced an excellent culture of working together; close cross agency management working as well as effective Integration Board [Katie; Imogen: people worked v v well in partnership on the ground. Brenda: PCT managers are keen to work together] A few key individuals with creativity but the question remains about how to sustain this when those individuals leave There has been more effective use of beds through the joint IC access desk Faced with insurmountable national pay differentials, Brenda did the best she could, and involved Human Resources in effective way.
Barriers
The following continued to be barriers to effective integrated care.
Pay Lack of co-location Delay in getting Section 31 ‘very very frustrating’ Katie
Professionalism Criteria for access to IC: also free v means tested
Different funding streams Imogen
Different Performance Indicators; different paper and IT systems
Cuts without consultation with partners Brenda
Lack of capacity to move clients on; not enough time for training [Edward] Lack of clinical accountability [Edward]
Boundaries PCT and Social Services Senior managers moving on, not knowing history, some not knowing about IC Culture – language PIs etc control and empowerment etc.
Powerpoint - dimensions and tensions
Major issues
Constructing Integrated Care has been going on for 10 years and is still difficult
Elderly people live longer, with more complex conditions; at home when previously would have been in hospital
Users still very grateful A lot of goodwill people on the ground want to do it; not sufficient support, resources, common data systems
Managers responding partly to Performance Indicators
Behaviour v structure: the barriers are structural and professions
Lack of resources. Why no section 31?
Lack of user involvement. Voluntary organisation there as service provider, not as part of strategy. no pressure group support.
Hardly any mention of privatisation/ externalisation
Read or download a PDF of all the stories in this case study.