Across various parts of social care and the NHS the last year has seen a great deal of planning to create what the NHS and local Government likes to call ‘integrated care’. (I commented yesterday on how providers of care like to call it this whilst patients like to talk about ‘co-ordination’).
Across the country, there are regular meetings where teams of people are sitting down and looking at their existing services and trying to stitch them together into a different pattern.
Over a year ago I tried to understand why this was so very difficult. Staff wanted to do it; patient’s carers and the public wanted to do it; resources were demanding it. But, meeting after meeting, it kept on not happening.
My answer to this conundrum is that we underestimate the passion with which staff and services have developed their fragmented bit of the whole. More and more people come to work in health and social care with greater and greater specialisation in their work. Most careers have been developed not around better coordinated whole person care but around greater specialisation.
Two weeks ago, tucked away in John Oldham’s report on Whole Person Care was the recognition that the way in which merit awards were granted to the medical profession not only encouraged but practically enforced body part care rather than whole person care.
In the field of social work, despite several decades of argument for generic social work, specialisation is how you get ahead.
Of course staff don’t come to work with the aim of fragmenting a person’s care. They come to work with the experience of working only with diabetes; only with residential homes for residents with dementia, or only with depression. The constant in their work is the specific illness – the variable is the human being.
And it is not wrong to describe staff as ‘passionate’ about their specialisation. Hearing specialist consultants, nurses, or residential social care staff talk about their specialism is a moving experience. They really want to improve their skills but talk about more and more specialist activity.
This process has created passionate fragmentation.
And there are very many who believe that coordinated or integrated care will be created if we bring these fragmented services together. Rather like a jigsaw puzzle. So the job of the coordinated care officer is in some way to find the picture on the top of the box and fit all the pieces together.
It’s a compelling analogy – but it doesn’t work.
The jigsaw takes an existing picture – let’s call it “Whole Person Care in the Home”, cuts it into bits, and then jumbles those bits up. The coordinated care person a) knows that somewhere in all the bits there is a real coherent picture and b) that whilst it will take time and effort their job is to fit the bits together to make that picture – and given time and skill that is what they will achieve…
The problem for real coordinated care is that the fragmented services have NOT been created as a single picture and then fragmented. They have been created to only deal with bits. They have been created as fragmentations.
The big problem is that the part of the jigsaw for an 85 year old woman called “diabetes care” has not been created to fit neatly with the part called “dementia home care”, which in turn has not been created to fit with the part called “COPD care”.
They have not been created in a way that they will fit together.
The organisations that create them have made these services as “bits” in their own right.
So a really clever coordinated care worker can shake all the pieces out of the box for Mrs Patel’s whole person care and then find that the problem is that when they try and fit them together – they won’t. They were not made that way.
At best they might get a few that look a bit similar to form a line, but they will not form a picture of whole person care. And when you look at that line, there are holes in between through which patients fall, and duplications where they have to do the same thing over and over again.
To build a picture of whole person care you have to fundamentally change these fragmented services so that they might just fit together.
To achieve that coordinated care staff will need much much more power to transform existing service than they are normally granted.
It won’t surprise blog readers that I think that this greater power comes from patients and tomorrow I will describe how I think that might work.