Jef Smith discusses levels of co-operation between health and social care agencies.
There has always been a need for health, social care and other services, such as housing and income maintenance, to work together as effectively as possible in the interest of their service users, but this has usually been expressed as a vague aspiration rather than a formal duty. Both organisational structures and professional status have been a hindrance to joint working. Codes of confidentiality, for example, often stress the need to preserve the secrecy of what the particular practitioner or agency knows about a client, rather than the value of sharing information to achieve the best, and best co-ordinated, standard of delivery.
Research suggests that service users are much less bothered about the risks theoretically involved in the passing of personal data between the various organisations to which they have entrusted themselves. More often their concern is that compartmentalised care requires them to repeat what can be rather personal and painful facts that they had expected to be available to anyone involved in their care. Official guidance, however, has continued to play down inter-agency co-operation as a specific objective, appearing to regard joint working as no more than a desirable add-on, not a mainstream requirement.
The old and the new Standards
The National Minimum Standards for Care Homes for Older People made only scant reference to collaboration in patient and client care. The Standard on needs assessment, for example, obliged homes to obtain a copy of a care plan produced for care management purposes, but this applied only to a tiny minority of mental health service users. The main section of that Standard listed the many areas of need about which a home’s management should obtain information, but did not refer to the sources of such material or to the reluctance staff might encounter in accessing, for example, a prospective resident’s psychiatric history or details of their problems with continence.
The Standards on intermediate care, the Service User Plan, protection, and death and dying, all areas where agencies clearly need to work closely together, were similarly blinkered in their approach. Even the Standards on healthcare and medication, while making reference to various areas of specialist treatment such as nutritional screening, tissue viability and the risk of falling, together with GP registration, did not seriously tackle the issue of how other bodies could be incentivised to integrate their contributions with that of the home providing the day-to-day care.
Guidance about Compliance: Essential Standards of Quality and Safety is much more explicit on the issue of co-operation. The theme runs through several of the 27 outcomes, which repeatedly call for an approach that is essentially holistic — a word defined by the CQC as “about the whole person, including all their needs and all aspects of their lives”.
Collaboration is specifically and very thoroughly explored in Outcome 6 under the title “Co-operating with other providers”. This outcome, like the others in the Essential Standards, draws its authority from the statutory regulations produced to implement in detail the Health and Social Care Act 2008. Regulation 24, which forms the basis for Outcome 6, enjoins providers to make suitable arrangements in situations where service user care or treatment is “shared with, or transferred to, others”. It specifically mentions working together in care planning and the sharing of information, and identifies admissions, discharges and transfers of service users as key points of inter-agency co-operation. The general statement with which the outcome opens announces this theme, setting out the objective that people who use services should “receive safe and co-ordinated care, treatment and support where more than one provider is involved or they are moved between services”.
That outcome, using the format regular users of the Standards will recognise, then provides a series of prompts, covering the various situations in which co-operation is particularly relevant, followed by more prompts applicable only to specified services. In this latter series, social care providers are required to take special note of Prompt 6K, which deals with registration for general practitioner, dentist and other health services. This is certainly a sensitive area, where practice has often fallen short of ideal.
Access to GPs
Managers of homes frequently complain that it is difficult to get GPs to accept their residents without their being paid additional, possibly illegal, fees. GPs rejoin that people in homes, being usually much frailer and more vulnerable than even the generality of the elderly population, tend to make particularly heavy demands on their surgeries’ resources, for which, they argue, they should be appropriately remunerated. The wrangling that can ensue has sometimes left vulnerable older people without routine GP cover for periods or, after intervention by a Primary Care Team, has shunted them between practices in a way which clearly breaches continuity of care.
Despite regular exposure of this issue by providers’ associations and bodies such as the Relatives and Residents Association, the problem has never been satisfactorily resolved. Whether the new commissioning roles which GPs will be taking on under recent legislation will ameliorate this situation remains to be seen.
If the assessment process vividly demonstrates the need to share information in service users’ interests, end-of-life care, at the other end of the care cycle, shows up how important co-ordination is in day-to-day working practice. Looking for guidance from the Essential Standards on this element of practice is less straightforward than it was under the National Minimum Standards, which had a useful section candidly headed “Dying and death”.
Within the wordier and more generalised content of the new document, one must seek out Prompt 4K of Outcome 4: Care and Welfare of People who use Services. This prompt, directed at care homes among others, refers to minimising unnecessary disruption to terminally ill people and respectfully maintaining — and, obviously, sharing — records about each individual’s wishes. If residents must be moved as death approaches — and there have been dark allegations of homes that ship poorly residents off to hospital simply to minimise their own mortality statistics — it is particularly important that there be great care and sensitivity in briefing the recipient agency on a dying client’s needs and wishes.
The prompt makes reference to another critical aspect of end-of-life care: the importance of homes having available information about other relevant services. Managers have a general responsibility for maintaining good and up-to-date files on local resources that may benefit their residents, but the capacity to access appropriate specialist help is never more required than when death approaches.
It is true that care homes should be able to continue to provide an appropriate service for most residents at the end of life, and statistically residential care remains a major location for deaths, but this should not inhibit homes from ensuring that they have good relationships with hospices and palliative care bodies in their areas. There are indeed some excellent examples of collaboration in staff training, with mutual benefits.
Moving to a new home
Between the assessment of need and the period of terminal care — the markers, as it were, at either end of a service user’s contact with a home — lie many other opportunities for beneficial co-operation between organisations. The move of a resident from one home to another may be relatively rare, but when it does occur it can present a unique challenge for continuity of care.
The Scottish Standards, to their credit, made specific reference to this critical transition, as well as to the equally uncommon circumstance of a resident choosing to return to their own home. In either event, the safe passage of records, personal contact between key workers in the two settings (where this is feasible), and the careful preparation of the service users themselves can greatly ease what may otherwise be a distressing, even a fatal, move.
One neatly indicative test of caring continuity: does the new agency need to ask the client afresh whether they like milk and sugar in their tea?
Shifts between homes and hospitals are necessarily much more common. Even the best equipped and staffed home with in-house nursing will recognise situations in which a resident’s interests will be best served by the specialist resources only a hospital can provide. The shock of a hospital admission, however, is not to be underestimated, worst perhaps for people with dementia, for whom changes of regime are notoriously confusing.
The staff of homes can mitigate these potentially traumatic effects by passing on as much information as possible and, if possible, by maintaining contact with a temporarily hospitalised resident. It is less easy for homes to exercise any influence over the many moves that characteristically take place within hospitals.
Sadly, a resident returning to a care home has often suffered mentally from the experience, even if their physical illness has been effectively treated. Nor do health organisations invariably take seriously their responsibility to brief a receiving home in detail about a discharged patient’s condition.
Worse still, recent evidence has emerged of an unjustifiably high incidence of night-time hospital discharges, surely an experience that could damage any vulnerable person’s morale if not their physical condition. It may be particularly tempting for doctors and nurses to use night-time discharges for people going into or returning to a care home, since they can expect at least some staff presence in such instances, but homes should decline to accept this procedure, and complain formally when it is even suggested.
Intermediate care brings together all the problems and opportunities of inter-agency co-operation. Again, the specific requirements of the National Minimum Standards, drafted when intermediate care was just being introduced, provide a more helpful guide than the vague injunctions of the Essential Standards, where the term scarcely features.
There have been many examples of excellent practice over the intervening decade, of careful transitions between homes and hospitals, of hospital admissions averted through timely interventions by community-based health services, and of well-managed joint working between support and rehabilitation staff. Most encouraging of all, perhaps, has been the growth of inter-professional understanding and respect such projects have produced. Their success should be a model to all other caring services.
Last reviewed 29 May 2012