Emerald Publishing Limited
Copyright © 2017, Emerald Publishing Limited
The power of small things
As hospitals have felt the pressures of another harsh winter, the challenges to health care systems stretched to their limits have become clear. One significant problem continues to be the shortage of beds in acute trusts. It seems all the more important to get a better understanding of the specific backlogs that frequently cause serious issues in intensive care or high dependency units as patients cannot be discharged into the community. The latest edition of this journal takes up some of the key challenges in creating an integrated health and social care system that may contribute to easing the seasonal pressures for acute trusts. The papers also incidentally cover various aspects of a patient journey through the health and social care system.
This issue starts with an article on the problems surrounding patient discharge from hospital. Mark Wilberforce et al.’s paper reports the findings of a pilot to introduce an electronic discharge referral system in hospital. Electronic systems replacing hand written notes are mainly motivated by notions of increased accuracy, efficiency and reliability. The downsides have been that electronic systems have remained difficult to introduce, have often proven costly and changed care practices even though they were supposed to simply aide them. The results of Wilberforce’s pilot demonstrate that there are clearly some benefits in introducing an electronic referral system. It may, for example, have the potential to reduce duplication of written information in some instances, be seen as more secure or provide additional confidentiality compared to paper records. However, technology adds its own challenges to the already existing issues. Electronic interfaces may be seen as “clunky” and there was some evidence that the quality of data decreases in the wake of introducing the electronic referral system. Overall, the time differential between the hand written and the electronic referral system appeared to be smaller than expected, questioning the efficiency gain from the new system.
In the next paper, Jason Scott and colleagues argue persuasively that health and social care operate with disparate safety concepts, safety and safeguarding, respectively, making it difficult to develop a shared understanding between the two sectors. They advocate a debate about a single unified safety concept that can help develop a common notion of safety across the care divide. Without this, the authors maintain, safety at intersections of the two care cultures remains difficult to navigate, even though both care communities share the same objective, to keep people safe.
Following discharge, patients are often confronted with the challenges of receiving appropriate and adequate social care support in the community. This is a particularly pressing issue for patients with dementia. One specific impediment to high-quality care has been when to intervene and how with this patient group. Elaine Argyle et al. present the findings of a systematic review on emerging evidence for care at home. Their paper shows that synthesising the evidence about the effectiveness of integrated dementia care faces the difficulty that there is a variety of care that is conceptualised as integrated care. They point out that what constitutes integrated care at home may be different things in different contexts. There are, however, some clear messages emerging from the systematically appraised evidence. Argyle et al. point to care worker autonomy and frequent reassessments which appear to contribute to improved quality of care at home. Further research, however, needs to be done to pinpoint the best time of intervention. There seems to be insufficient evidence, so the authors, about what is the best time to start home care to defer institutionalisation. This is of critical importance if we want to relieve pressures on acute trusts and improve the quality of care for this growing patient population.
The fourth paper explores the practice of supervision in health and social care. Its authors, Helen Albutt and colleagues, examine current standards of practice in a pilot study and find considerable variations in the way they are implemented. The study provides some evidence that good supervisory practice depends on managerial skills and commitment from staff. It also requires an atmosphere of mutual trust where constructive criticism can be voiced. Further harmonisation of supervisory practice is clearly an important part of harnessing the immense potential of the health and social care workforce and critical to reducing irregular practice.
The issue closes with a comparative overview of integration policy in health and social care in the four home nations. The authors suggest that despite devolution of health and social care to the four constituent parts of the UK (England, Scotland, Wales, Northern Ireland) there are some striking similarities in the way in which integration is pursued. However, devolution has also brought about a growing momentum of divergence between the home nations’s health care systems and we are likely to witness more as devolution within the nations, such as DevoManc, may gather speed. The authors argue that this should be seen as a strength rather than weakness of the NHS. Increased divergence means more opportunities to experiment and learn from each other pointing to the fundamental benefit of federalised systems of governance. However, it appears that effective systems of shared learning are still rare and the authors argue that this undermines the single most important advantage of policy divergence, learning from each other’s successes and mistakes. The most instructive case is perhaps the structural integration of health and social care services in Northern Ireland which contains important lessons for those who advocate full structural mergers between social and health care providers. The authors also point out that divergence in health systems create unique research opportunities. Quasi-experimental designs may help marshalling robust comparative evidence from an increasingly federalised health and social care system across the four nations providing lessons for everyone.
Whilst policy makers often look for singular solutions to multi-faceted issues, the articles in this issue chip away at some of the discreet problems that may accumulate to cause the current state of health care systems. It remains to be seen whether gradual progress on specific issues up-stream can bring about the necessary change downstream, ultimately improving the quality of care for patients.