Editorial

Citation

Iphofen, R. (2013), "Editorial", Quality in Ageing and Older Adults, Vol. 14 No. 2. https://doi.org/10.1108/qaoa.2013.55914baa.001

Editorial

Editorial

Article Type: Editorial From: Quality in Ageing and Older Adults, Volume 14, Issue 2.

The integration of health and social care has been successive governments’ policy for some time, but little has been done to evaluate how well this is accomplished. In some cases it is evident that more resources need to be invested in infrastructures that facilitate cooperation across the sectors and enable more strategic coordination between policy and practice. We open this issue with two papers that address these concerns in different ways.

It has been more than ten years since Unified Assessment (UA) Policy Guidance was published in the UK. The paper by Diane Seddon and colleagues at Bangor University adds to the admittedly sparse evidence on the effectiveness of UA policy and how it has been implemented in practice. The team interviewed the care coordinators who oversee the delivery of support to older people with complex needs. But this is a controversial role and highlights the difficulty of cooperation across spheres of competence and responsibility. There are still differences of terminology across health and social care, professional ownership concerns and structural mismatches which lead to policy not being fully implemented in practice. Seddon and colleagues argue that guidelines need to be more prescriptive and with roles being more clearly defined and joint training programmes developed to promote shared understanding of key concepts. They also suggest that further research is needed to develop and evaluate evidence-informed practice-based interventions that test solutions to the problems faced.

In similar vein Seraphim Patel and David Walton argue that measures for whole system working should be developed and applied at local levels. They take us through some existing measures and then develop ways of extending the value of such an approach for service outcome measures within localities. Further they argue that maintaining the personalisation agenda requires evaluation that takes into account the individual – not just measures for the “whole system” but for the “whole person” too. Through a detailed analysis they show how costs can be controlled and resource allocation improved if proper systems measurement approaches are adopted.

Keeping in mind the “whole person” must be central to any caring relationship but is too often neglected with concern for the practicalities of care. When I first came across Ellen Langer's foundational work on mindfulness I remember thinking how obvious it was that the main problem facing older people in formal or informal care is losing their sense of responsibility – the ability and opportunity to care for themselves and for the “others” in their life. Thus Bill Thomas’ “Eden Principles” are aimed at alleviating boredom, loneliness and helplessness and set a framework for person-centred care for older people. Whether houseplants are being looked after or pets attended to seems irrelevant as long as the “responsibility” is taken up. Here Sandra Downes looks at how the Eden Principles were implemented at one location in rural Australia to improve the quality of life of elders with dementia – and of their carers – in a day respite centre. This is the early stage of a longer term project but Sandra found that carers of people with dementia who used the services report better than average health, less stress/burden and better quality of life. In many respect the operation of the Eden Principles leads to enhanced valuing of the individuals involved and may even help to defer a move to full-time care.

Another way of respecting the whole person is to encourage them to tell their life story. It was this approach that encouraged Cara Pouchly, Louise Corbett and Kati Edwards to explore the value of life story work in the older adult community service in which they worked. Staff in their dementia unit felt that encouraging the clients to tell their life story helped to really get to know their patients and the insights into their clients’ lives helped with their care management and they felt it empowered the patients to some degree. But Cara and her colleagues grew concerned about the ethics of getting dementia patients to talk about themselves. Clearly there are tricky issues associated with gaining consent and maintaining confidentiality. Gaining written and informed consent with this client group poses particular challenges – both of legitimacy and any consequent effects on the professional/client relationship. Their paper focuses upon the many dilemmas associated with the valid and reliable use of life stories with dementia patients. Some of the conventional data management concerns are brought into sharp relief with such a vulnerable client group. Do life story documents constitute clinical records? Who “owns” the life story “data”? When staff transitions occur is it acceptable or even permissible to share the life stories with new staff? Cara and colleagues make an argument that life story work ought to be managed with respect to best client care and not too stringently tied to issues of consent and confidentiality. The therapeutic value to the patient is such that consent and confidentiality should be seen as secondary concerns and the paper concludes with practical recommendations about how to achieve fair outcomes in the best interests of the patient. Not everyone will agree with these conclusions but, as with all ethical debates, the answers are never easy and compromise usually inevitable.

We have been keen increasingly to explore “intergenerational” themes in QAOA as well as bringing in as much comparative work as possible to expand the international reach of the journal. In this regard we were pleased to receive Yelena Smirnova's study of employer age preferences for their workers in Kazakhstan. If there is an area ripe for ageist practices it is the employment sphere – whatever the government policies require there are always ways around them. Yelena first rehearses the standard arguments for and against employing older as against younger workers and then goes on to explore the recruiting preferences of Kazakhstani employers. Her study shows that while both young and older employees face problems during the recruitment process, older people clearly experience more difficulties in obtaining employment than do their younger colleagues. The major limitation companies saw with older workers was that their prior rigid training under the Soviet system meant that they were not readily adaptable to changes in the organisational environment. They were consequently seen as less flexible, less imaginative, more likely to suffer ill health and less technically competent – being trained in narrow spheres. While this may seen as a particular problem of a rather rigid totalitarian political and economic structures the mentality which restricts opportunities for older employees may still be detected in societies lacking such history.

Despite these obstacles Yelena found that both young and older employees have a chance of finding good jobs. Young candidates are hired because they are considered enthusiastic and highly loyal to the organisation, quickly absorb corporate culture and follow its principles with commitment. Older workers are hired more because of their work and life experiences: they have expertise, are reliable and committed. Interestingly both the young and the older generation rely primarily on personal contacts to secure work. Again this might be a cultural phenomenon but by no means restricted to former totalitarian societies.

Finally in this issue Steve Simpson, Janet Craven and Rebecca Weekes offer us a follow-up to their previously published paper in QAOA which is connected with examining the factors that influenced the discharge outcomes and duration of stay in an elderly mental health assessment ward. Longitudinal research is vital to understanding the effectiveness of different forms of funding and care and discharge practices. They found that funding arrangements are the best predictors of duration of stay in hospital – regardless of clinical factors. Whether patients are returning home or being discharged to a private long-term care home there is a need to find the optimum period for assessment and unnecessary delays can be “costly” to the patient as well as to the Health Service. Comprehensive assessment tools and good communication between multidisciplinary teams and families helps towards providing the best outcome for patient needs. The team demonstrate that the issue of long-term funding for this vulnerable group is complex and requires more simplification and adjustment to reduce unnecessary delays.

Ron Iphofen