A seamless serviceBMJ 1998; 317 doi: http://dx.doi.org/10.1136/bmj.317.7174.1723 (Published 19 December 1998) Cite this as: BMJ 1998;317:1723
I would put money on the tediously overused, and intrinsically ridiculous, phrase “a seamless service” having been invented by a man. The most rudimentary knowledge and experience of needlework teaches the usefulness of seams.1 Indeed, a structure can be seamless only if it is made of a uniform material, seamless nylon stockings being a classic example. But as soon as the desired structure requires a number of differently shaped pieces or a variety of materials, seams are needed to hold the whole together. The construction of the seam overlaps the edges of the different pieces or materials, and it is the overlap that gives the seam its strength. Without seams, and without overlap, the whole construction ruptures under the slightest strain and falls apart.
Increasingly, services to patients are delivered by multidisciplinary teams of healthcare professionals. Each member of the team brings different knowledge and skills, thus extending the range of each that can be made available to the patient. The team is a structure made up of distinct components, each of different materials. If the patient is to be offered a coherent service, there must be obvious seams between each area of skill, with sufficient overlap to ensure that the whole holds togeter.
It is inevitable that different disciplines will share experience and expertise, and such sharing provides the overlap. Each member of a team needs to know which tasks may be appropriately shared and precisely where skills diverge. It is for this reason that it is more helpful to think in terms of interdisciplinary, rather than multidisciplinary, working and education. An interdisciplinary approach implies the recognition of both common and distinct areas of expertise, and makes devising and defining ways of working effectively together an explicit part of the learning and practice agenda.2
strength is in the overlap
If attempts are made to demarcate roles so precisely that there is no scope for overlapping roles, seams disappear and the service to patients rapidly develops gaping defects. An obvious example is the common experience of my frail older patients and, most recently, my own mother, when in hospital. Meals are delivered to the bedside, and may or may not be left within reach, but there is no one to help cut up the food or get it to the mouth. Many patients are too frail and weak to manage this for themselves, but providing the required help is not a modern nursing task. Neither is it the job of the person who delivers the food nor, it seems, of anyone else. Clearly, it should be a task of anyone and everyone present on the ward when meals have been served and are mysteriously not being eaten. If there is insufficient overlap in our structures of care to ensure that the weakest and frailest get sufficient food, then we have extreme pressure on a seamless construction and a hopelessly inadequate service to patients.
Patients are reassured by obvious seams between the different components of the service they receive. They are comforted by seeing the various professionals taking the time to talk to each other and to undertake some joint tasks. Shared three way consultations confirm that everyone has sufficient information to work to a common plan of care. Overlapping roles enhance the flexibility of the service provided and reduce the stresses on all concerned.
The idea of a seamless service has become an integral part of the rhetoric of modern health service management. It is a ludicrous, and even a dangerous, aspiration.
I thank Professor Paul Freeling for reminding me of the importance of seams