Margaret McCartney: The social care system has become inherently unsafe
BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2329 (Published 30 May 2017) Cite this as: BMJ 2017;357:j2329All rapid responses
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Margaret McCartney’s call for reflection on the current status of social care in the health system (BMJ, May 30 2017) and the need for its integration in the larger system no doubt resonates in many practices. Pending greater initiatives in this huge task we would like to describe the following modest innovation which facilitates awareness of the various agents involved in supporting and caring for individual patients.
For some years we have been examining the utility of the conceptual structure of ‘communities of clinical practice’ in healthcare delivery in the community. Initially our interest was in student learning in clinical workplaces, particularly in primary care, but our interest rapidly expanded into the provision of care and led to the adaptation of the concept of ‘community of practice’ (Wenger, 1998) to clinical practice and the diverse group of practitioners contributing to the care of individual patients. The composition of these groups varied uniquely with each patient and their needs.
Borrowing freely from Wenger’s work, an early initiative was to map key providers of care onto a simple diagram of concentric circles with the patient represented on the innermost circle and the rest of the community of practice distributed around, with distance from the centre serving as a proxy for their importance as defined by the patient. At a glance this visual image captured all the carers and their value to the patient. The power of human perception enabled the rapid assimilation of a great deal of relevant information. The patients validated the maps and generally were appreciative of them as meaningful representations of their world. The other members of each such ‘community’ could quickly identify, or discover, who else was involved in each patient’s care and, to some extent, infer the nature of their involvement. They were literally all on the same page.
It would not be going too far to say that patients were delighted and generally eager to have a personal copy. Laminated, they could be handily placed on the fridge! As the first page of a clinical record they would facilitate understanding of the patient’s situation. Admittedly they took some time to develop in conversation with the patient and, from time to time they would change in accordance with changes in the patient and carers. Consequently they would require some maintenance and that comes at a cost. The benefit is in their capacity to quickly inform or update the members of the group. In addition their inclusiveness from the patient’s perspective emphasises the roles of relatives, friends and neighbours, all of whom may make useful contributions to care, or, whose absence quickly defines social isolation.
In our most expansive moments we envisage such maps as the point of entry into an electronic clinical record: the patient and their community in a visual display. Click on each member and ‘drill’ down into their role, contact details, recent activities and so forth, as far as the user’s rights of access allow. Perhaps that is in Never Never land, but a map of a patient’s community of clinical practice is only a conversation away.
References
Communities of Practice: Learning, Meaning, and Identity. Wenger, E. (1998). Cambridge: Cambridge University Press.
Communities of clinical practice: the social organisation of clinical learning. Egan T and Jaye C. Health 13 (1), 107-29, 2009.
An exercise to map patient-centred care networks Young J, Egan T, Williamson M, Jaye C, Kenrick K, Ross J & Radue P. The Clinical Teacher 13, 2016 (6), 448-450. DOI: 10.1111/tct.12459
Competing interests: No competing interests
Communication is like an asymptote. Asymptotes are geometrics with two lines that approach but don't quite reach each other; while comunication is dialectics with two lives that approach but don't quite reach each other. Sadly, asymptotic talk lacks the nexus of context and impact of contact.
Competing interests: No competing interests
Re: Margaret McCartney: The social care system has become inherently unsafe
We have had an inadvertent trial of the effects of funding mechanisms on the availability of carers here in Aberdeen: a few years ago I asked one of our district nurses how was it that our patients in one area of the city always seemed to get carers whilst they seemed to struggle in another comparable area? The answer was very simple: the ones in the well supplied area work for the Council, but in the other they came through an agency, and the agency just could not get enough people to work for the money they could offer.
The (cash-starved) council only had to pay for care when it the contractor could find a carer - if the agency could not provide the carer, the council got to keep the money in its coffers. I can only imagine that this ecology of perverse incentives has sustained the situation of carer scarcity.
Now that the performance of the new integrated joint boards ( of the health and social care partnerships) is being measured by their ability to solve the care crisis, this system of perverse incentives seems to be coming to an end - it looks very much now that provision of carers by independent and so-called 'arm's length ' providers is over and that carers will again be directly employed by the partnerships.
Our own experience of integration in our practice has been less than convincing - since integration came in to force we have lost our co-located care manager, and along with the frequent absence of DNs from the same meetings, our MDT meetings are now far less MD and no longer have a social work presence, none of which sounds very much in the spirit of the Act.
Competing interests: No competing interests