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A proposal of change to improve the quality of care for vulnerable older people who after being admitted into hospital and on discharge do not have a lot of choice in services that they receive. They are either sent home with a care package which does not meet all needs of the older person or moved to a residential home.
It has been said that independence and mobility are the two most precious commodities that the elderly, as a group, need to nurture as a significant decline in either will significantly increase their dependence and reliance on others, either in the family or in the community. (Whitely, S. et al 1996)
In general terms, the plight of the elderly in hospital is probably the most precarious of all of the age ranges, irrespective of the illness for which they were admitted. Any form of debilitating pathology, even if it only puts them in bed for a few days, may very well weaken their already tenuous grip on independence. The result may be either a prolonged stay in a hospital bed, home discharge with a care package which may not be totally satisfactory and all too often dependent on the ministrations of a group of overstretched healthcare professionals, or discharge to some form of residential care – which, although possibly seen by some as being the best option for the debilitated or infirm elderly, has an enormous impact on both the independence and the lifestyle of the elderly person.
Let us briefly consider this last option which is not as straight forward an option as may appear at first sight. Let us personalise the discussion by referring to a hypothetically representative Mrs J., a 78 yr. old lady who has lived alone since her husband died some ten years previously. She is fiercely independent but has been getting progressively more frail as the years have gone by to the extent that it is a struggle to get her shopping. As a result her diet is becoming progressively more inadequate.
Her personal hygiene, which was meticulous a few years ago, is now also failing, and she spends a great deal of her time alone and in bed. She has developed a low grade chest infection which required her to spend three days in hospital. When it came time to discharge her, her daughter could not look after her and took the decision that she would be better in a residential home. Mrs.J. had virtually no choice in the matter and on the fourth day she found herself in a residential home, surrounded by people with an average age rather greater than hers, many of whom were suffering from varying degrees of dementia.
The home had a completely imposed and inflexible regime which was a major imposition on her as she had previously been able to do what she wanted when she wanted. There was virtually no privacy and never a time, day or night, when there was silence or quiet. Her house had to be sold to pay the fees, so she knew that there was no possibility that she would ever go home again and any money that she had, she was not able to spend as her savings were also taken to pay the fees. In the space of four days her life had been overturned and although she was warm, fed and cared for, by any rationalisation her quality of life had changed for ever.
Mrs.J. is quoted as being fairly typical of many and her case used to illustrate the enormity of the life changing impact of admission to a residential home.
Critically examination the need for the proposed change
The particular change that we shall highlight in this particular essay is the need for multidisciplinary discharge planning, a move which is highlighted in the National Service Framework for the elderly (Standard Two).
As we shall discuss later in this essay, the National Service Frameworks have been conceived and drafted in response to the perceived need for change. It therefore follows that it is a self-serving argument that it is a recognition of a need for change in this area that has prompted its inclusion in the National Service Framework .This rather tautological argument is given credence by a number of studies that have both looked at, and demonstrated the need for change in this area.
The paper by Richards (et al 1998) was a first rate examination of the problem. It covered a number of areas, but, with specific relevance to our considerations here it highlighted how the patient outcome could be improved by a timely multidisciplinary pre-discharge assessment by a team which included social workers.
This paper, if nothing else, underlines the need for change and provides a model for how improvements in the multidisciplinary discharge function can produce potential benefits for patients
Evidence to support this view can be found in anyone of a number of recently published papers (such as Ham C 2004) which has specifically surveyed patient and carer satisfaction levels in the area of welfare and associated services after hospital discharge for the elderly.
An outline and critical discussion of how change can be implemented
Change can be a trophic factor in any organisation but no matter how good the intentions and aspirations, if it is badly managed, then the end result can be a catastrophic mess. One only has to consider the debacle of the implementation of the Griffiths Report (Griffiths Report 1983) in the NHS in the 80s to appreciate how a major management change could be badly implemented. The Government even set up its own commission to see what lessons could be learned from the episode. (Davidmann 1988)
If we consider the overall implications of the report in terms of change management, the innovations failed because they were imposed rather than managed. (Davidmann 1988)
Another fundamental concept in the field of change management is expressed by Marinker (1997) who points to the rather subtle difference between compliance and concordance. He suggests that human beings generally respond better to suggestion, reason and coercion rather than direct imposition of arbitrary change.
The management of change is perhaps the most critical of the elements in this discussion. There is little point in having vision or ideas if you cannot successfully implement them into reality (Bennis et al 1999).
The whole study of the Management of Change is built upon a set of constructs known as the General Systems Theory (GST). (Newell et al 1992). The process is both general and adaptable and can be summarised in the phrase “Unfreezing, Changing and Refreezing” or in simple terms, assessing a situation changing it, and then making the changes stick. (Thompson 1992).
All changes, but particularly health and welfare related ones, should only really be made after careful consideration of the evidence base underpinning that change (Berwick D 2005). In specific terms one should evaluate the need for implementation of a multidisciplinary discharge procedure by considering the evidence that the current situation could be improved, make managers aware of the findings of need and than be proactive in encouragement in terms of support of any decisions that are made to implement such moves.
The Political context
If one considers the pre-2000 structure and organisation of the NHS, one could come to the conclusion that there were three major problems which, some observers stated were not consistent with what was required of a 21st century care provider, namely:
- a lack of national standards
- old-fashioned demarcations between staff and barriers between services
- a lack of clear incentives and levers to improve performance
over-centralisation and disempowered patients. (Nickols 2004)
There have been a number of reforms in the NHS which potentially impinge on the cases of the dependent elderly. Arguably the most important was the NHS Plan (DOH 2000). This is a lengthy document which calls for some fundamental changes in the working practices, and in some cases the actual roles of a number of healthcare professionals.
An analytical assessment would have to conclude that, although there is a lot of detail in some areas of the plan, there is actually comparatively little detail in just how these changes should be actioned and arguably even less detail in what it expected the changes to be (Krogstad et al 2002). In the context of our discussion here, we should also note the natural ideological successor to the NHS Plan, was the Agenda for Change (2004). The National Service Frameworks were then introduced after seminal guidance from the National Institute for Clinical Excellence (NICE 2004)
The other reforms that have a bearing on our considerations are Choosing Health: making healthier choices easier (2004) and Building on the Best (2003). Both of these have considerable implications for the care of the elderly. The Choosing Health paper outlines the Government proposals for giving patients greater choice in the implementation of their health care and Building on the Best examines ways of improving and modifying current practices. There are specific references to the discharge procedures which are relevant to our discussions here.
The Health context
In the context of this essay the NHS Plan called for a number of reforms including:
- Increase funding and reform
- Aim to redress geographical inequalities,
- Improve service standards,
- Extend patient choice.
Each of these areas has a bearing our Mrs.J. The geographical inequalities were primarily due to the historical context in which each area had implemented their own services together with the balance between funding and demand in each area. The improvement in service standards is mainly driven by the National Service Frameworks and he extension of patient choice clearly has a bearing on Mrs.J. although the choices available may well be less in practical terms than the complete spectrum of what is actually available and may well be constrained by factors such as available funding and the patient’s own physical state. (Wierzbicki et al 2001)
The National Service Frameworks (amongst other things) sets out to reduce inequalities in service provision between providers and also to set standards of excellence, together with goals and targets that are nationally based rather than locality based. (Rouse et al 2001).
National Service Framework Standard Two has as its stated aim to:
Ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries.
It is formulated within the concept of “Person Centred Care”. This is intended to allow the elderly (and their carers) to feel entitled to be treated as individuals, and to allow them to be responsible for their own choices about their own care.
The Social Care context
If we accept that a patient’s discharge from hospital is dependent on many disparate and variable factors including (apart from their obvious health considerations), for example, their financial, dependence and support network status. It therefore follows that before a considered decision can be made to discharge the patient, a full and careful assessment of these various aspects should ideally be made. (Gould et al. 1995). The input of the social worker to the multidisciplinary pre-discharge team is therefore vital in this respect as it is unlikely that other healthcare professionals will be in a position to make an assessment of all of these factors.
If one reads contemporary peer reviewed literature on the subject, the term “seamless interface” is a concept that frequently appears. (Dixon et al 2003). This reflects the moves towards the dismantling of the “Empire” concept of each health and welfare related subspecialty. (Lee et al 2004). And the positive integration of each, for the overall benefit of the patient.
Central to this process is the advent of the Single Assessment Process (SAP) which is arguably the most important new work practice to facilitate good multidisciplinary working practices. This reduces the duplication of work, derivation of facts and paperwork that hitherto was commonplace (Fatchett A. 1998).
In specific consideration of our Mrs.J. we could find that she was visited by one member of the discharge team (typically the social worker), and an assessment of all of the factors that we have discussed could be made and recorded in a single central document or reference point (computer). It is the stated aim of the SAP that the needs and wishes of the elderly patient will remain at the heart of the whole process. (Mannion R et al 2005)
To consider the requirements of the National Service Frameworks and in the context of social work we should also mention the concept of the carer’s or patient’s “Champion” that has been specifically encouraged. (Bartley M. 2004). These are designated workers (often specially trained or experienced social workers), who would stand up for the need of the patient or their carers. In Mrs.J.’s case we could postulate that such a champion could assess her needs as being more appropriately dealt with by an intensive course of both physiotherapy and an occupational therapy input rather than necessarily being arbitrarily placed in a residential home.
The social worker is ideally placed to assess and indeed to action interventions such as that of the occupational therapist, who can be shown to produce considerable impact on the ability of the infirm elderly to remain at home. (Gilbertson et al 2000). We should not leave this area without a demonstration that the evidence base in this area of social worker input as being both positive and beneficial by quoting the Logan paper (et al 1997)
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