Health care in the time of austerity and the funding divide: 'scrub epic veils'

individual

|

INTERPERSONAL : SCIENCES

humanistic --------------------------------------- mechanistic

SOCIOLOGY : POLITICAL
|

group

FUN  ? 'PUBLIC'	DING ? 'AGENCY'

Smyth, C. (2015) Locum paid £500,000 as costs sore soar for the NHS, Doctor's deal reignites row over 'rip-off' agencies..., The Times, 2 October, p.1. (My source)


'scrub epic veils' = 'public services'
c/o http://wordsmith.org/anagram/index.html

Manet & the art of nursing - never unresolved: (and The Francis report)

Yesterday I travelled to London for a nurse related meeting and used the opportunity from 8pm - 11pm to take in the Manet exhibition at the Royal Academy of Arts. Brilliant! It is a great event. There really is no comparison apart from the very high resolution close examination that our technology makes possible; but then that is a difference experience, a different purpose.

Manet's work at the RA includes paintings that do appear unfinished. Areas of the canvas being unresolved brings home the relationship and dependency of the artist with the subject, and the artist's approach to portraiture. Manet was quite demanding on his subjects apparently and while not completely averse, he did not routinely rely on the new opportunities that photography afforded. Here are some thoughts from the Art Fund website:

'Summer' or 'The Amazon', by Edouard Manet

Manet was a great risk-taker and critics of day rallied against his inconsistent approach, as you will see many of the works seem 'unresolved' or 'unfinished' but one of Manet's great skills was this ability to stop painting at the right moment, and it is this technique which gives the works a sense of movement and life.

Manet once said to his friend Antonin Proust, 'I must be seen whole. Don't let me go piecemeal into the public collections; I would not be fairly judged.' This exhibition, which brings together the largest selection of works by the artist to be exhibited together in a UK museum, is a great opportunity to judge Manet's extraordinary talent as a 'whole'.

In nursing we are accustomed to impatient patients. Many though have no choice but to 'sit' and 'lie'. They are static, not able to walk or run away.

Unconscious patients - we speak to them: redrawing the outlines. Searching verbally where we cannot go, reaching for the centers of personhood. We sculpt them back to their optimal health. Sometimes the brush strokes are urgent, sometimes we improvise with touch.

All the time an ideal: a portrait of care. No matter how busy we are basic nursing care should never remain unresolved.

That part of the canvas is always completed. The outline is integrated. The horizon, foreground, middle and background may be sketchy in the extreme cases, but the real mission critical bases are covered.

What we should never countenance, collude, or indirectly sanction are the cutting of those bases.

If we do the work of art is not just unfinished: it is corrupt.

The Francis Report

Anagram graphic c/o Wordsmith

Manet's 'The Amazon' from: Reproarte.com

Integrated Health and Social Care Data: GIS torch

Last month the HSJ announced plans to integrated health and social care data (July 5th, pp. 6-7). The purpose is specific to support care commissioning, but ...

The related topic of integrated care is a round-robin element of policy debate. It may go quiet for a time, but it is there, needing to be fed in successive governmental and policy turns.

You might reasonably expect that integrated health and social care data, would be a by-product of integrated care. So the fact that data integration remains a 'to-do' demonstrates the patchwork nature of care integration and the many levels by which it can be defined: commissioning, practice (within domain) across care domains, budget, teams - disciplines, service organisations, care and education, public involvement and data.

I hope the integration of health and social care data at the commissioning level might also put data into the hands of clinicians and social care teams - integrated of course!

The local insights that could flow would represent a real, tangible benefit. The news item stresses the potential value for commissioners. There are as ever several caveats:

• To what extent can health and social care staff influence the shape of the dataset?
• Is it crystallized (centralised) already?
• Can the new role for councils in public health finally ignite the GIS torch to illuminate what is really happening in the local community?

It happens that:

data 'integration' 

also = data 'orientating'

So - come on policy people, commissioners and managers, don't leave the workforce out of the loop. Staff on the ground are disoriented enough by the relentless pace of change. They need a sat-nav for care. Give them the torch they need.

What is that you say? They don't have the time to critique their (integrated) practice, to formulate their questions. And anyway - they don't have the access or the skills to use the informatics resources, let alone the nous to interpret the data! Well, if that is the case then shame on you.

Person centred care, wormholes, pesterers, care domains (iii)

Person centred care, wormholes, pesterers, care domains (i)

Person centred care, wormholes, pesterers, care domains (ii)

Mentor: Shall we re-turn to your question?

Student: OK. Good idea.

Mentor: So to recap how we can define and represent person centered care? Where does person centered care fit in h2cm (Hodges' health career model)?

The INDIVIDUAL-GROUP vertical axis places the person, the individual - at the top of the model. That could be a positive if we are thinking hierarchically, but shouldn't a model that is situated AND person centred be explicit and put the person at the center? Is that the nub of it?

Student: Yes.

Mentor: So can you suggest an avenue to pursue?

Student: No... but I was struck by the talk of movement.

Mentor: And that was your suggestion if I recall correctly. In a similar way you also mentioned ensuring that the individual is taken into account across all the domains of care. So it sounds like there is a theme there?

Student: Yes, but this may as well be a foreign language - ironically I am stuck - conceptually and physically.

Mentor: Mmm.. What do you do?

Student: Exactly!

Mentor: No sorry, really - what do you do?

Student: I study obviously. Mentor: And...? Student: Well I study and work as a nurse - a student nurse...

Mentor: So you should know the answer? I do not practise clinically as much as I used to, so you have an advantage over me in terms of finding the answer.

Student: If the answer lies in practice?

Mentor: For matters 'person centered' is there a better place to look?

Student: True. OK. So - movement... reasoning... 

Mentor: Is your job easy in practice?

Student: It varies of course, but in general - no it's not easy: it takes effort.

Mentor: Ah, now you may have something there!

Student: Oh well that's heartening [with a smile]. In terms of effort then - nursing - health and social care takes concentration and attention as per active listening. You finish a shift and you know you're spent - and there's that assignment and self-directed study to complete.

Mentor: So it sounds like nursing requires - demands even several forms of effort.

Student: Yes in thought and action.

Mentor: And the model - h2cm - can support you in your reasoning and action?

Student: Yes it can because the model encourages you to consider each of the care domains back and forth - and in so doing you move the individual from the top of the I-G axis to the center of the model. Right at the heart, the nexus!

Mentor: So if the model says something about person centered care what does it say?

Student: Well, it says that person centered care is not a given it has to earned. And there - clearly [smiling] is the effort!

Mentor: Well found. Yes, it takes a lot of effort on the part of individual practitioners to put the patient, carer, member of the public - the person - at the center and keep them there. Socio-political factors and lest we forget sometimes the individual themselves will sweep the center clear. What we find and place there are the constraints which are always many and can always be found, such as; location, finance, beliefs, politics... Nursing, health and social care is a constant struggle not necessarily against nature, but with nature and many other factors.

Student: You said something about the INDIVIDUAL-GROUP continuum being irregular and I'm sure there must be more to that?

It's almost as if there are the four pages - the care domains - through which we consider and write our care assessments, plans, evaluations and outcomes. And yet I'm intrigued regards the movement between these pages and the knowledge domains they give rise to.

 Mentor: That is another very worthwhile question and in the same way that we remember the fifth care domain - the spiritual; I am sure you will find a way with that question also in good time ...

-+-

"Riemann's cut, with two sheets are connected together along a line. If we walk around the cut, we stay within the same space. But if we walk through the cut, we pass from one sheet to the next. This is a multiply connected surface."

Kaku, Michio (1994). Hyperspace: A Scientific Odyssey Through Parallel Universes, Time Warps, and the Tenth Dimension. Oxford: Oxford University Press. Fig. 2.4, p. 42.

Person centred care, wormholes, pesterers and care domains (ii)

Person centred care, wormholes, pesterers and care domains (i)

Mentor: Sorry my friend where were we up to?

Student: I am still puzzled as to how we can define and represent person centered care? Where does person centered care fit in h2cm (Hodges' health career model)?

The INDIVIDUAL-GROUP vertical axis places the person, the individual - at the top of the model. That could be a positive if we are thinking hierarchically, but shouldn't a model that is situated AND person centred be explicit and put the person at the center?

Mentor: This is a good question and you are right to ask it. As our previous discussions have illustrated our models are idealised and yet they should reflect the real world and experiences they seek to model and re-present for us:

Student: but in this case....?

Mentor: Well, not so quick...

As we noted the World's governments get the citizenry they deserve and vice-versa. If peace, political engagement, legitimate government and contentment are not a given but have to be earned then is person centred care any different?

Student: So, you are saying that peace, being a citizen, and mm... well-being I suppose are in a sense similar to person centered care?

Mentor: Perhaps?

Student: That seems quite a leap.

Mentor: Well your question prompts exercise - a certain gymnastics even - and with that a daily requirement we'll save this point for another time.

For now though... I know we don't necessarily need a precise definition of person centered care at the moment, but humour me and see what you can come up with in terms of this model of care. As you have mentioned it includes the INDIVIDUAL, the GROUP. And with the interpersonal and science domains the person's mind and body are literally in the frame.

Student: Well unless we are talking medical emergency then person centered care is about ensuring the individual is taken into account across all the domains of care.

That is - intra-interpersonal, physically - through the sciences, socially and politically. 

Oh - and spiritually too of course.

Mentor: So person centered or being person centered concerns domains of care?

Student: No. It's the content that matters. Take the interpersonal and myself as an example - what are my beliefs, previous experiences, writing skills and interests, my mood, disposition and attitude towards others. That only scratches the surface.

Mentor: I see. Can you go on from there...?

Student: Well I suppose each domain is visited according to various cues - and this is where context and situation come in. These supply the cues. They determine what is significant, what counts as information. For experienced nurses and health care practitioners this travel within and across the care domains comes as second nature.

Mm... I suspect that even if someone was not using h2cm explicitly their cognitive - conceptual movement could still be traced through the model, like passes on a football pitch.

Mentor: Very poetic! So if these care domains are being reflected upon does that mean person centered care is a consequence?

Student: Well I suppose it could if you take your mention of 'reflection' literally. Yes, picture the patient - the person - in the center of the h2cm matrix. We might even argue that our reflections place them there? Within the model what is the position of the person? If our deliberations could be measured - and practically that would be quite a task given patient engagement and dialogue - then is there an average across the domains? And is that the center - hence person centered?

Mentor: An interesting idea. And yet as you questioned initially the INDIVIDUAL in the model is at the top, at the top of an irregular continuum, so...?

Person centered care, wormholes, pesterers and care domains (i)

Student: I am puzzled as to how we can achieve and represent person centered care? Where does person centered care fit in Hodges' health career model?

Mentor: Can you recall the questions posed to formulate the model?

Student: Yes, I think so ... In h2cm there are two axes. The first is the vertical with the INDIVIDUAL - GROUP. The INDIVIDUAL is the primary recipient of nursing, medical and other disciplinary care. [Pauses] That's right, in the question posed in creating the model, the individual is identified first. Followed by the GROUP. It is the individual that I must learn to assess, plan care for, intervene and then evaluate that care. It is the individual who provides consent and then ... whose observations I record. It is this one person I am learning to observe, understand, reassure, and nurse back to health, or a peaceful, dignified and comfortable end.

Mentor: And in these times of the demographics, economic pressures 

and ongoing organisational change is that all?

Student: Mmm... No. The individual can also self-care and be taught to manage their condition and whenever possible to find their own (unique) way to recovery.

Mentor: That is right and will be very important in this century.

Student: What I do not understand is that in the model the INDIVIDUAL is hardly at the center, but at the top. This can very quickly become a word game played by the policy makers and the authors of care philosophies. It seems to me this model is merely playing games too. After all there are only so many letters in 'person centered' however we spell it!

Mentor: Enough ... to spell ... 'conned pesterer'?

Student: [Pauses, scribbles...] Hah! Goodness me! Hardly an appropriate term, even if my path crosses that of someone the 'team' regards as an 'unpopular patient'. That certainly highlights the true state of affairs. The public, and not just the public is repeatedly duped into believing person-centred care is a reality. Patients who are ill, not taking advice and especially those with long-term medical conditions and so a potential 'pesterer' [looks aside...]...

Mentor: Yes [wry smile] - do go on....

Student: Well your words not mine... These people, plus those who recover - are also citizens and they are the - supposed - stock in trade of the politicians. In that sense you are quite right - they are 'conned'. There aren't always the resources to deliver person centered care. Even then there is no definition of what person-centered should mean now - is there?

Mentor: Well I thought I was being clever with the anagram, but that is an excellent response.

Well done. I don't believe we are done here yet though...

'situated' in Hodges' model #2

So, Hodges' model is person-centred and situated
- a conceptual springboard for all.

In the 1970-80s the nursing process challenged task-based care.

Ever since we have stressed individualised, personalised care and now today self-care.

Interpersonal and communication skills are central to nursing theory,
practice, management and informatics.

In Hodges' model the individual is the primary focus*.

The science and art of nursing
is predicated upon the
nurse - patient
relationship.

Situated = 'Its a duet' (anagram)

*Inclusion of the 'group' in the model also facilitates
consideration of relatives, parent-child, family, community and populations.

"What's in a (blog) name?"

As regulars here will be aware I've been wondering what Hodges' model might learn from other conceptual frameworks produced around the world. ...

When I first read the following blog title - 'World Health Care Blog'

I thought - 'World Health Care' - now this sounds really interesting.

Unfortunately, upon investigation the world health contextual cupboard was bare.

I looked again at the label.

I looked in the tin.

I'm sorry, but from the top-down this blog proved a disappointment.

It's not that I was expecting a paper on world health care models or frameworks.

Don't get me wrong the business (economic, industry) world of health care is essential (reading) for those who want to stride - not step - from today into the future. Health care has been commodified for ages, for all ages. To be fair the 'subtitle' and 'about' statement makes the focus of the blog very clear. From the bottom-up there is clearly content to satisfy the ardent business-info-addict with posts and contributions from leading players.

Maybe it's me and my digital preoccupation has regressed to hairs; but this title IS imho very misleading. How so? Well from the perspective of world health care business-industry insiders all seems well with the-ir world. Meanwhile, non-'business' visitors like this one, may spend their visit exercising ruined expectations. (If the target audience is specific then somebody had better go sort the stage and the sights: there's still a debate to had.)

'Stuck' (and essentially 'skint') as I am here in Lancashire, UK I can't exactly throw stones. Hodges' model is a small - very tasty - fruit (when ripe!) with four (or five) kernels possessed of global - world health aspirations. We need global conceptual frameworks for health and social care and education.

Browsing the 'World health Care Blog' and searching for 'world health' revealed posts totally unrelated to what many people would consider the real issues surrounding 'world health'. There are posts on global health funding and global health program, India, Mexico, Thailand.

At the time of writing 'World Health Care' is not even listed as a category. Try 'poverty'...?

Perhaps 'world health' is implied in the content, but is this sufficient given the title?

Noting the sponsor perhaps there's a risk of confusing or conflating 'World Health Care - Congress' with 'World Health Care'?

The World Health Care Blog is not listed on the main Corante site, so perhaps this blog is off the beaten track?

All this makes we wonder about Google-SEO ranking and semantic web weighting? [Actually, where does (will) the weight of blog, website, and Web 2.0-3.0 application purposes and titles feature on the semantic web?]

'Corante' may have been the world's first English language newspaper, but *global health care* comprises a multitude of languages that must be given a voice. Especially as many of those languages are threatened species (including Danish).

There - was - an interesting brief video clip by Dr Anil Kumar

I realise of course that many contributors and agencies at the World Health Care Blog and Congress will be greatly involved in major world-wide humanitarian and philanthropic projects. The concern is one of impressions.... Reflecting on the meaning of 'world health' and the inclusion of these term(s) might pay great dividends in terms of publicity, balance, governance, corporate and social responsibility.

So, come on Corante if you - as blog managers - insist on this title, on this stage then pick up the theme of 'World Health Care' holistically - you know you want to.... since after all

Corante = Enactor

'To act (something) out, as on a stage: enacted the part of the parent.' http://www.answers.com/enactor&r=67

Lead the way...

All trademarks acknowledged.

Risk: Triangles that Trip [ack. Siegel, HSJ 20 Dec. p.23]

Happy holidays to one and all! Your interest is greatly appreciated.

In last weeks HSJ Matt Siegel's Data Briefing featured 'Missing pieces of the emergency plan', the focus was the risk relative to the population average of emergency admission, outpatient and A&E visits for specific intervention groups.

One of the figures comprised a pyramid which lists the intervention strategies that aim to reduce these service contacts:

CASE
MANAGEMENT
[Very high relative risk]
DISEASE MANAGEMENT [High risk]
SUPPORTED SELF-CARE [Moderate risk]
PREVENTION AND WELLNESS PROMOTION [Low risk]

By pursuing case management of course we can reduce the number of people needing to visit or be admitted to health services. Siegel highlights that if efforts are limited to those at very high risk then we can only influence (at best) 10% of total emergency admissions.

I've been working quite closely with a community matron recently and this 10% are a worthy target, but looking at triangles there are two essential dimensions here. One concerns the 'ascent'. Although it usually takes time (and may even entail oxygen at home) we need to entertain people at base camp for as long as possible. Why?

Because when viewed in terms of the health career every one of us is a climber.

As the supported self-care and prevention labels reveal this is recognised and is very much a part of overall strategy - but; in the low-lands though, the fog can cloud our vision.

The other dimension also lies in the very structure of triangles. The sticky-out-bits: the feet - can trip you up. Siegel points out the need to intervene elsewhere; apparently for example, the two middle risk levels which account for 20% of the total population. In the saga of joined-up health and social care the value of day care for example seems lost in the debate about who/how it should be provided? I need to check the latest literature, but I thought the size and stability of an individual's social network is a key determinant in +ve mental health? Another research question relates to how the number of required day places is derived?

In looking to make changes in the towering heights, let's not forget the nitty-gritty of care on the ground.

It isn't just having these varied intervention programmes in place. It's about managing the traffic on the passes (now there's a subtle interface!). There are many communities out there and they are far from equal. Community care: define. ...

an·a·gram: triangle = alerting, altering, integral, relating

TEMSS - Therapeutically Enhanced Medium Secure Service for Women [II]

Dear Rachel (Ms Magee)

Delighted to help you and well done on picking out Hodges' model. It sounds like an exciting time for you personally being newly qualified and working on a new unit.

Apart from several occasions as a student (late 70s at Winwick Hospital) and more recent liaison through my Trust's NHS Care Record Service Project I have not worked in forensic/secure mental health services. So what follows is a very generic over view. That said Hodges' model is more than an out-liner - brainstormer tool. As your experience grows the model will grow with you and your clients if it is appropriate to share it with them. Anyway, here are some initial thoughts a real mish-mash running through the care (knowledge) domains in turn (with some repetition).

If you wish to develop and elaborate on what follows, casting a distinct TEMSS light on each care domain I'd be happy to place your prioritised version in a graphic (with you duly ack.)

intra-INTERPERSONAL
Screening on admission. Existing psychic 'injuries'.

An·a·gram: 'secure' = 'rescue' .....

Life history, experiences +ve/-ve (including hospital care), skills, strengths, beliefs, mood, expectations, RISK behaviour, personality, psychological reactions to situation (admission, secure environment, diagnosis, prognosis, treatment - psychotropics, locus of control, helplessness, motivation, family contact...), specific, individualised - person-centred care. Thought disorder? Attribution. Risk - self-harm, harm to others, self-neglect. Psychological dependence. Intelligence. Literacies: 3Rs, visual, social, information. Boredom, Mental capacity. Cognitive functioning. Religious beliefs. Personal skills, strengths, interests. Education - access to training. Response to stress - existing coping mechanisms. Sleep. Attitudes. Sexuality. Biopsychosocial influences PMT (sorry don't wish to seem sexist!)? Stress-vulnerability. Biases, prejudices. Orientation time, place, person (not just older adults).
(YOU as a nurse are also in this domain - your skills, control and restraint, anticipation of needs, observation, empathy, self-awareness, non-judgemental, bias etc....) Assessment tools. My care plan. 'personal' time. Quality - therapeutic time if used.

SOCIOLOGY
Family, pressure on existing - new relationships, spouse-boy/girlfriends, socialisation into the 'secure' environment, dependencies - children / pets. Observation. Group activities. Group therapies. Routine. Co-operation. Team work. Leadership. Status, stigma, respect. Communication. Social skills, Assertiveness. Media - papers, radio, TV. Qualitative research - client narratives. Demographic profiles - catchment areas - deprivation indices.

SCIENCES
Screening on admission. Existing injuries. Access to GP, emergency services if needed. Physical characteristics, height, weight - BP, temp, bloods, mobility. Evidence based care? NICE. Drugs, side-effects (+ substance misuse / alcohol), physical effects of addiction, physical environment - lighting (on-off [fade]), noise (acoustic) signature, colour, architecture (sharp corners vs curves), physical health problems, trauma. ADLs. Assessment toolkit - what's in yours? Nursing (care) process. Hygiene, Domestic services. Infection control. Physical space allocation. Multidisciplinary assessments - occupational therapy, physiotherapy, psychology, pharmacist. Unit viewed as a system - ecology. Complexity within TEMSS. Literature review. Site visits / conferences. Learners. Staff course study opportunities. Academic partnerships. Quantitative research. Triangulation. Statistics. Data gathering processes. Geographic profile of referrals.

POLITICAL
Human rights, policies, protocols, GP service provision, right of appeal as relevant, 'disciplinary constraints', compliance-concordance, 'offence' category. Client space - privacy / dignity. Access to therapies, rehabilitation, training opportunity, AUTONOMY, ability to exercise choice, institutional 'rules' make-up, clothing, bathing, kitchen, toilet facilities, dignity and privacy, 'unwritten' rules - bullying - vulnerable adults, abuse, financial, sexual, physical. Inspection - Commissioners - accountability. Referral process-pathway. Thresholds, waiting lists? Travel distance - regional resource. Transport links - visiting times. Cost of fares. Staff establishment. Health & safety rules. Disability. Care transitions. Learning disability. Early onset dementia. Ageism (other '-isms') RECORDS. CPA. Community Team. Qualified-unqualified staffing. Patient-relative groups. Service user representation on management. Academic links. Visiting. SAFETY - patients-staff. Serious untoward incident reporting. Translation. Advocacy - short-long term. Other agencies - Social Services, third sector voluntary partners? Philosophy of care, OUTPUTS vs OUTCOMES? 'contracts', Mental Health Act, appeals, hospital managers. Politics of care. Psychiatry in Dissent. Audit, data collection, IT systems. Access to REPORTS - INTELLIGENCE "How are we doing?" "Where are we going and is that the right way?" Your involvement - engagement - in these processes. Client - carer - public involvement. Finance budgets - (unit budget - resources), staff support / supervision. Energy use. Recycling. Client abilities with finances / debts. Homelessness. Re-housing. Existing tenancy. Opportunity for (regular) TEAM BUILDING ;-) Innovation and creativity. PDP - KSF. Targeted issues: Managed care. Personality disorder....? Professional associations, groups:
http://health.groups.yahoo.com/group/forensic-psychiatric-nursing/
No group for TEMSS for women? Over to you! .....

As you can see the model is high level. It does not DICTATE how your unit is run, what therapy is undertaken. It can help as an aide memoire prompting you and your colleagues to systematically consider all the care domains according to the context-situation and can help ASSURE an holistic assessment and evaluation.

The model can also be used to help explain problems, issues and their solution - or realistic outcomes to clients and their families. So the model doubles as an educational resource - very helpful to engage the INDIVIDUAL or a GROUP (family). You can do this EXPLICITLY using paper or flipchart for example, or implicitly with you using the model mentally as you go along...

By including a POLITICAL domain Hodges' model is ideally suited to your speciality - in fact POLITICALLY and SOCIALLY there are 'nested' issues within your 'secure care' context: gender, ethnicity, equality and equity, public attitudes, institutionalisation, citizenry, public involvement....

This blog includes many labels (on the right hand side) I will also add 'secure services'.

Rachel - I noticed on your organisation's website there are the names of the wards and address - there's a space to fill there...

Good luck, hope this helps and thanks again for your interest.

Best,
Peter

an·a·gram: "Nursing Politics" = ...

"nursing politics" = "counting lips sir" (no comment)

"Health career model" = "cremated, hello Hera ..."

"nursing care" = "cures rang in"

or better still "curing nears"

or "curing earns" (really?)

or "incurs anger" (yep, nursing's a great job, but frustrating at times)

or "sun care ring" (Holistic care - New Age tendencies?)

"nursing theory" = "hurrying notes"

or "syringe hurt on" ( - entry?)

or "gunnery hot sir" (... then stop using depleted uranium!!)

or "hungry in store" (whatever happened to basic nursing care?)