Social Care: in the round and square c/o King's Fund

Simon Bottery's Long Read -

What’s your problem, social care? The eight key areas for reform

- and listed below, have been mapped to Hodges' model. The full article and comments are well worth reading and may help readers discern the relationships between the key areas identified.

1. Means testing: it’s not like the NHS 
2. Catastrophic costs: selling homes to pay for care 
3. Unmet need: people going without the care and support they need 
4. Quality of care: 15-minute care visits and neglect 
5. Workforce pay and conditions: underpaid, overworked staff 
6. Market fragility: care home companies going out of business 
7. Disjointed care: delayed transfers of care and lack of integration with health 
8. The postcode lottery: unwarranted variation in access and performance

I have associated each with the respective knowledge (care) domain in which they are placed:

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group - population

1. Parity of Esteem in Means Testing 2. (Catastrophic) Cost to me, anxiety, depression, stress 3. Unmet need (mental health, counselling ...) 4. Quality of Care (Mental Health, Well-Being..) 5. Workforce (values, person-centred, self-esteem, job-well-done, BE the Difference?) 6. Market fragility (attractiveness as career pathway, having a leader) 7. Disjointed care (number of carers, lived experience...) 8. Postcode (I thought this had been addressed?) (postcode? - a remote 'thing' outside through the window and (summer) garden]

1. Parity of Esteem in Means Testing 2. (Catastrophic) Cost to NHS - innovation, change, prevention, transformation 3. Unmet need (physical, access ...) 4. Quality of Care (Time, Logistics) 5. Workforce (tasks, scheduling, physically reasonable?) 6. Market fragility (scale, bed occupancy, local demographics...) 7. Disjointed care (geography, transfers, A&E admissions...) 8. Postcode ('literally') North, West, East, South, Regions, London, Urban, Rural ...

1. What is your Parity across 2. (Catastrophic) Cost to my family. 3. Unmet need (socialising, access, carer ..) 4. Quality of Care (Relationships, Belonging, Communication, Family Groups..) 5. Workforce (job satisfaction, status, social worth ..) 6. Market fragility (Public perception, marketing, negativity bias - local news, time for outreach, intergenerational engagement...) 7. Disjointed care (input of family, local provisions, self-funding - budgets...) 8. Postcode (pre-social care, pre-lottery?)

Means (let's Test that.) here too?  2. (Catastrophic) Cost to the State? 3. Unmet need (my choices, informal carer ...)  4. Quality of Care (Value for £, Measures, Inspection, safety..) 5. Workforce (pay and conditions, minimum wage?, Unions, contracts, training, BREXIT ..) 6. Market fragility (FUNDING settlements, estate, investment, staff turnover, Qualified staff, commercial history, profit, governance..) 7. Disjointed care (commissioning, ...) 8. Postcode (local policy, funding, protocols ..)

c/o The King's Fund: Making sense of integrated care systems, integrated care partnerships and accountable care organisations in the NHS in England

When I see a 'model' I ask myself; what does this mean in itself? What is its purpose? I also (invariably) ask how does it relate to, or how might it support the theory and application that might underpin h2cm?

In February 2018 The King's Fund posted this item on integrated care systems. It wasn't just the 2x2 figure that caught my eye, but the axes and the additional amber tab (figure 1). Pondering for a time I have transposed this to Hodges' model below figure 1. Beneath that, I've provided an explanation for the altered schematic; recognising that as with h2cm such models are idealised representations.

c/o The King's Fund

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

Individual care management Care for patients presenting with illness or for those at high risk of requiring care services	Population Health (systems) Improving health outcomes across whole populations including the distribution of health outcomes [Improving population health outcomes requires multiple interventions across systems]
'Making every contact count' Active health promotion when individuals come into contact with health and care services	Integrated care models Co-ordination of care services for defined groups of people (eg. older people and those with complex needs)

INTRA- INTERPERSONAL:
Individual care management has been changed from care services and individuals to this domain, which conceptually preserves the original placement. In h2cm as can be seen the interpersonal domain combines the individual and humanistic. In the 4Ps this domain also includes 'purpose'. Whenever possible it here (individual motivation) that self-care and self-efficacy and staying as well as possible relies on the patient's awareness and education about their condition and level of health literacy. There is recognition now that children need some awareness of mental health issues and the law needs to protect what images and content youngsters are exposed to on social media. So, ultimately 'how I manage myself' has a major bearing on the 'whole care management enterprise.' The focus on 'high risk' also denotes a need for an assessment and one that is part of the move to parity of esteem in respect of physical and mental health.

SCIENCES:
I have shifted Population Health (systems)from population to this (physical) individual domain, on the basis that our research, as in, quantitative and qualitative, needs to be synthesized and then ultimately generalised - across populations. While complex systems cannot be taken apart it is from the sciences (including social sciences) that evidence-based practice flows. There should be a feedback loop here, research that also takes into account the multiple interventions across systems (the amber tab in figure 1) and the outcomes achieved.

POLITICAL:
The King's Fund's figure 1 stands as it is of course, but I have 'moved' Integrated care models most radically. If there is no organisation, rules, order, policy, procedures ... then things will NOT happen (as they should). Agreement is also needed on definitions for reasons of standards, measures and accountability. Such matters are political (even if ignored - kicked in the long-grass). For services that are evidence-based (as just mentioned in SCIENCES) we need when possible for health and social care policies to also be evidence-based (for reasons of efficiency, equity, effectiveness and equality). While we cannot 'break' complex systems we can break models; 'health care systems' need to break ("be broken whilst still in flight") in order to be transformed for the 21st century.

SOCIOLOGY:
Making every contact count I have placed in the h2cm's Sociology domain. To me this initiative remains with care services, but I have switched this from individual to group-population within h2cm. Health care education places constant emphasis (research, CPD, mandatory training) upon interpersonal - communication skills and this is where clinical and social care interactions and interactions ultimately count. It is here that trust, the 6Cs, unconditional positive regard ... are 'counted' in qualitative terms. If the psychological represents the theory of psych-social intervention, it is in the social outcomes and benefits were the practice is (truly) delivered. It is also here that partnerships are forged and social capital found.

In social care as an example, the integrated care model should politically permit - allow for a sufficiently skilled and remunerated work-force (socially valued?) with sufficient time to ensure that every contact really does count.

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Forty years in the NHS suggests that when ever 'integrated care' is being written and even spoken about, then the context should be indicated at the same time; so at least - integrated care^1-5 as above?

'integrated' as in -

• philosophy (ethics, morality, values)
• spiritual (values) (and part-whole of 1-5)
• political - policy, government funding
• economically - commissioning (models of care, sustainability)
• management
• care delivery
• team organisation
• community involvement
• patient involvement
• health literacy, health promoting

...?

Accessibility: apologies that there is no equivalent text to figure 1.

My source: https://twitter.com/TheKingsFund/status/1093556280248147969

A vision for population health: Towards a healthier future - c/o The King's Fund

To improve health and reduce inequalities, local and national action is required across four pillars of #populationhealth. Resources currently focus on the health system. We need to rebalance this: https://t.co/q06pK8NxQM pic.twitter.com/ZNGlEhM0N6

— The King's Fund (@TheKingsFund) December 1, 2018

I have taken the four pillars above and mapped these to Hodges' model, essentially a horizontal flip -

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group - population

Health behaviours  and lifestyles	Wider determinants  of health
The places and communities  we live in, and with	Integrated health  and care system

Social prescribing: c/o @TheKingsFund - Three questions

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

Does it work?	What is it?
What is #socialprescribing? Does it work, and how does it fit in with wider health and care policy? A quick refresher ahead of our event tomorrow… https://t.co/46cJqjBKeR — The King's Fund (@TheKingsFund) November 5, 2018	And how does it fit in  with wider health and care policy?

Social prescribing is not a quick fix, a social distraction from a clinical problem. How this is approached - negotiated - will be a clear factor in the shared success of social prescribing as an effective, intervention for the person concerned, the NHS AND society.

Quality (and Safety) Organisations come and go but ... care domains ...

"The NHS Improving Quality delivery team has developed and tested a new measure of "energy for change" which is helping to support innovation and improve service delivery." p.26.

"The energy index is evidence based - built up from a combination of academic and desk research - coupled with interviews with NHS staff." pp.26-27.

The 'energy domains' are:

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

psychological intellectual	physical
social

spiritual

Land, M. (2014) Pedal to the metal to improve the NHS, HSJ, 7 March, 124: 6389. pp.26-27.

Another perspective is provided by The Kings Fund, from:

"Improving quality in the English NHS"

A brief history of policies on quality of care in England

...

• the establishment and later disbandment of the National Patient Safety Agency to collect and analyse data about adverse events
• the establishment and later disbandment of the NHS Modernisation Agency as a central support system for improvement
• the establishment and later disbandment of the NHS Institute for Innovation and Improvement as a (smaller) successor to the Modernisation Agency
• the establishment and later disbandment of NHS Improving Quality as a successor to the NHS Institute for Innovation and Improvement
• the establishment and later disbandment of strategic health authorities as regionalised resource centres for a range of tasks, including facilitating quality improvement pp.6-7.

Ham, Chris, Berwick, Don, Dixon, Jennifer, Improving quality in the English NHS: a strategy for action. London : The King's Fund, 2016, pp. 6-7.


The truly relevant - critical domains have remained a constant over the years, decades even.
 
Clearly, this is evidence-based -this is rocket science...?

How many times do we 'reinvent' this - evidence and desk research based...?

See also*: https://hodges-model.blogspot.com/2014/08/compare-and-contrast-potentia-energy.html

*Yes, I'm starting to repeat myself!

What does improving population health really mean? c/o The King's Fund

INDIVIDUAL

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

POPULATION

Individual as a Person# Individual Lifestyle Choices Mental Health NHS AND Social Services*? Motivation - PURPOSE Unhealthy behaviours Health Coaches

Local plans Individual as a Person -  Age, Sex, constitutional factors Individual Lifestyle Choices New Care Models* (and PROCESSES) Pop. Health = Aggregated Data Environmental conditions (Does the colour of Gov matter?)

Public Mental Health Health Care Demand in the community  Living and Work Conditions "Population health means the health outcomes of a defined group of people, as well as the distribution of health outcomes within the group." Social and Community Networks Social Care PRACTICE Education (informal) General Cultural and Socio-

NHS POLICY<-> Population Health Sustainability and transformation plans (STPs) "... health equity – the avoidable differences in health between different parts of the population – is a core part of understanding population health." Education (formal) Health Care Services Housing Water and Sanitation Agriculture and Food Production Work POLICY "In United States - Pop. Health defines aims of health system" Unemployment -Economic Conditions

Within Hodges' model the * items are automatically included in all four care domains (five with the Spiritual), for reasons of brevity and presentation they are included in what I consider their primary contextual domain.

Individual as a Person# in the Sociological and Political Domains in a group context (From: Dyad ... To: Current Human Population).

My source: Twitter @TheKingsFund

Everybody in NHS policy seems to be talking about population health. But what does it really mean? https://t.co/geV4R3S5DT pic.twitter.com/G8msXpzbet

— The King's Fund (@TheKingsFund) April 28, 2017

Place-based systems of care: The King's Fund

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

individual workers mindset Leadership placEmotion	'place': physical & virtual? estates, buildings technology, e-health? travel - efficiency
Local need - availability "Home" "Hospital" "Community" Social Care : Health Recovery, Rehabilitation, Reablement	King's Fund Place-based systems of care leadership, commissioning, organisations, budgets, integration, populations, strategic budgets,

My source:
Ham, C., & Alderwick, H. (2015) Take a place-based approach to care, Health Service Journal. 125:6469, 16-17.

Report - Integrated care for patients and populations: Improving outcomes by working together

I've posted on integrated care previously on W2tQ. The core recommendations of this New Year  report on integrated care are:

• government policy should be founded on a clear, ambitious and measurable goal to improve the experience of patients and service users and to be delivered by a defined date
• patients with complex needs should be guaranteed an entitlement to an agreed care plan, a named case manager responsible for co-ordinating care, and access to telehealth and telecare and a personal health budget where appropriate
• change must be implemented at scale and pace; this will require work across large populations, significant reform and flexibility to take forward different approaches.

Publication prompted Time to integrate words with action by Chris Ham and Jennifer Dixon (HSJ 5 January pp. 16-17 - and my source for this news). The report and mention of measures of integrated care that include patient experience provoked further reflection.

Integration in health and social care should be considered critically over the past 25 years and more (but that's a thesis). Evolution in policy matters, but there is a deep archaeology that illustrates the policy aspiration - practice gap the reports priorities seek to address. A comment in response on the King's Fund's site notes the need for (strategies, methods and) a framework. While no magic wand there is a framework that can at least unify disciplines, public and policy makers. And act as a bridge between words and actions.

Integration needs a shared and agreed origin.

(A point* around which disintegration turns)

Although brief (20 pages) the report is an excellent source for references (3 pages) that includes:

Kodner D, Spreeuwenberg C (2002). ‘Integrated Care: Meaning, logic, applications, and implications – a discussion paper’. International Journal of Integrated Care, vol 2,
Available at: www.ijic.org/index.php/ijic/article/view/67 (accessed 13 December 2011).

Kodner D (2009). ‘All together now: a conceptual exploration of integrated care’. Healthcare Quarterly, vol 13(Sp), pp 6–15.

Leutz W (2005). ‘Reflections on integrating medical and social care: five laws revisited. Journal of Integrated Care, vol 14, no 5, pp 3–12.

As we try to integrate words and actions we need to remember:

how we dice and slice influences the scope of integration.

We'll explore this more soon.
*Points?

Nick Goodwin, Judith Smith, Alisha Davies, Claire Perry, Rebecca Rosen, Anna Dixon, Jennifer Dixon, Chris Ham Integrated care for patients and populations: Improving outcomes by working together. Report to the Department of Health and NHS Future Forum from The King’s Fund and Nuffield Trust

Point of care? The King's Fund - patient experience

The real 'point of care' is that there are several points with many perspectives:


Patient (person) - Care professional - Manager - Carer
Public (citizen) - Student - Lecturer - Service User Groups
Physical - Emotional - Political - Social
Patient - Inspectors - CEO information governance - Commissioners

Don't drown seeking gaps in processes. All of the P's count!

The King's FundThe Point of Care: Improving Patients' Experience.


Image source:
Multiple Faces: Insight Management Group