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Seamless health and social care at a price

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VOL: 97, ISSUE: 26, PAGE NO: 36

Davina Allen, PhD, BA, RGN, is lecturer and deputy director (nursing) Health and Social Care Research Centre, School of Nursing and Midwifery Studies, University of Wales College of Medicine

Patricia Lyne, PhD, BSc, RGN, is RCN professor of nursing research, vice dean (research), Health and Social Care Research Centre, School of Nursing and Midwifery Studies, University of Wales College of Medicine;Lesley Griffiths, PhD, BA, is senior lecturer, School of Health Science, University of Wales, Swansea

The metaphor of seamlessness reflects the long-held aspiration of successive governments: that the divisions between health and social services should not be visible to those who use them. There should be neither service gaps nor service duplication.

The metaphor of seamlessness reflects the long-held aspiration of successive governments: that the divisions between health and social services should not be visible to those who use them. There should be neither service gaps nor service duplication.

The notion of joined-up working is a new addition to the policy literature but it embodies a well-established view - that seamlessness can be achieved only if health and social services staff work more closely together.

New funding mechanisms that permit the pooling of health and social services budgets are recent examples of policy developments that, over the past 30 years, have aimed to improve coordination between services (National Assembly for Wales, 2000; Department of Health, 2000).

Our research into the provision of health and social services in stroke rehabilitation looked at one factor that has been overlooked in policymakers' scrutiny of the relationship between health and social services: private finance. We use two case studies (see boxes) to illustrate that although seamless services are enjoyed by many, others cannot afford them. These findings have important implications for a further policy: equity of access to health and social services.

The goals
The aim of the research was to identify factors that help or hinder the provision of integrated health and social care. It was undertaken in two Welsh health authorities and focused on adults undergoing stroke rehabilitation.

At each study site we carried out four in-depth case studies that centred on the patient but also took in the wider context of his or her care network and the broader policy framework.

The care of each client was evaluated over six months, and for each case we identified the key players and processes involved in planning and providing services. Tape-recorded interviews were carried out with all care providers, the patient and his or her carer. Key events, such as meetings and home visits, were observed and, where possible, tape-recorded. Qualitative data analysis software helped us to analyse the data and compile detailed case studies.

Resources
The two study sites were marked by significant socioeconomic differences.

The National Assembly for Wales has calculated an index of socioeconomic conditions for each Welsh electoral ward. The cases at one of our study sites recorded higher socioeconomic deprivation scores compared with the second site. The allocation of health and social services budgets in Wales is done on a per capita basis, which fails to recognise higher levels of disadvantage.

Tudor Hart's inverse care law (Hart, 1971) tries to explain how those in greater need usually live in areas where, because demand is high owing to the links between poverty and ill-health, services are often stretched to the limit.

We found wide disparities in service provision which, as well as having serious implications for equity and social exclusion, affect key aspects of the management of health and social services. For example, conflict between the two services was most marked at the site where resources were most stretched. Such tensions are not only a drain on service providers' time and energy, but they also hamper the establishment of trusting relations and do little to support the development of flexible approaches to service provision that the government is so keen on.

Private finance
Our research revealed that private finance was an important catalyst in the relationship between health and social services. Faced with shortfalls in funding, health and social services staff had to find other means to secure resources for clients.

We became aware of numerous cases where health and social services staff encouraged families to privately fund equipment and modifications to their home to ensure an early discharge. While private finance was crucial for some families, many others were unable to contribute towards care costs, raising important issues about equity.

The case studies reveal that although seamless health and social care results in a quality service, it is available only to those who can afford it.

Conclusion
Our findings suggest that the health and social services cloth has been cut so sparingly it is difficult to make a strong seam without the edges fraying. In both cases resource constraints had implications for the services provided. Daniel Howard's family had sufficient wealth to make good the shortfall in public provision, but this was not an option for Mary Barton (see case studies). Private finance seems to hold the edges of services together. As our cases illustrate, this is fine for those who can afford it, but not so good for those who cannot, raising important issues about equity and social exclusion.

- The patients' names have been changed

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