PRSB interview - Ian Turner

This month we published the Care Home Information Flows Report, which analyses the information gaps between care homes and health care providers. The report, which can be found online, shows that nine in 10 care homes are still getting paper records, while others are getting inadequate information.

One of the main challenges for us is to get away from fax communications. They’re very insecure and can go anywhere. The standard route for discharging someone to social care is via fax- so it’s still one of our biggest challenges. We definitely need to move towards a more secure system.

Another big challenge for us surrounds transfers of care. We need to make sure we have accurate information about a person’s care, particularly about medication. There are often last minute changes to a person’s medication as they come out of hospital and this needs to be communicated properly. The other issue is knowing where these medications are actually available, particularly end-of-life care drugs which aren’t always available from every pharmacy, such as morphine.

There’s a lack of standardisation between hospitals and GPs. Ideally, we would want to have access to GP records for up-to-date medication information, but this can take up to 24 hours after the transfer of care because we aren’t using digital information. As well as information on medication, we need to know whether someone has an infection and needs ongoing treatment. For older patients with weaker immune systems, there’s a higher risk of infection when in hospital. These infections can spread quickly and it’s important that we’re aware of these issues, to protect both the patient and other care home residents.

What steps do we need to take to move forward?

We need more standardisation in information, so that everyone involved in care planning is clear what care is needed and who is responsible for it. The next big step towards this will be the development of the digital integrated care and support plan standard. There are so many different services involved in a care plan, with many different views on what should be included. We want to get to the point where we have structured data, that can be shared easily between different areas of health and social care. In recent years, self-care and patient autonomy has become a more pressing issue. In the care sector, we need to have access to information, and know who the information should be available to, particularly for people who have problems understanding their care and needs. For more information go to www.theprsb.org/projects.

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Successful teams have the functional skills to lead a task, benefit from diversity, and are led in a way that creates time and space for reflection; the ability to take stock periodically, of the task and of the way in which the team is engaged in delivering it. Your stakeholder analysis [HYPERLINK] should help you assemble the most appropriate team and identify how the team interacts and relates to other stakeholders like sponsors, services users, etc.

The variation in the size, both in terms of population served and numbers of constituent organisations, and of complexity, between Integrated Care Systems, precludes the possibility of any prescriptive guidance on the way in which this team is assembled.

Engeström’s expansive learning cycle of learning actions explains how there are 7 stages of learning actions;

CHAT theory also explicitly addresses five areas which if addressed systematically will help overcome stakeholder differences in pursuit of the common goal:

1. Understanding the artefacts that characterise the group and its activity.
• The artefacts might be clinical settings or the forms and templates used to capture and share information. During the pilot we heard about hard copy Dialog response forms; locally generated templates for collating information from different systems; letters and emails to GPs; images, poems or other non-text artefacts that service users might want to include in their ‘about me’ or care plan.

2. Understanding the multi-views of the group. Such groups are always a community of multiple points of view, traditions and interests. 
• Different participants in the group will have different roles and will bring to the group and their roles their own histories, language, and ‘rules’. During our Stocktake preparations and workshops we worked with psychiatrists, mental health nurses, occupational therapists, social workers, transformation leads and voluntary sector representatives, all professions and interests with their own language, approaches professional ‘rules’ but united in their interest in care plans, care planning.

3. Activity systems (like the ICSs) take shape and get transformed over periods of time. ‘Historicity’ is a term coined to express how the group’s problems and potentials can only be understood against their own history. 

 

• ‘We’ve always done it this way’, ‘that didn’t work before’, ‘it’s always like this’, ‘it wasn’t always like this’, ‘they are changing things again’, are all typical statements that often frustrate those charged with overseeing change initiatives. Without addressing the experiences that lie behind such comments you risk repeating mistakes of the past, alienating your stakeholders or just not understanding the real starting point for your transformation project. This is particularly the case for the implementation of the PCSP standard, the success of which will be largely reliant on point-of-care practices and information protocols as well as having systems which are user friendly and appropriately configured.

4. The central role of contradictions as sources of change and development. Contradictions are not the same as problems or conflicts. Contradictions are historically accumulating structural tensions within and between activity systems. Collectively addressing contradictions in how policy, practice, culture and technology interact will empower teams to find genuinely novel solutions for apparently intractable challenges, like interoperability and shared care plan/planning. 

This links to the fifth principle that:

5. the possibility of expansive transformations in activity systems. As the contradictions of an activity system are aggravated, some individual participants begin to question and deviate from its established norms. In some cases, this escalates into collaborative envisioning and a deliberate collective change effort. “An expansive transformation is accomplished when the object and motive of the activity are re-conceptualised to embrace a radically wider horizon of possibilities than in the previous mode of the activity.”