Falling through the gaps: working ethically across health and social boundaries

This paper charts a consultancy to an NHS client who wanted an integrated care model for older people at risk of falling. It asks: how can professionals transcend professional and service boundaries to achieve better outcomes for elderly patients. What does ethical working mean in this context?As the UK population has aged and patient needs have become more complex so too have the services set up to deal with them. Most services, however, restrict their criteria to provide a one-sided response 1. with pre-determined pathways based on contractual commissioner-provider relationships, rather than the multi-sided needs of the patients, which require a collaborative effort between interacting services on the ground 2. One-sided responses are unethical: ultimately they betray the patient and result in silos and duplication, leaving large gaps in provision of services to support the needs of increasingly frail and very elderly people in the community, such as personalised transport, befriending, practical help in the home, and emotional support, etc. In this system, the dilemma of holding the balance between the social and acute contexts fell to the individual practitioners. They tried, on the one hand, to meet the multi-sided need by stepping outside of their role to co-ordinate appropriate services for their clients, leading to sickness absence, burnout and poor quality caredelivery; and on the other, to find refuge in rigid procedures (similar to the 'ritualistic' practice that Menzies Lyth described)3, as a defence against the anxiety and helplessness their clients' lives which were often chaotic, cluttered, dirty and isolated. This internal professional conflict created confusion about ethics and what constituted a 'duty of care', echoing that described by Miller in geriatric institutions 4. Any resistance by the patient to the procedural process was interpreted by practitioners as 'non-compliance', but could be understoodbetter as 'resistance' by the patient to one-size-fits-all structures that did not fit with their particular needs and circumstances; and 'counter-resistance' by professionals who had an investment in preserving the system as it is.In reviewing intermediate care services, Moore et al 5 concluded that it could only be understood as a key element of wider services. They asked: what are the requirements for intermediate care to work as a system, proposing that there is a need to go beyond partnership-type models and create 'integrated service networks' 6. Meeting the complex needs of older people at risk of falling, therefore, suggested a different alignment and collaboration between multiple service providers within an integrated network, where the network took up the responsibility for through-life-management, and also the ethical dilemma of what types of response might acceptable to the individual older person.The author set up a Working Group to review the care pathways, using a 'problem-bounding' 7. approach - orientating around the individual patient's problems rather than around the provider's strategy to deliver services. The aim of the Working Group was to understand the particular circumstances and problems of these older people through a forensic examination of individual case studies, which highlighted gaps and inadequacies in typical service architectures. The forensic approach was a tool for understanding the variability of 1 I.e. 'Its relationships to its customers (are) defined by the products and services it (has) planned to provide'. Boxer, P.(2014). Leading organisations rithout boundaries: 'Quantum' organisation and the work of making meaning. Organisational & Social Dynamics 14 (1) 130-153.2 Boxer, P. (2014). Op Cit.3 Menzies Lyth, I. (1988). The functioning of social systems as a defence against anxiety. In Containing anxiety in institutions, Free Association Books, London. 4 Eric Miller et al. (1993). Geriatric hospitals as open systems. In From dependency to autonomy, Free Association Books, London. 5 Moore et al. (2007). Networks and governance: the case of intermediate care. Health and Social Care in the Community, 15(2), 155-164.6 Moore et al. (2005). An evaluation of intermediate care for older people. Final report. Institute of Health Sciences and Public Health Research. 7 Alberts, D & Hayes, R., 2003. Power to the edge. In Command and control in the information age. circumstance and need, and for uncovering gaps in the pathways and provisions of services to trying to meet these needs.The Working Group was tasked with designing more agile and multi-sided combinations of synchronized care to these older people to create 'effects ladders' 8. It meant also designing a model where by information could flow from agency to agency at the right time via a care co-ordinator who collated 'situational awareness' 9. and 'integration' could emerge as a consequence rather than as a cause 10. Finally, and in terms of the consultative process, the forensic process was crucial to gaining insight into why previous reviews and good ideas for a similar approach to falls prevention had been 'killed off', as Boxer describes: through 'the cumulative effects ofmany small exclusions, micro-aggressions against forms of thinking and behaviour that are felt to be alien.' 11. This necessitated the unearthing of vested interests in the commissioner-provider relationship, and the intra- professional 'disclusion' 12 of patients.