Sharing the burden, or the burden of sharing?
It is a truth universally acknowledged that a sharing of
information, and thus a continuum of care between the NHS and social
services, is a good thing. Policy pronouncements over recent years
in relation to mental illness, to the care of the elderly, and to
the care of children, have stressed the benefits that can flow from
integration of this kind, and — of more concern — some of the
disadvantages to patients caused when integration is not achieved.
As a conference recently organised by BJHC Limited shows, there is
very considerable interest in this topic, and ways in which it might
be achieved.
The objective, however, desirable though it may be, is one
fraught with considerable difficulty. Though they work side by side,
the Health Service and local government are two very different
animals. Healthcare is centrally funded. Despite the fact that a
high proportion of its funding also comes from central taxation,
local government levies local taxes for local ends, and in the
process is perhaps committed to a closer relationship with the local
electorate. In the past, some local authorities have made much about
their democratic base, and have decried what they regard as the
non-accountable nature of health authorities. And the differences
between the two types of organisation can be seen plainly in the
differing relationships between members and officers, and in the way
in which business is conducted and decisions are reached.
There are, therefore, some considerable barriers of culture and
custom to be tackled as the policy of integration is urged on. Nor
are these the only problems. Setting aside for the moment the host
of technical problems, a question that has to be addressed is the
degree to which integration could be usefully pursued. Would it, for
example, be valuable in caring for the elderly to have access not
only to social-services records but to other council records such as
housing benefit? Some local authorities may see integration within
their own services as being more immediately valuable than a link to
healthcare: for example, Hertfordshire County Council has recently
integrated that part of Social Services which deals with children
with the former education services. As — and in these
circumstances, if — integration with healthcare records proceeds
at some stage in the future, much thought will need to be given to
properly controlled access across not two, but three functional
boundaries.
None of this slightly gloomy analysis of the problem ahead should
be taken to say that it cannot be done. Northern Ireland has tackled
the problem by combining healthcare and social services under one
head. This course — one that on the face of it has much to commend
it — was positively rejected for England and Wales in 1974: local
authorities, already aggrieved at their loss of responsibility for
ambulance services and public healthcare, were strongly opposed to
yet another reduction in their spheres of influence. In recent years
however, it has been shown possible to create a joint authority that
goes some way towards removing the cultural and organisational
differences that make functional integration difficult.1,2
Equally encouraging, within the NHSIA’s recently completed
Electronic Record Development and Implementation Programme (ERDIP),
there are signs that the perceived benefit from integrated care
records can overcome organisational doubts — and in one case has
even secured a social services link to NHSnet.
Setting all these problems aside, however, there are still some
very considerable technical difficulties ahead that will require
determination and good will to overcome. In its first two articles,
this issue of the Journal looks at some of the preparatory
work that has been done in healthcare for the integration of
citizens’ integrated care records. Philip Crouch, the ERDIP
Programme Manager, and Glyn Johnson, the Evaluation Project Manager,
report on the main findings of the ERDIP projects that tackled the
practicalities of bringing together socialcare and healthcare
information cultures, systems and technologies. And Philip Firth,
IM&T Implementation Manager for Wrightington, Wigan and Leigh
NHS Trust sets out some of the most troublesome obstacles to
integration facing local implementation teams in the NHS for
England. Both articles emphasise similar elements of difficulty that
will have to be overcome. There are, of course, problems that are to
be expected — for example, those of confidentiality and
connectivity. In addition, however, there are others — such as
problems of language (client or patient), the use of the NHS number
as a common identifier and the absence of a common standard for
labelling data items across the two systems.
All this may seem to be setting a positively daunting agenda that
must be tackled if the integration necessary to achieve shared
healthcare is to be realised. Indeed it is: but the fact that work
is in hand to identify and to solve those problems is encouraging.
We must wish those undertaking this enormous task well.
Michael Fairey
References
1. Hayward R. Somerset’s development of an integrated
information system for mental health services: organisational
foundations. Br J Healthcare Comput Info Manage 2000; 17(1):
18–19.
2. Hayward R, Shuff C. Somerset’s development of an integrated
information system for mental health services. Br J Healthcare
Comput Info Manage 2002; 19(3): 18–19.
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