National Service Frameworks - Essay Example

Running Head: national service frameworks Are national service frameworks and quality standards necessary for improving services, and is there any evidence that they are working? [Name of the writer] [Name of the institution] Are national service frameworks and quality standards necessary for improving services, and is there any evidence that they are working? Introduction One οf the main targets linked with Standard 4 (general hospital care) οf the National Service Framework for Older People (NSF) (Department οf Health 2001) is the development οf a multidisciplinary group that targets the needs οf aged people (Department οf Health 2003). Acute outreach services are already established in other clinical areas such as critical care, palliative care, acute pain management and cancer care, and there has been ongoing debate about the most appropriate ways to measure their clinical and organisational effectiveness (Hess 1999, Leary and Ridley 2003, Morgan and Lowler 2002, Robson 2002). However, neither the concept nor the implementation οf an acute-based, multidisciplinary older persons outreach and support team (OPOST) has been reported in the literature to date. The 2004 report, Better Health in Old Age, from the national director for older peoples health, provides an impressive range οf comments, with supporting evidence, on the success οf the National Service Framework for Older People (NSF) as seen through the eyes οf various stakeholders. This attractively presented document looks back over the three years since the launch οf the NSF and forward to a vision οf the future. Readers οf Nursing Older People may find it somewhat irritating that the image chosen for the cover is in stark contrast to their own experiences οf caring for older people. The photograph οf older people canoeing, and clearly enjoying it, on the reports cover may have encouraged some newspapers to adopt the theme οf taking responsibility for personal fitness as a spur to better health. Tai chi is an increasingly popular form οf exercise, suitable for many older people, and given the imminent publication οf the White Paper on public health it was no surprise that it was used as the focus, and to illustrate news reports. While adopting such a theme is undoubtedly a positive approach it may also mask many οf the other significant achievements. My chosen theme is climate change. Let me explain what I mean. The NSFs first standard is aimed at eliminating ageism and that must, in my view, start with the language and attitudes we use to express ourselves. We have all come a long way from the days when a report describing the pressures emerging as a result οf longer life expectancy, and the growth in the number οf older people experiencing mental health problems could be published with a title as pejorative as The Rising Tide (HMSO 1983). The health secretary, writing the foreword to the new report, states that the NSF has galvanised the NHS and social care ... and reduced ageist attitudes and practices. That tide is now irreversible.... So, by that measure, as far as Im concerned, ageism, if not defeated, is certainly in retreat. Its up to us to drive it out altogether. Before reporting progress in relation to the individual standards, the report highlights four principles that have underpinned the development οf the NSF: - person-centred care: providing a personalised response that gives respect and dignity to the older person - joined-up services: bridging the gap between hospital, home and wider community - timely response to needs: giving rapid access to services, following assessment, or in a crisis - promotion οf health and active life: aiming to prevent the onset οf illness. Looking back over the ten years to 1993, evidence is presented οf growing life expectancy, based on significant reductions in deaths resulting from cancer, strokes, coronary heart disease and even suicide among over-65s. This seems to support a number οf views: that medicine itself is becoming more effective; that earlier interventions are preventing the onset or seriousness οf some conditions; that individuals have assumed greater personal responsibility for their lifestyle; and finally that more older people are receiving treatment due to the removal οf age-related barriers. Statistics supporting specific claims relating to each area οf activity are clearly presented and it is difficult and probably undesirable to argue against them. But, when reporting that 70 per cent οf the country is covered by integrated community equipment services, or ICES, it has to be noted that in nearly one third οf the country people may wait too long for a good response to their needs — defying those underpinning principles οf timeliness, joined-up service and early intervention to support a continuing independent life. Returning to climate change, lets celebrate jobs well done — improved life expectancy and quality οf life, and the setting οf meaningful goals; expanding integrated services, building on successes that many readers will have been associated with — while seizing opportunities to champion the needs οf older people. This is where we must head, so that waiting times for hearing aids are reduced and access to foot care matches the needs οf weary feet! Background The OPOST is a new initiative, funded for one year (April 2003 to April 2004) as a result οf a successful bid to the Modernisation Agency. The funding secured did not support the implementation οf a full-time team so the structure was developed to buy out clinical time to provide both part-time sessional and full-time input, which consisted οf one whole-time equivalent (WTE) senior elderly care nurse, 0.8 WTE senior elderly care physiotherapist, 0.5 WTE occupational therapist, 0.3 WTE speech and language therapist and one WTE social worker. This core team was supported by two non-funded members: a consultant nurse for older people (the author) and a consultant geriatrician. The team worked across three directorates within the hospital — medicine, surgery and A&E — for a maximum οf 12 hours per week per directorate. The only full-time secondee was the social worker who did not start until August 2003. Other posts were supported by between one and five clinicians from the multidisciplinary team. When OPOST members were not engaged in OPOST activity they resumed their regular ward or department/trust-based activities. A proportion οf the funding was used to employ an audit facilitator for the duration οf the project, with a specific remit to undertake clinical audit using the OPOST operational standards in the directorates where OPOST provided a service. In line with the implementation οf Standard 4 οf the NSF, the overarching function οf the OPOST has been to improve the management οf the care οf older people within acute clinical settings. This core function is realised through a number οf key aims: - to improve the discharge planning process - to improve the clinical management οf older people through early identification οf potential/actual complications using a range οf multidisciplinary assessments - to reduce length οf stay associated with complications by working with clinical staff to plan and implement appropriate interventions - to identify and maximise rehabilitation potential wherever this is appropriate - to collaborate closely with other teams in order to reduce ward admissions from A&E, expedite timely and safe discharge from acute wards and follow up into the community whenever appropriate - to develop the skills οf clinically based staff in the management οf care οf the older person. A range οf objectives was developed to support the implementation οf the above aims along with a set οf operational standards. Service evaluation The OPOST has been subject to ongoing service evaluation which has used an illuminative evaluation approach (Parlett 1981, Parlett and Hamilton 1977). This methodology is well suited to evaluating new and innovative services because it facilitates various lines οf enquiry in order to build a picture from a number οf perspectives (Sloan and Watson 2001). The use οf illuminative evaluation is well established in the investigation οf curriculum developments in mainstream education. It has also found an application in the exploration οf nurse education from a number οf perspectives, ranging from academically based programmes and module evaluation to in-depth investigation οf new teaching and learning strategies as they apply to particular groups οf learners (Barber and Norman 1989, Crotty 1990). It has been used to explore academic/service partnership working in the provision οf continuing professional education (Ellis 2003) and, in addition, has been applied outside the academic context to examine the processes inherent both in clinical supervision (Sloan and Watson 2001) and professional development. The OPOST service has been evaluated from three perspectives: - the perceptions οf the members οf OPOST - the perceptions οf key stakeholders — personnel from the directorates in which OPOST operates (these were analysed from audio-taped interviews, using an adapted method οf thematic content analysis described by Chambers (1998) - the results οf audit which measured existing clinical standards οf care against the OPOST clinical operational standards. Organisational issues Establishing a new service in a large, complex organisation such as the NHS can be fraught with difficulty, especially when it involves new ways οf working and challenging existing practice. The perceptions οf both the OPOST members and the key stakeholders highlighted a number οf operational, organisational issues related to getting the OPOST service started and dealing with challenges and obstacles during the first few months. The terms used by team members to describe their experiences during this time reflect the feelings οf going into the unknown. For many team members this was the first time they had worked in this way, away from the elderly care unit, and it provided them with a unique and challenging undertaking. Having to deal with change can be very stressful (Merry 1995) and OPOST members struggled to articulate their new roles while many ward staff struggled to understand the concept and how it would work in practice. However, within a relatively short period, sound relationships had been built and understanding developed as a result. OPOST members initially spent a lot οf time explaining in detail the role and function οf the team and, by being flexible and accepting a wide range οf referrals, it soon became apparent where the efforts οf the team would be most effective. This was reflected in the case-mix profile that emerged from analysis οf the first 100 patients referred to and seen by OPOST (Table 1). These data show that there was a high complication rate (complications present on referral to OPOST) for this group οf patients, which would suggest that problems had already set in by the time referrals to OPOST were being made. In setting up the service there were clearly elements οf instability and unpredictability that appeared to be high initially, especially as a flexible and loosely structured approach was taken. However, the pattern οf patients referred and seen suggests that ward staff soon recognised that a rapid access, multidisciplinary team such as OPOST could support them in meeting the needs οf complex older patients. This move towards clarity and understanding reflects the strong relationships that were built up fairly rapidly from the outset οf the OPOST service becoming operational, and one οf the key features οf these relationships is that they are underpinned by positive feedback and reciprocity (Fox 1993). As well as having to manage negative responses to change, another issue raised was related to the sheer complexity οf the organisation. Because most οf the team members had not worked across the trust before but were directorate-based, it appeared to be a struggle for them to conceive how this vast network οf directorates, teams, units and individuals actually interacted and, more importantly, what would be the best way to establish clear lines οf communication with each directorate. This dilemma is one that has been experienced by a number οf peripatetic multidisciplinary teams in community and acute settings (Kesby 2002). Setting up communications was compounded to an extent by the way the OPOST service was organised, which was on a sessional, part-time basis. This had an impact within the team because they felt limited by not being able to provide a full-time service and by not having one central contact number. There was a need to be flexible and responsive and this resulted in a high degree οf creativity to meet the needs οf the clinical areas covered by OPOST with efforts directed towards improving communications and getting it right. The team changed the way the service was delivered in A&E, moving from a sessional service to bleep and run, where two οf the team members acted as contact points for the A&E department during core hours (Monday to Friday, 8am to 5pm). The team appeared to view improving communications as their responsibility and put a lot οf effort into clarifying the OPOST role, function and means οf access by giving referral guidelines as well as work-based updates that used case scenarios to illustrate the kinds οf interventions that clinical areas could expect. OPOST members used a variety οf strategies to improve communications depending on the needs οf different clinical areas — for example, taking advantage οf existing lines οf communication (such as ward/unit induction sessions or handover periods) was seen to be an effective way οf increasing awareness and understanding, as was responding to specific problems as they arose by having ad hoc question and answer sessions in ward areas. Team members and key stakeholders described the ways in which this consistent, repetitive approach to building understanding and improving communations started to pay dividends in terms οf better access to the service and increased understanding among ward staff about who to refer. It was also apparent that efforts had gone into raising the awareness οf OPOST among patients and relatives. This posed a real challenge because in the initial stages ward/unit staff were unable to articulate who or what the OPOST service really was and did not engage with the patients but simply made the referrals. The OPOST response to this was to use business cards giving each team members name and contact details. These were left with patients and/or their relatives or carers and it helped patients to recall who had visited them and for what purpose. The need to define and delimit roles, in most aspects οf life, is a recognisable social trait. Handy (1993) has described the characteristics οf increasing complexity as it is reflected in the number and varying remits οf the roles we occupy in society. The OPOST members who participated in this illuminative evaluation reported feelings indicative οf role conflict, ambiguity and, in some cases, overload. This may have been compounded by working to achieve team and, to an extent, organisational objectives, which were established before the team began to operate and evolve. This illustrates the difficulties faced by most teams operating in the NHS (Hurst et al 2002, Manley 2000). However, one οf the central themes emerging from the illuminative evaluation is the perception οf the multidisciplinary team as a supportive mechanism, in terms οf dealing with the initial stages οf change, learning from it and adapting to it (Boaden and Leaviss 2000). Multidisciplinary team-working Developing a team as the vehicle for active participation in an organisation has been described as a collective act οf will (Gorman 1998). A team is more than just a functional unit that brings individuals together to work towards a common set οf goals, and, during the emergent stages οf a team, the process itself is non-linear and chaotic (Marion 1999). The quality οf life in a team and the subsequent benefits to all aspects οf the organisation (in this case, to patients, staff and organisational structures and processes) are closely interwoven. The services they were able to deliver to patients is reflected in an activity review οf the first five months οf operation, which showed that οf the 220 patients seen by OPOST, all were given a complete review, comprehensive assessment and management plan. Fifty per cent received direct intervention from the OPOST physiotherapist; 22 per cent from the OPOST occupational therapist -10 per cent οf these were home visit assessments to facilitate discharge. Οf all the patients discharged back into the community (n=213) there were no failed discharges (these are defined as no re-admission to hospital within one week οf discharge). OPOST members and key stakeholders thought that one οf the keys to success in delivering a responsive service was having the time to provide individual care, which worked towards empowering the patients to achieve goals based on their needs and preferences. Delivering person-centred care Person-centred care for the older person, an approach to health care that focuses on individuals and their perceptions οf the situation they are in, has been explored in the literature in relation to practice-based educational and research developments (McCormack 2003, Wright and Titchen 2003) and approaches to practice development (McCormack and Garbett 2003, Wright and McCormack 2001). The core concepts underpinning these approaches to person-centred care are respect for, value οf and promotion οf personhood, and the development οf professional relationships, between professionals and the patients they care for, that are proactive in acting out person-centred care as part οf everyday practice. The results οf the audits showed the beginnings οf improvements in the areas οf risk assessment (nutrition, pressure injury, continence and falls) and discharge planning. These appeared to be associated with increased awareness οf the complex health and social care needs οf frail, older people and the need to invest time in assessing these needs with the patient and their family or carers in order to plan and effect a safe and timely discharge back into the community (Atwell 2002). Conclusion The initial stages in establishing the OPOST were challenging in terms οf managing change and satisfying in seeing the rapid development οf sound working relationships, good communications and person-centred care and positive outcomes for patients. 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