Some years ago I was asked to speak to the need for and advantages of ‘seamless services’: it was the time that fragmentation was beginning to threaten continuity of support for individuals and families with on-going needs. The situation has developed on from there – unravelled you might say.
The picture I explored in my talk was of pieces of material rather than individual strands because people’s needs are not one dimensional. Even two dimensions are not enough to represent them in their breath, complexity, interaction and change over time. First thoughts were about health care and social care – provided then by different authorities. Would ‘seamless’, as in the fine materials of my best suit, be a good model? Not really – If you pull hard on that sort of seam, it is likely to separate. We demonstrated that at the Royal College of Physicians! Mesmer might have approved.
A sounder seam has overlap for strength and security, at the price of elegance – So the seams of Levi jeans were brought forward – And they stood the test. There are lessons here.
The setting now is one of multiple patches with edges both within health and social care as well across health and social care. A patchwork of activities, with each patch wishing to define its limits of responsibility – inclusion and exclusion criteria – determining payment even when the needs of individuals and families go unresolved.
I have been bewildered to find that the most common avenue to admission to a mental health bed is via an A and E department of a general hospital. This week I am reading about there being more and more people with dementia being ‘dumped’ in general hospitals by families exhausted and frustrated at the lack of consistent, flexible support in the community. It was the case before the creation of the NHS that hospitals in towns and cities were the only place for poor people to obtain help when in difficulty – for they could not afford the fees of private doctors. It feels as though we have drifted back to those brutal times.
There is strength when individuals, families, professional agencies and voluntary organisations work together to an agreed and comprehensive plan. We saw that in early psychogeriatric services. We saw it certainly again in the Gnosall model of care, and we see it when hospices reach out. It is an old lesson but sound. A and E should be for occasional problems which fall outside what we can reasonably plan for – a safety net. It cannot function effectively or economically or humanely as the main channel of access for people who have predictable and preventable needs.
Togetherness is a function of more than numbers – It requires shape across several dimensions.