“Nobody disagrees with the concept of a case manager,” [Jeremy Hunt] said.
…don’t they? You sure about that?
For starters, the scheme is dead in the water unless the scope is widened to include social care agencies, whether statutory, voluntary or third sector. That care of the elderly, in particular, requires the co-ordinated efforts and inputs of health and social care is at least and at last accepted in theory, if all too often lacking – or indeed absent – in practice. Even up to the mid-Nineties you could meet a Social Services commissioner who would ask: “What’s Chronic Disease Management [as it was then known] to me; what am I to CDM? That’s changing leg dressings, that’s a matter for the District Nurses.” Similarly, health professionals would be resistant to receiving progress reports or alerts from Home Care workers who were not medically qualified.
If the Great Leap Forward of the ‘Single Assessment Process’ [NHS Plan 2001 – remember that or it?] achieved anything other than massive organisational disruption to deliver the blindingly obvious – talk to each other professionals! – it was in opening eyes to the mutually necessary contributions health and social care each made, not only to individual older people but also to respective organisations and systems; and their all-important purses. Road to Damascus moments did indeed occur as silo inhabitants suddenly got it that they hung together or were hanged apart.
So if this next GLF – this plucked from the manual of integrated care rather – notion is to be of any use whatsoever it cannot only be a matter for the NHS alone. But then, having accepted that, does the task become any easier; is it still incontrovertible that a ‘case manager’ is the thing to do – the big thing that will 1) work, 2) deliver what’s needed? It isn’t.
A ‘manager’ implies someone with authority to act and, where necessary, to instruct. A ‘case manager’, therefore, requires not only a skills set that may well be absent in a worker with specific but limited operational skills, but also an agreed role and function to command and control if needed.
A Community Nurse may well aspire to a hospital based re-enablement team completing their work before a consultant decides the older person recovering from a double lower limb amputation is medically fit for discharge home; a Social Worker may equally hope that the social housing agency has completed the necessary adaptations to that person’s home before they arrive, and that the GP has arranged for Community Nurse attendance, or that the Home Care agency has the capacity to provide a three times a day double-handed crew with specialist knowledge in the use of hoists and tracking. But neither can insist on it. Open communication between agencies, careful and negotiated planning between individuals, are both needed; but you simply cannot just put one person in charge and say “You’re the Case Manager. Get it sorted.” That way madness and a stampede for the door both lie.
Where there is an established pattern of services for an older person with a chronic, progressive disease or illness – for example, in dementia care – there may well be an existing and integrated team of health and social care professionals (a Dementia Resource Centre) who are the natural, go-to hub of both activity and oversight. Regular monitoring occurs and reviews can be held to assess the stability or otherwise of the placement, with agencies able jointly to consider adjusting or re-aligning their inputs in order to avert any potential or impending crises; though even here front-line workers are unlikely to empowered and authorised to agree changes without reference to line-managers.
But there are also many circumstances in which an older person, as any other, may need to travel down a health path with discrete, time-limited interventions. A suspected cancer diagnosis, for example, requires a progression from primary to secondary health services (general then specialist maybe), through perhaps surgical teams and on to other oncologists, rehab workers – physiotherapists, S&L therapists – counsellors, support groups, then on to social care agencies and back to primary care for pain management and review. Who within all of that is ideally – or even usefully – placed to be the ‘Case Manager’. The initially referring GP? The diagnostic or treatment specialists? The rehab workforce? No one but the GP will have been there from the onset, so unless they take on every case – yeah right! – there would need to be lead hand-overs to other disciplines over time, as and when they come to the fore.
But hang on a moment! Isn’t there one other person who is present throughout this or any other progress through the complex, inter-related yet not often speaking to each other, systems that comprise comprehensive care of the elderly? Why of course! It’s the older person themselves! Now there’s a scary novelty – put each person in charge of their own case; give them the authority to communicate and co-ordinate, to command and control.
You’ll never see that happen of course. The NHS would have an attack of the vapours, Social Services would faint clean away. But that’s what you would do isn’t it, if you could and if you had to? Would you leave it to ‘them’ to do it on your behalf? You would the one, and you wouldn’t the other.
Tell that to Jeremy Hunt. Someone should before he wastes everyone’s time and money coming up with grand schemes – with ‘delivery teams’ who meet every second Monday for something to do, and evangelical ‘champions’ who are always desperate to make eye contact in corridors – that are badged ‘Case Management’ to keep the policy wonks happy and management quiet, but which deliver little good or – more likely – simply more muddle, mess and mayhem.
I won’t say ‘if Jeremy Hunt thinks something’s a good idea, it isn’t’; but it’s a decent working rule of thumb, and a temptation harder to resist by the day.