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  1. OJIN Homepage
  2. Table of Contents
  3. Volume 2 - 1997
  4. Number 1: January 1997
  5. Care Management in the UK

A Consideration of the Nature of "Needs-Led Service": Within Care Management in the UK

  • Owen Barr, BSc (Hons), RGN, RNMH, CNMH, Ad. Dip. Ed
    Owen Barr, BSc (Hons), RGN, RNMH, CNMH, Ad. Dip. Ed

  • Lecturer in Nursing, Nursing - School of Health Sciences
    Lecturer in Nursing, Nursing - School of Health Sciences

    Owen Barr is a Lecturer in Nursing at the School of Health Sciences, University of Ulster, Colerain, N. Ireland. He is currently the option leader for the specialist post registration community learning disabilities nursing option with the Baccalaureate Professional Development in Nursing program. Within this program he teaches a 12-week module on Care Management (in the U.S. termed "Managed Care"). His research interests focus on services available to people with learning disabilities and their families. More specifically, he is interested in the involvement and empowerment of people with learning disabilities in the Care Management process.

Contents
Abstract

The purpose of this article is to discuss the "care management" (in the U.S. termed Managed Care) as it is implemented and practiced in Great Britain. Challenges to this needs-led service are discussed along with the responses to these challenges. Suggestions are made that would ensure a more client-focused implementation of care management.

Keywords: Decision Making, Needs Assessment; Managed Care Progs.; Patient Assessment; United Kingdom; Pt Centered Care

Introduction

CareManagement(intheU.S.termed"ManagedCare")washeraldedintheUKseveralyearsagoas"thecornerstoneofhighqualityservices"(DHSSl990p7).Newserviceswouldtargetthoseingreatestneedandchallengepractitionersto"acquireneeds-ledattitudesandapproaches"(SSI1991ap29).Theanticipatedbenefitsofcaremanagementincluded,"aneedsapproach,tailoringindividualservices,...acommitmenttoindividualcareplanningandspecificdesiredoutcomes...andanactivepartnershipinvolvingusersandcareersindeterminingservicesrequired."(SSI1991ap.13)

Priortotheimplementationofcaremanagementin1993muchdiscussiontookplaceonexactlywhat"needs-ledservice"meant.Aneeds-ledservice?Thefundamentaldifferencebetweenthetraditionalservicesandonewhichwastobeneeds-ledwasthepositionoftheclientsinrelationtothecareprocess.Intraditionalservicesthetaskwasseenasassessingclientsneedswithintheframeworkofservicesthatalreadyexisted.Theprioritywastouseexistingservices,i.e.,theexistingserviceswerethecentralfocusoftheapproach.Bycontrast,aneeds-ledserviceassessesaclient'sabilitiesindependentofserviceswhichalreadyexistandassesseswhetheradditionalservicesareneeded.Humphries(1992)reinforcedtheneedoftheservicestoadapttotheclient,insteadoftheclientadaptingtoservices.Insomeservicesthisgoalisfacilitatedbyhavingsomeonecompletetheassessmentwhowasnotaserviceprovider.Bycontrast,aneeds-ledserviceassessesaclient'sabilitiesindependentofserviceswhichalreadyexistandassesseswhetheradditionalservicesareneeded.Allneedsareidentified;thenitisconsiderediftheseneedscanbemetfromexistingservices,requirenewservicesorifitisnotcurrentlypossibletomeetthem.Ifnosuitableservicesareavailablefromwithinthemixedeconomyofcare,thenanunmetneedisrecorded.Theinformationonunmetneedsisthenusedtoplannewcontractsfromstatutoryorindependent(private/voluntary)serviceproviders.

McGrath(1991)recognizedthatitwouldtaketimetoevolvefrom"servicesled"provisionto"needs-ledprovision",andthatitwouldinvolveareorientationofseveralthings:delegatedauthority,teammembersroles,teammanagement,servicesdelivery,serviceco-ordinationandconsumerparticipation.Shemappedoutatransitionalstageintheevolutionaryprocesstoillustratehowdelegatedauthoritywouldbecometeamcenteredratherthancentrallycontrolled.Demarcationinteammembersroleswouldbecomeincreasinglyblurredwithlessownershipofspecifictasksbyspecificprofessionals.Jointassessmentswouldleadtoincreasedjointworkandaclearfocusontheindividualwithintheirfamilyandneighborhoodcontext.Thebiggestchangewasenvisagedinservicedelivery.Thischangewouldmovefromtheuseoflocalservicestotheeventualprovisionof""individuallytailored"packagesofcarewithmoreuseofindependentserviceproviders.McGrath(1991)sawincreasedco-ordinationduetogreaterappreciationoftheworkofcolleagues.Consumersandhealthcareprofessionalswouldgraduallybecomemoreactivelyinvolvedindiscussionsaboutthecaretobeprovideduntileventuallytheybecomecentraltothedecision-makingprocessandhaveaccesstoindependentrepresentation.

BrayeandPreston-Shoot(1995)emphasizedtheroleofclientcenteredobjectiveswhentheystate"...theobjectivesofinterventionbecometheoutcomestobeachievedratherthantheservicestobeprovided.Thepurpose(ofneeds-ledassessment)istoidentifytheendbeforefocusingonthemeans"(p156).Thereisageneralconsensusthataneeds-ledserviceispreferabletothetraditionalstyleofprovisioninwhichtherewasatendencytoviewclientsasrecipientstobecaredfor,ratherthanactivecollaboratorsinservices.FollowingaseriesofpilotprojectscaremanagementwasimplementedacrosstheUKon1stApril1993.Itwaswidelywelcomedasaninnovationincommunitycarepoliciesandaframeworkwhichwoulddeliveraneeds-ledservice.Forsomepeopleithasresultedinincreasedaccesstoflexibleservices.However,currentliteratureontheimplementationofcaremanagementhasraisedseveralkeychallengestothedevelopmentofneeds-ledservices.

ChallengestoaNeeds-LedService

Therearefourchallengestoa"needs-ledservice."Firstisthechallengeofdefinitionofneed.Muchoftheliteratureoncaremanagementtalksaboutneedsasifthereisanagreedunderstandingofthetermwhichisnotthecase.Bradshaw(1972citedbyBraye&Preston-Shoot,(1995),forexample,distinguishedbetweenfeltneed(feltbytheclient)andexpressedneed(expressedbytheclient).Heacceptedthatwhatisfeltmaynotalwaysbeexpressed,attimesduetoaperceptionofdisempowermentintheclient.Further,thecategoriesofprescribedneed(prescribedbyaprofessional),normativeneed(consideredwithinnormsforsociety)andcomparativeneed(theneedofoneindividualorgroupcomparedwithwhatisavailableelsewhere)havebeennoted.

Thecomplexityoftheconceptofneedisrecognizedincaremanagement(SSI1991b).Despitetheemphasison"acommitmenttoindividualcareplanningandspecificdesiredoutcomes...andanactivepartnershipinvolvingusersandcarers(supportpersons)indeterminingservicesrequired"(SSI1991ap13),needwasdefinedinofficialguidanceoncaremanagementas"therequirementsofindividualstoenablethemtoachieve,maintain,orrestoreanacceptablelevelofsocialindependenceasdefinedbytheparticularcareagencyorauthority"(originalemphasisinSSI1991bp14).

Thisdefinitionsuggestsasecondandrelatedchallenge,namelythatcaremanagementintheUKisdesignedaroundtheconceptofa"prescribed"needs-ledservices.Theclientthusmayremaindisempoweredinthecurrentcaremanagementapproach.Althoughtheirviewsmaybesought,thedecisionsaremadebytheprofessionals.Ifprofessionalsandresourcesavailable--ratherthantheclient--decideprioritiesoftreatment,aneeds-ledservicecanbecomea"resourceled"service.BrayeandPreston-Shoot(1995)arguethatrealityisthataneeds-ledservicewithinaprioritiesframeworkisaresourceledserviceindisguise.Ifprofessionalsandresourcesavailable--ratherthantheclient--decideprioritiesoftreatment,aneeds-ledservicecanbecomea"resourceled"serviceThisimageisdifferentfromtheprojectedimagethatoriginallywasputforth(SSI1991a).Somearguethatthecurrentimageisinconsistentwiththesentimentsoftheoverallcaremanagementapproach(Nolan&Caldock,1996).

Athirdchallengeinvolvesthestrategythatinfluencestheidentificationofclientneed,namelythecollectionofinformationaboutwhattheclientfeelshe/sheneeds.Oftentheprofessionalthendistinguishesbetweenwhatisa"realneed"andwhatisa"want,desire,orpreference."Onceagain,aresourcedrivenandprofessionaldeterminedserviceisdelivered.Althoughitisnecessarywithincaremanagementtoremainrealisticaboutwhatservicescanbeprovided,itisalsonecessarytonegotiatewithclients.Ifaclientstatestheirneedandthisneedisunmet,itgetsrecordedassuch.Disregardingsuchunmetneedsasunrealistic"wants,desiresorpreferences"restrictsinnovationandperpetuatespreviousservicestructures

Theprecedingchallengeshingeonthecontinuedunequalbalanceofpowerbetweentheclientandtheprofessionals.WolfensbergerandThomas(1994)highlightedtheunequalbalanceofpowerasamajordifficultyinthedevelopmentofcommunityservices.Theyassertedthatprofessionalsare"unrealisticallypridefuloftheirowncapacities,theirsupposedlyspecialistknowledge,educationandtraining...anddeeplydistrustfulofordinarycitizens,skepticalandpessimisticastowhatsuchcitizenscanandwilldo"(p53).Professionalsovervaluingoftheirownjudgementsandundervaluingofclientviewshasbeenreportedwithincaremanagementpractice(Richardson&Higgins,1993).Further,professionalsviewdisabilityasaphysicalentityonlywithoutconsiderationofthepsychologicalandsocialcomponentsofthedisability(SSI1995).

Astudyoncaremanagementforpeoplewithlearningdisabilitiesidentifiedafourthandimportantchallenge.Thisstudyconcludedthatassessmentisoftenrestrictedtoimmediateneedswithoutconsiderationoflongtermaspirationsandneeds.Peoplewithlearningdisabilitiesarenotassistedintakingpartinthedecision-makingprocess,andtheircarer'sneedsareoftenignored(Mencap,1995).Researchhasalsohighlightedtheinsensitivitytowardspeopleintheminoritywhileimplementinganeeds-ledservice.

RespondingtotheChallenges

Themajorchangeofferedbycaremanagementwasthegreateractiveinvolvementoftheclientinallstagesofthecareprocess.Centraltothischangedroleistheprovisionofinformation.Despitetheprioritygiventotheneedforinformation,thiscontinuestobeanareathatrequiresurgentattention.Publicityinformationaboutcaremanagementisoftenwrittenbyprofessionalsfortheircolleaguesanditcontainsinformationthatprofessionalsviewasnecessary.Someofthisinformationisofbenefittotheclient,butotherimportant(attimesunpalatable)informationaboutchargesforservices,limitedprioritiesbeingrespondedto,andthestricteligibilitycriteriaforservicesareoftenomitted.

Theinvolvementofpotentialclientsandfocusingofinformationtospecificclientgroupscouldhelprefinethecontentoftheinformationprovided.Substantialprogresshasbeenmadeintheproductionofinformationinavarietyoflanguagesandonaudiocassettes.Agapstillexistsintheproductionofinformationinpictorialformatforpeoplewithdifficultyintheuseoflanguage.

ResearchinaHealthandSocialServicesBoardAreainNorthernIrelandfoundthatdespiteamajormailingcampaignofinformationleafletsaboutcaremanagementtoallresidencesinthearea,only12%ofrespondentsrememberedreceivingtheinformation(SHSSC,1996).Thisfindingsuggeststhatothermethodsofdisseminationofinformationisnecessary.

Somethoughtmustgointothephysicalappearanceoftheleafletanditscontent,however,criticaltoitseffectivenessistheaccessibilityoftheleaflet.Leafletsmustbevisibleinfacilitieswhichareusedbythemembersofthegeneralpublicandaswellasspecifictargetingoffacilitiesusedbypotentialclients(peoplewhoareelderly,havementalhealthneeds,physicaldisabilitiesorlearningdisabilities).Whenpeoplehaveaccesstoinformation,moreeffectiveusecanbemadeofthevariousservicesduringassessment,planning,implementation,andevaluationofpackagesofcare.

Educationandsupportforstaffandclientsarealsonecessaryifaneeds-ledserviceistoprevailoveraservicethatrespondsonlytoprescribedneeds.Thisincludesin-serviceandpubliceducationaboutproceduralguidelines,aswellasacrucialchangeinphilosophy,adifferentpositionoftheclient(intermsofpower),partnershipactivitieswithclients,supervisionofcaseload,andpositiveconstructivefeedbackonprogress.

Onabroaderperspectiveservicestructuresmustconsidertheircontractsandhowthesecontractsmeetindividualneedsasopposedtowhatservicestheyprovide.Evaluationofserviceswithincaremanagementmustincludenotonlystructureandprocessmeasuresofservicequality,butalsoincludemeasuresofclientperceivedoutcomes.Clientsatisfactionandservicecoveragewillalsoprovideusefuldataforservicedevelopment(Evans,Felce,Hobbs,1991).Overallthereisaneedtorecognizethatneedsassessmentandneeds-ledservicesareaproductofpeople,resourcesandproceduresengagedina"socialandpoliticalprocess.Inthisprocesstherearedifferentandconflictingperceptionsthatmustbereconciledtoformamoreinformedpicture'ofneeds"(Ovretveit,1993p24).Asprofessionalsitisimportanttoremainawareofbiaswithintheprocess,services'objectives,andclientsaswellasourownbeliefs,behaviorsanddecisions.Fromthisbalancedperspectiveitwillbepossibletomovebeyonda"prescribedneeds-led"servicetoamoreusercentered"expressedneeds-led"service.

Author

OwenBarr,BSc(Hons),RGN,RNMH,CNMH,Ad.Dip.Ed

LecturerinNursing,Nursing-SchoolofHealthSciences
UniversityofUlster,N.Ireland
Jordanstown,N.Ireland

OwenBarrisaLecturerinNursingattheSchoolofHealthSciences,UniversityofUlster,Colerain,N.Ireland.HeiscurrentlytheoptionleaderforthespecialistpostregistrationcommunitylearningdisabilitiesnursingoptionwiththeBaccalaureateProfessionalDevelopmentinNursingprogram.Withinthisprogramheteachesa12-weekmoduleonCareManagement(intheU.S.termed"ManagedCare").Hisresearchinterestsfocusonservicesavailabletopeoplewithlearningdisabilitiesandtheirfamilies.Morespecifically,heisinterestedintheinvolvementandempowermentofpeoplewithlearningdisabilitiesintheCareManagementprocess.

EvaluatingServiceQuality.SCOVO.Cardiff,NorthernIreland.

HumphriesR.(1992).ChampionsofChange.CommunityCare940,24-25.

Mencap.(1995).Communitycare:Britain'sotherlottery.London:Mencap

McGrath,M.(1991).Multidisciplinaryteamwork.Aldershot:Avebury

Nolan,M.,&Caldock,K.(1996).Assessment:Identifyingbarrierstogoodpractice.HealthandSocialCareintheCommunity,4(2),77-85.

Ovretveit,J.(1993).Co-ordinatingcommunitycare.multidisciplinaryteamsandcaremanagement.Buckingham,UK:OpenUniversityPress.

Richardson,A,&Higgins,R.(1993).Implementingcaremanagement.SocialcareresearchfindingsNo.33.York,UK:JosephRowntreeFoundation.

SocialServicesInspectorate(1991a).Caremanagementandassessment:practitioners'guide.London:HMSO.

SocialServicesInspectorate(1991b).CareManagementandAssessment:Managers'Guide.London:HMSO.

SocialServicesInspectorate(1995).AMultidisciplinaryInspectionofAssessmentandCareManagementArrangements.Belfast,NorthernIreland:DHSS.

SouthernHealthandSocialServicesCouncil(1996).FromPolicyintoPractice.UserandCarerPerceptionsofCareManagement.Armaaugh,NorthernIreland:SHSSC.

Wolfensberger,W.,&Thomas,S.(1994).ObstaclesinprofessionalhumanservicesculturetotheimplementationofSocialRoleValorizationandcommunityintegrationofclients.CareinPlace.1(1),53-56.

©1997OnlineJournalofIssuesinNursing
ArticlepublishedJanuary6,1997

References

Braye, S., Preston-Shoot, M. (1995). Empowering practice in social care. Open University Press: Buckingham. Department of Health and Social Services. (1990). People First. Belfast, Northern Ireland: DHSS.

Department of Health and Social Sciences (1990). People first. Belfast, Northern Ireland: DHSS.

Humphries R. (1992). Champions of Change. Community Care 940, 24-25.

Mencap. (1995). Community care: Britain's other lottery. London: Mencap

McGrath, M. (1991). Multidisciplinary teamwork. Aldershot: Avebury

Nolan, M., & Caldock, K. (1996). Assessment: Identifying barriers to good practice. Health and Social Care in the Community, 4(2), 77-85.

Ovretveit, J. (1993). Co-ordinating community care. multidisciplinary teams and care management. Buckingham, UK: Open University Press.

Richardson, A, & Higgins, R. (1993). Implementing care management. Social care research findings No. 33. York, UK: Joseph Rowntree Foundation.

Social Services Inspectorate (1991a). Care management and assessment: practitioners' guide. London: HMSO.

Social Services Inspectorate (1991b). Care Management and Assessment: Managers' Guide. London: HMSO.

Social Services Inspectorate (1995). A Multidisciplinary Inspection of Assessment and Care Management Arrangements. Belfast, Northern Ireland: DHSS.

Southern Health and Social Services Council (1996). From Policy into Practice. User and Carer Perceptions of Care Management. Armaaugh, Northern Ireland: SHSSC.

Wolfensberger, W., & Thomas, S. (1994). Obstacles in professional human services culture to the implementation of Social Role Valorization and community integration of clients. Care in Place. 1(1), 53-56.

January 06, 1997

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Citation: Barr, O. (Janaury 6, 1997). "A Consideration of the Nature of "Needs-Led Service": Within Care Management in the UK." Online Journal of Issues in Nursing Vol. 2, No. 1, Manuscript 7. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol21997/No1Jan97/CareManagementintheUK.aspx

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