District nursing services and home care (and previously home help) services have a long history of disputed territory and responsibilities in the provision of care.
The 1990 NHS and Community Care Act, which legislated for greater co- ordination in the planning and provision of care for people in their own homes, allowed for local negotiation about responsibilities and funding in areas where the distinction between health and social care may be blurred.
As the Royal Commission on Long-Term Care pointed out, personal care - care that directly involves touching a person - has become the main source of contention in the debate about the distinction between health and social care. Local negotiation became epitomised by the question: 'When is it a social bath and when is it a health bath?'
But personal care encompasses more than bathing, and many authorities used a task list, devised in the implementation phase of the act, to inform their local negotiations. This included washing, dressing, grooming, feeding, going to the toilet, and the giving and taking of medicines.
The definitions and boundary issues are important for three reasons. The first is whether personal care (and all that entails in relation to issues of intimacy, privacy, dignity, and confidentiality) would be provided by or under the daily supervision of a qualified nurse or by another type of carer. The second aspect is that the definitions are likely to affect the number of different carers entering the client's home and the daily pattern of care. The third aspect is that personal care identified as the health service's responsibility is free at the point of delivery, while the local authority would undertake a financial assessment and may charge the person for the service.
An agreement was drawn up between the London boroughs of Camden and Islington, Camden and Islington community trust and Camden and Islington health authority.
The home care/district nursing joint operational policy was implemented in 1996 and launched with joint training sessions. Using a literature search and telephone enquires to a sample of district nursing services across England, we identified only one other similar written agreement, which was between authorities in Birmingham.
The Camden and Islington operational policy provided:
a process for deciding the funding responsibility for personal care activities;
criteria for this decision, based on the medical condition of the person and the objectives of the nursing care;
joint guidelines on the responsibility of each service in different personal care activities - for example, when the local authority was responsible for personal care, home care activities could include application of eye drops not linked to recent surgery.
Evaluating the new system
The policy had been in place for 18 months when an evaluation was commissioned. This included six group interviews involving 50 people, the purpose being to discover the views of care managers, district nurses and home care managers.
In order to clarify their different perspectives and identify any variation between boroughs, each group represented only one discipline in one borough: a group interview was held for district nurses in Islington separate from those in Camden.
The existence of a written policy was viewed by all groups as beneficial. There was a clear view that it was in need of amendment in the light of the experience amassed from putting the policy into practice, rather than radical overhaul. The areas where a need for improvements was identified fell into broad categories:
Communication and information;
Reaching the whole care system;
Balancing consistency and flexibility;
The division between health and social care;
The imperative of improving communication.
The need for better communication and better quality and dissemination of relevant information was by far the greatest concern of all groups in the study. A sound joint operational policy was generally viewed as a positive foundation, but good personal communication was seen as equally necessary, not least because the complex situation of many clients did not fit into neat categories, however clear the policy might be.
Each of the group interviews devoted considerable time to discussing communications issues, and prioritised communications among their major concerns.
Having different groups of staff working in the same office or building was seen as very beneficial in facilitating communication and working relationships. There was considerable agreement from all parties that good working relationships between individuals were as necessary as good communications systems.
Almost all the group interviews identified continuing training as an important issue, and it was clear that many participants had a sophisticated view of what training could and should offer. Training was not viewed as a simple, didactic process, but as a way of encouraging and enabling different groups of staff to get to know one another and to facilitate a greater understanding of their respective roles and the pressures on them.
Reaching the whole care system
This set of issues related to the dual challenge of the whole care system being both reflected in the inter-agency policy and its content being absorbed by all the individuals in that whole system. There was a consensus in the groups that awareness of the policy and the detail of its provision was patchy. The highest level of concern about inadequate knowledge of the joint operational policy was directed at hospital staff, who were involved in discharging patients home.
Care managers and district nurses in particular commented on the lack of knowledge among GPs and therapists of the policy.
The care managers in both boroughs identified the lack of detail in the policy relating to its place in the wider borough systems of community care assessments and plans. Issues such as monitoring processes were not included in the policy. The district nurses in particular commented on the lack of visible monitoring of home care through independent agencies.
Balancing consistency and flexibility
The group interviews revealed an interesting tension between the need for a policy that is clear and explicit on the one hand, while allowing room for judgement and flexibility on the other hand.
Most of the problems raised about consistency related to a perception that differences in interpretation of the policy were not needs-led, but a reflection of some more arbitrary factors.
The care managers and home care managers thought that use of the policy in determining roles and duties was inconsistent between district nurses.
Since the joint home care/district nursing policy is about caring, the reality is that it is not possible for a single policy to give infallible guidance to cover every situation. In fact, all staff have to work along a continuum, with the balance between following guidelines and exercising personal judgement varying in different circumstances.
Much has been written about the collaboration between health and social care professionals, including knowledge of each other, occupational cultures and work practices.
In our group interviews we identified many signs of a sensitive understanding of the pressures and high levels of demand experienced by the other groups of staff. But we also observed that negotiating over the division in personal care placed individual staff in almost adversarial relationships. This was reflected in care manager comments that district nurses were reluctant to take cases on, and 'push them to home care'. But equally, some district nurses identified 'dumping' - pushing cases between agencies - as one of the issues that most concerned them.
In addition, care managers in both boroughs thought district nurses did not fully understand their role in commissioning care as opposed to providing care.
The policy provides a concrete and rarely documented example of partnership working. Central government policy continues to promote the development of closer working relationships between health and local authorities through many mechanisms, including joint investment plans, health improvement plans and health action zones.
The discussion paper New Opportunities for Joint Working between Health and Social Services offers possibilities of new flexibility through pooled budgets, lead commissioning and integrated provision. The landscape for partnership and joint working is set to shift between health and social care, and the findings from this evaluation may help inform the development of further joint working initiatives.
Most striking is that, irrespective of the partnership in a written policy, the imperative for the professionals and service providers closest to the clients is to establish good working relationships and systematic methods of communicating with each other. A dynamic process of joint learning is seen as one method of supporting this. Trying to reflect whole-care systems in cross-agency protocols is both necessary but challenging - not least from the perspective of frontline staff who feel they are drowning in paper.
Finally, the central policy division of responsibility in personal care has created adversarial relationships rather than collaborative ones. The Royal Commission on Long-Term Care has suggested that all personal care is the responsibility of the health service - such a definition from central government would certainly reduce the potential for dispute among professionals and the anxieties of people receiving care.
Vari Drennan is senior lecturer in primary care, health policy evaluation unit, Royal Free and University College Medical School, London. Ros Levenson is a freelance research associate.
A written agreement on responsibilities for home care between local authorities, a health authority and a community trust has been welcomed by staff affected.
But staff believe a written agreement is no substitute for good personal communication between different groups.
Staff taking part in an evaluation of the agreement expressed concern at elderly people refusing help because of charging.
1 Command 849. Caring for People: community care in the next decade and beyond. HMSO, 1989.
2 National Association of Health Authorities and Trusts, and West Midlands RHA. Care in the community: definitions of health and social care, research paper five. NAHAT, 1992.
3 The Wavy Line: home care and community nursing working together. Birmingham city council social services department, Birmingham health authority and trusts. 1994
4 Moore C. Group techniques for idea building. Sage Newbury Park, 1987.
5 Department of Health. Partnership in Action (new opportunities for joint working between health and social services). A discussion document. DoH, 1998