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With dispersed staff and a strong need for communication and control, community care is a natural environment for taking advantage of telematics. Yet the right commitment and attitudes are missing to make it effective. Why?
Currently, not all acute trusts may have got their IM&T act together but at least there is a growing realisation that more progress is needed. Yet acute trusts are comparatively centralised and it not generally too difficult to see what is going on. Travelling time between departments can usually be measured in minutes rather than in hours and, although it may not be very efficient to operate by shuffling around pieces of paper, at least acute trusts can demonstrably survive on this basis.
Effective use of resources needed
Travelling time between the various parts of community trusts, on the other hand, can be very substantial - because of distance or traffic conditions. Staff can be widely dispersed and working largely on their own with little physical contact with any permanent base. This creates a strong need for communication to both monitor and control field work activity. Here, control by physical movement of paper is not feasible if care is to keep pace with events on the ground. Some form of network-based controls are essential.
In an attempt to keep tabs on what is going on in the community, structures have been put in place to collect information in the form of minimum datasets on all activities. This often involves some travelling on the part of field workers to get access to information and to file their reports (sometimes after queuing to get access to a PC or workstation). Such data provides the basis for statistical returns but does little to address the issue of effective use of resources in the community.
Telematics - computers and telecommunications - have the ability not merely to record what is happening in community care but to transform the processes of delivery of care. This means attention has to be paid to the opportunities offered by telematics to make community care more effective. Good practice does not automatically come from finding out what people are actually doing but from directing what they should be doing to make best use of resources.
Order communication is key
If all the resources demanded of community care are matched against all the resources available, it is clear that there is a shortfall. This can either be reduced by putting more money into community care or by making existing activities more effective. The former is unlikely, the latter is essential, but not easy to achieve.
With the change of Government, emphasis on integration between community services and primary care has switched back to Health Authorities. Some smaller community trusts are now seeking either to amalgamate or return to the safe haven of a mixed acute/community environment.
In acute hospitals, the order communications system has been found to be the key to automating care processes and getting the best from the staff and other resources available. Order communication is not just a question of linkage. The system itself helps users specify requirements while at the same time providing subsidiary information. An obvious example is the way in which such a system can suggest standard order sets both to avoid excessive input and to ensure nothing is overlooked. Similarly, time is saved at the recipients end because instructions are unambiguous and accompanied with information that does not have to be repeated when results are returned.
Telematics at the core of community activities
A similar approach is needed in community care. Community workers are akin to service departments in acute hospitals. They need guidance on what to do, they need information to help them do it and they need help in recording what has been done. This does not restrict their own professional judgements on the work involved but does help ensure that requests for service are met in a timely fashion and results recorded.
Of necessity, community carers operate largely on their own with minimum supervision. What they actually spend their time doing has to be a balance between using their own judgement and being guided and helped centrally. Currently, the balance is light on the side of central co-ordination and control and heavy on the side of data collection and reporting. As a result, there is too much duplication of effort, too little information and too much administration.
Guidance from other sectors
Given their current degree of autonomy, it is not surprising that community workers are resistant to the whole idea of 'someone else scheduling' their time. Excessive data collection has also soured their outlook to the idea of more information in the system because it is equated with more 'paperwork'. In practice, however, community care has got to get to the point where telematics is not only a valuable part of their working life but the only way in which their activities are operated.
Models for this type of operation abound in other industry sectors. Assignment of peripatetic maintenance engineers, for example, is often carried out through network-based applications which schedule activities and record results and feedback. They also contain information, eg parts lists and maintenance manuals, which can be accessed by the engineer to help complete the task and provide for ordering of spares and scheduling of return appointments. Community workers may justifiably argue that they are not engineers, but in many respects their work is very similar (including not knowing what to expect when they arrive at the next case).
Currently there is deep concern in the community sector about the amount of time spent collecting activity information. The worry is not only the time that such activity takes away from delivering care, but also the fact that few see the results or benefits of all the information so collected. This not only gives data collection a bad name but also does nothing at all to help guarantee its accuracy. Indeed, the only return for which there is a universal interest in accurate and timely submission is personal expense claims.
Any talk of managing diaries, scheduling visits or controlling community staff is viewed with great suspicion and scepticism. There is also little enthusiasm for new technology and even less for using it to produce data of unknown value. As a result, the various aspects of community care go their own way in their own time and there is very little operational integration of activities or resources.
Some trusts are seeking to address this issue through procurement of new systems which offer integrated Community, Mental Health and Child Health facilities. But the real stumbling block is management's vision and determination to transform old ways of working. Excuses abound - most often in the form of financial constraints or lack of clear direction from the NHS Executive.
Support, not control
To overcome these problems, it may be that the vocabulary has to be changed. 'Orders' , 'controls' and 'schedules' are threatening terms and the systems rhetoric needs to be geared more towards 'support' for the community worker. If, for example, the bulk of activities can be defined in a systematic way (possibly through the use of standard order sets or protocols), then much of the reporting back can be simply in the form of yes/no responses to completion of the tasks. If, at the same time, all relevant information about the patient is made available, the carer feels more in control of the situation. Although, in practice, this is a form of ordering and scheduling of tasks, it begins to look more like support for the carer's activities and the chance to avoid hassle through lack of information or guidance.
How this type of activity can be achieved through technology is a matter that can be resolved once the will is there to operate this way. The current rush to provide hand-held terminals to community workers is one possible sign of progress. But what really matters is how the technology contributes to getting the work done more effectively. This can only come by using technology to change the processes and culture which currently exist in the community.
Failure to grasp this issue will only perpetuate ineffective use of community resources. In this context, money spent on proliferating handhelds without adequate central control infrastructure may be seen to be another case of IT diverting funds away from patient care.
First published in BJHC Oct 97
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