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.
Key Words: Decision Making, Needs Assessment; Managed Care Progs.; Patient Assessment; United Kingdom; Pt Centered Care
Care Management (in the U. S. termed "Managed Care ") was heralded in the UK several years ago as "the cornerstone of high quality services" (DHSS l990 p7). New services would target those in greatest need and challenge practitioners to "acquire needs-led attitudes and approaches" (SSI 1991a p 29). The anticipated benefits of care management included, "a needs approach, tailoring individual services, . . . a commitment to individual care planning and specific desired outcomes . . . and an active partnership involving users and careers in determining services required." (SSI 1991a p. 13)
Prior to the implementation of care management in 1993 much discussion took place on exactly what "needs-led service" meant. A needs-led service? The fundamental difference between the traditional services and one which was to be needs-led was the position of the clients in relation to the care process. In traditional services the task was seen as assessing clients needs within the framework of services that already existed. The priority was to use existing services, i.e., the existing services were the central focus of the approach. By contrast, a needs-led service assesses a client's abilities independent of services which already exist and assesses whether additional services are needed. Humphries (1992) reinforced the need of the services to adapt to the client, instead of the client adapting to services. In some services this goal is facilitated by having someone complete the assessment who was not a service provider.
By contrast, a needs-led service assesses a client's abilities independent of services which already exist and assesses whether additional services are needed.
All needs are identified; then it is considered if these needs can be met from existing services, require new services or if it is not currently possible to meet them. If no suitable services are available from within the mixed economy of care, then an unmet need is recorded. The information on unmet needs is then used to plan new contracts from statutory or independent (private / voluntary) service providers.
McGrath (1991) recognized that it would take time to evolve from "services led" provision to "needs-led provision", and that it would involve a reorientation of several things: delegated authority, team members roles, team management, services delivery, service co-ordination and consumer participation. She mapped out a transitional stage in the evolutionary process to illustrate how delegated authority would become team centered rather than centrally controlled. Demarcation in team members roles would become increasingly blurred with less ownership of specific tasks by specific professionals. Joint assessments would lead to increased joint work and a clear focus on the individual within their family and neighborhood context. The biggest change was envisaged in service delivery. This change would move from the use of local services to the eventual provision of ""individually tailored" packages of care with more use of independent service providers. McGrath (1991) saw increased co-ordination due to greater appreciation of the work of colleagues. Consumers and health care professionals would gradually become more actively involved in discussions about the care to be provided until eventually they become central to the decision-making process and have access to independent representation.
Braye and Preston-Shoot (1995) emphasized the role of client centered objectives when they state ". . . the objectives of intervention become the outcomes to be achieved rather than the services to be provided. The purpose (of needs-led assessment) is to identify the end before focusing on the means" (p 156). There is a general consensus that a needs-led service is preferable to the traditional style of provision in which there was a tendency to view clients as recipients to be cared for, rather than active collaborators in services. Following a series of pilot projects care management was implemented across the UK on 1st April 1993. It was widely welcomed as an innovation in community care policies and a framework which would deliver a needs-led service. For some people it has resulted in increased access to flexible services. However, current literature on the implementation of care management has raised several key challenges to the development of needs-led services.
Challenges to a Needs-Led Service
There are four challenges to a "needs-led service." First is the challenge of definition of need. Much of the literature on care management talks about needs as if there is an agreed understanding of the term which is not the case. Bradshaw (1972 cited by Braye & Preston-Shoot, (1995), for example, distinguished between felt need (felt by the client) and expressed need (expressed by the client). He accepted that what is felt may not always be expressed, at times due to a perception of disempowerment in the client. Further, the categories of prescribed need (prescribed by a professional), normative need (considered within norms for society) and comparative need (the need of one individual or group compared with what is available elsewhere) have been noted.
The complexity of the concept of need is recognized in care management (SSI 1991b). Despite the emphasis on "a commitment to individual care planning and specific desired outcomes . . . and an active partnership involving users and carers (support persons) in determining services required" (SSI 1991a p13), need was defined in official guidance on care management as "the requirements of individuals to enable them to achieve, maintain, or restore an acceptable level of social independence as defined by the particular care agency or authority" (original emphasis in SSI 1991b p14).
This definition suggests a second and related challenge, namely that care management in the UK is designed around the concept of a "prescribed" needs-led services. The client thus may remain disempowered in the current care management approach. Although their views may be sought, the decisions are made by the professionals. If professionals and resources available -- rather than the client -- decide priorities of treatment, a needs-led service can become a "resource led" service. Braye and Preston-Shoot (1995) argue that reality is that a needs-led service within a priorities framework is a resource led service in disguise.
If professionals and resources available -- rather than the client -- decide priorities of treatment, a needs-led service can become a "resource led" service
This image is different from the projected image that originally was put forth (SSI 1991a). Some argue that the current image is inconsistent with the sentiments of the overall care management approach (Nolan & Caldock, 1996).
A third challenge involves the strategy that influences the identification of client need, namely the collection of information about what the client feels he/she needs. Often the professional then distinguishes between what is a "real need" and what is a "want, desire, or preference." Once again, a resource driven and professional determined service is delivered. Although it is necessary within care management to remain realistic about what services can be provided, it is also necessary to negotiate with clients. If a client states their need and this need is unmet, it gets recorded as such. Disregarding such unmet needs as unrealistic "wants, desires or preferences" restricts innovation and perpetuates previous service structures
The preceding challenges hinge on the continued unequal balance of power between the client and the professionals. Wolfensberger and Thomas (1994) highlighted the unequal balance of power as a major difficulty in the development of community services. They asserted that professionals are "unrealistically prideful of their own capacities, their supposedly specialist knowledge, education and training . . . and deeply distrustful of ordinary citizens, skeptical and pessimistic as to what such citizens can and will do" (p53). Professionals over valuing of their own judgements and under valuing of client views has been reported within care management practice (Richardson & Higgins, 1993). Further, professionals view disability as a physical entity only without consideration of the psychological and social components of the disability (SSI 1995).
A study on care management for people with learning disabilities identified a fourth and important challenge. This study concluded that assessment is often restricted to immediate needs without consideration of long term aspirations and needs. People with learning disabilities are not assisted in taking part in the decision-making process, and their carer's needs are often ignored ( Mencap, 1995). Research has also highlighted the insensitivity towards people in the minority while implementing a needs-led service.
Responding to the Challenges
The major change offered by care management was the greater active involvement of the client in all stages of the care process. Central to this changed role is the provision of information. Despite the priority given to the need for information, this continues to be an area that requires urgent attention. Publicity information about care management is often written by professionals for their colleagues and it contains information that professionals view as necessary. Some of this information is of benefit to the client, but other important (at times unpalatable) information about charges for services, limited priorities being responded to, and the strict eligibility criteria for services are often omitted.
The involvement of potential clients and focusing of information to specific client groups could help refine the content of the information provided. Substantial progress has been made in the production of information in a variety of languages and on audio cassettes. A gap still exists in the production of information in pictorial format for people with difficulty in the use of language.
Research in a Health and Social Services Board Area in Northern Ireland found that despite a major mailing campaign of information leaflets about care management to all residences in the area, only 12% of respondents remembered receiving the information (SHSSC, 1996). This finding suggests that other methods of dissemination of information is necessary.
Some thought must go into the physical appearance of the leaflet and its content, however, critical to its effectiveness is the accessibility of the leaflet. Leaflets must be visible in facilities which are used by the members of the general public and as well as specific targeting of facilities used by potential clients (people who are elderly, have mental health needs, physical disabilities or learning disabilities). When people have access to information, more effective use can be made of the various services during assessment, planning, implementation, and evaluation of packages of care.
Education and support for staff and clients are also necessary if a needs-led service is to prevail over a service that responds only to prescribed needs. This includes in-service and public education about procedural guidelines, as well as a crucial change in philosophy, a different position of the client (in terms of power), partnership activities with clients, supervision of caseload, and positive constructive feedback on progress.
On a broader perspective service structures must consider their contracts and how these contracts meet individual needs as opposed to what services they provide. Evaluation of services within care management must include not only structure and process measures of service quality, but also include measures of client perceived outcomes. Client satisfaction and service coverage will also provide useful data for service development (Evans, Felce, Hobbs, 1991). Overall there is a need to recognize that needs assessment and needs-led services are a product of people, resources and procedures engaged in a "social and political process. In this process there are different and conflicting perceptions that must be reconciled to form a more informed picture' of needs" (Ovretveit, 1993 p24). As professionals it is important to remain aware of bias within the process, services' objectives, and clients as well as our own beliefs, behaviors and decisions. From this balanced perspective it will be possible to move beyond a "prescribed needs-led" service to a more user centered "expressed needs-led" service.
Lecturer in Nursing, Nursing - School of Health Sciences
University of Ulster, N. Ireland
Jordanstown, N. Ireland
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.
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