Multidisciplinary Case Conference; Fulcrum, Fudge, or Fix? Dr Stephen
Fowlie, MD, MRCP
Mr Peter Perman-Howe
Department of Clinical Geratology, Radcliffe Infirmary, Oxford OX2 6HE and Oxfordshire County Council Social Services Department
INTRODUCTION The multidisciplinary case conference (MCC) has assumed an almost mythical role in the care of elderly people, both in hospital and in the community. As a forum for sharing information and for developing strategies for individual patients and services, MCCs seem a logical approach given that several disciplines and diverse agencies are frequently required for treatment, rehabilitation and social support (Challis and Davies, 1986). The DHSS acknowledges that effective cooperation in community care depends largely on collaboration between staff on the ground, much less on organisational structure (Caring for People, 1989). Much has been written of the team dynamics in MCCs, and of the leadership skills upon which they depend and by which they are influenced. However surprisingly little attention has been paid to the impact of developments in the provision and delivery of health and social services on the function of multidisciplinary teams. Most professionals will be aware of the strains which resource limitation and structural change can bring to the day-to-day relationships within (and between) such groups.
POTENTIAL CONFLICTS Different disciplines, different approaches , Several potential sources of conflict are inherent in the values
approaches professionals of different disciplines bring to multidisciplinary interaction. That between the prosthetic tradition of social services (Greengross and Greengross, 1989) and the therapeutic paradigm of the emergent geriatric medicine speciality has long been recognised (in theory if not in practice). This conflict has been exacerbated by a continuing difference of approach within the medical profession itself - where ageism is often accompanied by therapeutic nihilism, and paternalistic prosthetic intervention is seen as most appropriate. The dominant social services response in services such as home care has always been prosthetic. Despite increasing recognition that change is as important an activity in social work as care and control, departments have continued to view elderly people mainly as receivers of services. Attempts to dethrone prosthetic paternalism are unlikely to be helped by multiagency provision. A further conflict arises in the pluripotential nature of MCC deliberation, and may be brought into still sharper focus by the structural changes occurring in the health and social services. Case (or care) management, soon to be central to the provision and
of services for elderly people, springs from a coalition between the medical tradition (case patient) and that of managers who are accountable to a system (rather than to a client). Case managers will have to struggle with this dichotomy (as increasingly do doctors) and with a complexity of roles within MCC which inevitably provokes conflict (Challis and Davies, 1986). =
Assessment, co-ordination, andadvocacyareparticularlyimportant. Needs or Service Orientated True multidisciplinary assessment is rare and service provision is often service orientated rather than based firmly on the needs of the client. The purchaser-provider split envisaged by ’Caring for People’ (Caring for People, 1989) is designed in part to encourage needs-based assessment, and the incorporation of some of the elements from the Kent Community Care Scheme is a laudable effort to make the services fit the client rather than vice-versa. But case managers will be expected to obtain appropriate services for the client largely from apool ofavailable (funded) services, designated as appropriate by and for the system. This assumes that the system is aware of the real needs of clients, and prepared to meet these needs. In reality in the ’free market’ agencies provide what they can sell; clients either fit their bill (literally and metaphorically) or are not offered the service. Only if the case manager has power to direct the operations of agencies, and contribute to defining problems, priorities, and appropriate levels ofprovision will comprehensive packages ofcare relevant to the individual be explored. Otherwise the impotent manager has little hope of producing services tailored to the individual needs of the client, and those with
’special’ needs may be marginalised. ’Designer care packages’, just like designer clothes, are likely to be more expensive than bulk buys. Financial constraints and uncertain future funding further restrict the choice available to the manager; the system is likely to become ever more complex as the number of agencies involved multiplies. Experience suggests that co-ordination of services from provider agencies is difficult, and that the results often fall short of expectation (Babbington and Charnley, 1990; Warren et al, 1974), particularly when new structures are introduced. This will be compounded if case managers are charged with the dual responsibilities of assessment of need and of balancing budgets; hopefully responsibility for rationing scarce resources will be held
at a
different level in the system. The alternative of
245 Downloaded from rsh.sagepub.com at NORTH DAKOTA STATE UNIV LIB on May 26, 2015
-’---------.--~-’._&dquo;.’_._---_._--~--’-’-’-_._.--.&dquo;...’._--~....--.---
delegating budgets to patients or clients is flawed : power does not (and should not) automatically arise from financial muscle, and problems of even greater exploitation may arise.
health, poverty, poor housing, poor education etc. How ~
....
can
these issues be
approached by members
of
multidisciplinary teams;
Issues of advocacy Within the MCC the coordinating and facilitating role is often accorded supreme importance and conflict may be produced when this clashes with issues of advocacy. As an advocate the case manager does not necessarily acknowledge the appropriateness of current services. Rather he/she examines the agencies and their services from the stand point of the clients’ social needs. An advocate will wish to engage in a dialogue with the client (and others involved) not merely to facilitate plans for the client, but to consider options with the client. However it is easier to do things for the client while maintaining a facade of advocacy - more comfortable, more certain, and more rewarding. This is particularly true if the MCC reinforces the imperative of co-ordination and facilitation over advocacy, as so often happens, especially in discharge planning and where the team is working under pressures of resource, personnel, or financial restriction. In such circumstances the team structure supports the primacy ofproblem solving over problem posing, though (paradoxically) this may reduce the clients’ control over aspects of daily life, and undermine their autonomy. The team imposes its view on the client and assumes that the available service agencies are appropriate. This ’constitutes a conspiracy of legitimated manipulation and self interest’ (Rose and Black,1985). This may be particularly important for the case manager where the advocacy role extends beyond discharge into the community in a much sharper way than do the roles and responsibilities of other team members. Team members may set up small cabals to by-pass the full team - in hospital work this is often doctors and nurses (common to all patients from the point of admission) failing to involve ’optional’ team members. This often leads to resentment and lack of trust even if done with the best of intentions. These conflicts are likely to be highlighted in the brave new world of resource management and ’community care’. Yet advocacy functions become ever more important in circumstances where care is ’privatised’. As Rose and Black (1985) have commented (with regard to community programmes for the mentally ill but of equal relevance here) ’the central force is profit - extraction of private benefit from poor and relatively powerless people’. The advocate must strike a delicate balance between over provision of care and unmet need. There is a danger that an unlikely alliance could develop between the for-profit sector and care managers schooled in theprosthetic tradition, who may be unwilling to acknowledge that the starting point for care provision must be need rather than client preference or wish. In this era of citizens charters and consumerism it is important that both clients and care providers agree that there are limits to the promotion of autonomy. Citizens have obligations as well as rights. When issues ofduties and rights are decided on an ad hoc basis those who come off worst are usually precisely those individuals already disadvantaged by ill-
_
~
~
~
~
insist on the imperative of patient/client should include the patient; most Discussions autonomy. services pay lip-service to this ideal in routine practice. The formulated team position is delivered to the patient/client for comment (the advocacy facade) but this clearly places the individual at great disadvantage: passive acquiescence may be the response to circumstances in which all ones’ perceived needs are controlled (ifnotmet) by outside agencies. Patient/ client choice and not organisational expediency must be the key to service delivery. Confidentiality must be safeguarded. This is no less an issue with elderly people, yet it receives little attention and information may be disseminated around many agencies and individuals. I The MCC must acknowledge the imperative of advocacy in the role of case managers and devise strategies to incorporate this as a strength rather than attempt to marginalise or diminish this role. The team must together coordinate what is being advocated rather than advocate what is being coordinated. It is generally unsatisfactory to attempt to separate the advocacy and coordinating roles - it merely shifts the focus of the likely conflict within the team. Leadership style may play a particularly important part where resource limitations (eg hospital beds) exist. Case managers and those who seek to lead MCCs must be aware of the complex nature of these inter-organisational dynamics and the way in which the forces can control their clients’/patients’ lives.
The
team must
Thevariousagenciesinvolvedincareofelderlypeopleshould agree common denominators which recognise individual roles and responsibilities but facilitate their integration.
Organisational fragmentation renders appropriate, effective ,
management impossible. The introduction of ’community care’ case
strategies for elderly people represents a great opportunity to restate the fundamental concerns and ethos of multidisciplinary team working. But this requires greater recognition of the difficulties we are likely to encounter, a willingness to challenge current practice and awareness of the potential positive aspects of conflict. m - x - ., - - - - -
References
BEBBINGTON A and CHARNLEY H (1990). Community Rhetoric and Reality. Br J Social Wk; 20: 409-432 Caring for people: community care in the next decade and beyond (1989). London: HMSO CHALLIS D and DAVIES B (1986). Case management in community care. Aldershot: Gower GREENGROSS W and GREENGROSS S (1989). Living, Loving and Ageing. London: Age Concern ROSE S M and BLACK B (1985). Advocacy and Empowerment. Boston: Routledge and Kegan Paul WARREN R L, ROSES S and BERGUNDER A (1974). The Structure of Urban Reform, Lexington, Mass. DC Health and Co
246 Downloaded from rsh.sagepub.com at NORTH DAKOTA STATE UNIV LIB on May 26, 2015
Fowlie, MD, MRCP
Mr Peter Perman-Howe
Department of Clinical Geratology, Radcliffe Infirmary, Oxford OX2 6HE and Oxfordshire County Council Social Services Department
INTRODUCTION The multidisciplinary case conference (MCC) has assumed an almost mythical role in the care of elderly people, both in hospital and in the community. As a forum for sharing information and for developing strategies for individual patients and services, MCCs seem a logical approach given that several disciplines and diverse agencies are frequently required for treatment, rehabilitation and social support (Challis and Davies, 1986). The DHSS acknowledges that effective cooperation in community care depends largely on collaboration between staff on the ground, much less on organisational structure (Caring for People, 1989). Much has been written of the team dynamics in MCCs, and of the leadership skills upon which they depend and by which they are influenced. However surprisingly little attention has been paid to the impact of developments in the provision and delivery of health and social services on the function of multidisciplinary teams. Most professionals will be aware of the strains which resource limitation and structural change can bring to the day-to-day relationships within (and between) such groups.
POTENTIAL CONFLICTS Different disciplines, different approaches , Several potential sources of conflict are inherent in the values
approaches professionals of different disciplines bring to multidisciplinary interaction. That between the prosthetic tradition of social services (Greengross and Greengross, 1989) and the therapeutic paradigm of the emergent geriatric medicine speciality has long been recognised (in theory if not in practice). This conflict has been exacerbated by a continuing difference of approach within the medical profession itself - where ageism is often accompanied by therapeutic nihilism, and paternalistic prosthetic intervention is seen as most appropriate. The dominant social services response in services such as home care has always been prosthetic. Despite increasing recognition that change is as important an activity in social work as care and control, departments have continued to view elderly people mainly as receivers of services. Attempts to dethrone prosthetic paternalism are unlikely to be helped by multiagency provision. A further conflict arises in the pluripotential nature of MCC deliberation, and may be brought into still sharper focus by the structural changes occurring in the health and social services. Case (or care) management, soon to be central to the provision and
of services for elderly people, springs from a coalition between the medical tradition (case patient) and that of managers who are accountable to a system (rather than to a client). Case managers will have to struggle with this dichotomy (as increasingly do doctors) and with a complexity of roles within MCC which inevitably provokes conflict (Challis and Davies, 1986). =
Assessment, co-ordination, andadvocacyareparticularlyimportant. Needs or Service Orientated True multidisciplinary assessment is rare and service provision is often service orientated rather than based firmly on the needs of the client. The purchaser-provider split envisaged by ’Caring for People’ (Caring for People, 1989) is designed in part to encourage needs-based assessment, and the incorporation of some of the elements from the Kent Community Care Scheme is a laudable effort to make the services fit the client rather than vice-versa. But case managers will be expected to obtain appropriate services for the client largely from apool ofavailable (funded) services, designated as appropriate by and for the system. This assumes that the system is aware of the real needs of clients, and prepared to meet these needs. In reality in the ’free market’ agencies provide what they can sell; clients either fit their bill (literally and metaphorically) or are not offered the service. Only if the case manager has power to direct the operations of agencies, and contribute to defining problems, priorities, and appropriate levels ofprovision will comprehensive packages ofcare relevant to the individual be explored. Otherwise the impotent manager has little hope of producing services tailored to the individual needs of the client, and those with
’special’ needs may be marginalised. ’Designer care packages’, just like designer clothes, are likely to be more expensive than bulk buys. Financial constraints and uncertain future funding further restrict the choice available to the manager; the system is likely to become ever more complex as the number of agencies involved multiplies. Experience suggests that co-ordination of services from provider agencies is difficult, and that the results often fall short of expectation (Babbington and Charnley, 1990; Warren et al, 1974), particularly when new structures are introduced. This will be compounded if case managers are charged with the dual responsibilities of assessment of need and of balancing budgets; hopefully responsibility for rationing scarce resources will be held
at a
different level in the system. The alternative of
245 Downloaded from rsh.sagepub.com at NORTH DAKOTA STATE UNIV LIB on May 26, 2015
-’---------.--~-’._&dquo;.’_._---_._--~--’-’-’-_._.--.&dquo;...’._--~....--.---
delegating budgets to patients or clients is flawed : power does not (and should not) automatically arise from financial muscle, and problems of even greater exploitation may arise.
health, poverty, poor housing, poor education etc. How ~
....
can
these issues be
approached by members
of
multidisciplinary teams;
Issues of advocacy Within the MCC the coordinating and facilitating role is often accorded supreme importance and conflict may be produced when this clashes with issues of advocacy. As an advocate the case manager does not necessarily acknowledge the appropriateness of current services. Rather he/she examines the agencies and their services from the stand point of the clients’ social needs. An advocate will wish to engage in a dialogue with the client (and others involved) not merely to facilitate plans for the client, but to consider options with the client. However it is easier to do things for the client while maintaining a facade of advocacy - more comfortable, more certain, and more rewarding. This is particularly true if the MCC reinforces the imperative of co-ordination and facilitation over advocacy, as so often happens, especially in discharge planning and where the team is working under pressures of resource, personnel, or financial restriction. In such circumstances the team structure supports the primacy ofproblem solving over problem posing, though (paradoxically) this may reduce the clients’ control over aspects of daily life, and undermine their autonomy. The team imposes its view on the client and assumes that the available service agencies are appropriate. This ’constitutes a conspiracy of legitimated manipulation and self interest’ (Rose and Black,1985). This may be particularly important for the case manager where the advocacy role extends beyond discharge into the community in a much sharper way than do the roles and responsibilities of other team members. Team members may set up small cabals to by-pass the full team - in hospital work this is often doctors and nurses (common to all patients from the point of admission) failing to involve ’optional’ team members. This often leads to resentment and lack of trust even if done with the best of intentions. These conflicts are likely to be highlighted in the brave new world of resource management and ’community care’. Yet advocacy functions become ever more important in circumstances where care is ’privatised’. As Rose and Black (1985) have commented (with regard to community programmes for the mentally ill but of equal relevance here) ’the central force is profit - extraction of private benefit from poor and relatively powerless people’. The advocate must strike a delicate balance between over provision of care and unmet need. There is a danger that an unlikely alliance could develop between the for-profit sector and care managers schooled in theprosthetic tradition, who may be unwilling to acknowledge that the starting point for care provision must be need rather than client preference or wish. In this era of citizens charters and consumerism it is important that both clients and care providers agree that there are limits to the promotion of autonomy. Citizens have obligations as well as rights. When issues ofduties and rights are decided on an ad hoc basis those who come off worst are usually precisely those individuals already disadvantaged by ill-
_
~
~
~
~
insist on the imperative of patient/client should include the patient; most Discussions autonomy. services pay lip-service to this ideal in routine practice. The formulated team position is delivered to the patient/client for comment (the advocacy facade) but this clearly places the individual at great disadvantage: passive acquiescence may be the response to circumstances in which all ones’ perceived needs are controlled (ifnotmet) by outside agencies. Patient/ client choice and not organisational expediency must be the key to service delivery. Confidentiality must be safeguarded. This is no less an issue with elderly people, yet it receives little attention and information may be disseminated around many agencies and individuals. I The MCC must acknowledge the imperative of advocacy in the role of case managers and devise strategies to incorporate this as a strength rather than attempt to marginalise or diminish this role. The team must together coordinate what is being advocated rather than advocate what is being coordinated. It is generally unsatisfactory to attempt to separate the advocacy and coordinating roles - it merely shifts the focus of the likely conflict within the team. Leadership style may play a particularly important part where resource limitations (eg hospital beds) exist. Case managers and those who seek to lead MCCs must be aware of the complex nature of these inter-organisational dynamics and the way in which the forces can control their clients’/patients’ lives.
The
team must
Thevariousagenciesinvolvedincareofelderlypeopleshould agree common denominators which recognise individual roles and responsibilities but facilitate their integration.
Organisational fragmentation renders appropriate, effective ,
management impossible. The introduction of ’community care’ case
strategies for elderly people represents a great opportunity to restate the fundamental concerns and ethos of multidisciplinary team working. But this requires greater recognition of the difficulties we are likely to encounter, a willingness to challenge current practice and awareness of the potential positive aspects of conflict. m - x - ., - - - - -
References
BEBBINGTON A and CHARNLEY H (1990). Community Rhetoric and Reality. Br J Social Wk; 20: 409-432 Caring for people: community care in the next decade and beyond (1989). London: HMSO CHALLIS D and DAVIES B (1986). Case management in community care. Aldershot: Gower GREENGROSS W and GREENGROSS S (1989). Living, Loving and Ageing. London: Age Concern ROSE S M and BLACK B (1985). Advocacy and Empowerment. Boston: Routledge and Kegan Paul WARREN R L, ROSES S and BERGUNDER A (1974). The Structure of Urban Reform, Lexington, Mass. DC Health and Co
246 Downloaded from rsh.sagepub.com at NORTH DAKOTA STATE UNIV LIB on May 26, 2015
