ABSTRACT
The implementation of health and social care policies directed at providing integrated user-centred services for older people remains perhaps the single most important challenge to the modernisation of adult social care in the UK. Research findings, policy reports and government directives have consistently documented the poor quality of services for older people arising from inadequate interagency communication and user-professional relationships that foster dependence (Payne et al. 2002). There can be little doubting the magnitude of the task of restructuring differentiated welfare institutions and specialised professional practices that have become so well established. The intention to meet this challenge and drive forward reform, which would instil collaborative working arrangements supported by integrative information systems, was proclaimed by the UK government in a series of influential policy directives. Foremost among these was the National Service Framework for Older People (Department of Health 2001a), which introduced the single assessment process (SAP). Significantly, this was quickly followed by the publication of the Information Strategy for Older People in England (Department of Health 2002a), which began a new emphasis upon information and communications technologies (ICTs) as an essential means to enable collaborative assessment and joint care provision. The SAP is intended to be a joint enquiry by those with an interest in the
care and support of older people. It is the principal mechanism by which information about the user’s social and health condition is drawn together from a variety of professional, agency, familial and community sources to a single point to enable decisions to be made and a course of action to be undertaken. This partnership approach to assessment is designed to both overcome the fragmented investigations and consultations between users and numerous separate agencies and replace them by a collaborative network of providers that places the user at the centre of decision making. Successful implementation of a user-centred partnership such as the SAP is crucially dependent upon developing a commonly accepted information system that facilitates a number of requirements. It should enable the sharing of
information, its analysis and interpretation, the communication of knowledge that arises, signal appropriate courses of action, store and archive information to develop a flexible and intelligent knowledge-based system for monitoring and continuous care. Adult social care is unquestionably an information-intensive business
requiring enormous amounts of data to be collected from a complex variety of medical and welfare institutions (e.g. hospitals, clinics, laboratories, surgeries) and social and community agents (e.g. housing, voluntary and community groups, social services, carers, community nurses). It should not be surprising, therefore, that ICTs are regarded as a means to both transform service information processing as well as ‘informing’ and empowering the service user (Emery et al. 2002). This restructuring process, which we describe as the informatisation of adult social care, is part of the wider agenda to modernise public services (Newman 2001) and restructure welfare relations (Loader 1998). Information and the nature of its communication are central to the assess-
ment process and the means to integrated service provision. Yet this very primacy also highlights how the processes of design, implementation and adoption of new information systems constitute domains for conflicting visions, interpretations, resistance and opposition. The codification and access to knowledge structure to a significant extent the relations of authority between respective professionals and users of health and social services. To attempt to reconfigure the ownership, flows and barriers to information therefore have important consequences for the self-perceptions and identities of patients, carers, managers and professionals alike. What is too often presented as a simple technical means to improve the efficiency of the system could more accurately be seen as a desire on the part of policy-makers to reinvent the system (Loader 1999). These tensions between the knowledge-based territories of professional,
managerial and user domains are often played out at the frontline of service delivery. The role of street-level bureaucrats such as health care professionals and social workers in influencing the implementation of policies has been a well-documented theme in the academic literature (Prottas 1979; Lipskey 1980). Local implementation of the SAP is significantly influenced by the respective responses to new collaborative working arrangements that arise from introducing integrated information assessment tools. This is especially important for facilitating changes in the relationship between service users and providers that has been a feature of government policy statements. A consumerist emphasis upon patients’ charters has been replaced by a rhetoric of ‘partnership’ that argues for the inclusion of users in the design and negotiation of their assessment. Underpinning this partnership and enabling its integration is the proposed development of fully functioning local electronic information systems (EIS) known as eSAP. This would appear to demand an information system that could be accessed by health and social care practitioners, patients/clients/users or carers,1 the voluntary and community sector, and also act as a resource for management.
