key: cord-0055659-jmdb6ba5 authors: Vicente Fuentes, Fernando title: Social and health care coordination: Towards a new culture of care() date: 2020-10-19 journal: nan DOI: 10.1016/j.enfcle.2020.09.001 sha: d88dabbc2c72bac8b1d8af1d213e04ba8acd16e9 doc_id: 55659 cord_uid: jmdb6ba5 nan The current COVID -19 pandemic has dramatically flagged up the weaknesses of the Spanish health and care system, which we believed to be immune to problems, because, together with pensions, social services and education, it is at the cusp of the so-called Welfare State, and therefore theoretically prepared to confront any situation. However, in the last few months we have seen hospitals that have collapsed, a scarcity of healthcare professionals, insufficient ICU beds and respirators, lack of PPE, care homes for the elderly overwhelmed by infected cases and deaths, and, from an ethical viewpoint, highly questionable healthcare decisions. To sum up, a long list of problems which we did not know about or were unable to resolve sufficiently at the necessary time and among which those relating to the ethics of care for our elderly, will require a specific forum for discussion. Consequently we now reflecting on what has been done and what we should change, on the erratic and short-term financial and human resources policies carried out in the healthcare sector, the inappropriate model of care in homes for the elderly, the non-existence of contingency plans, the lack of social, retributive and formative recognition of residential care staff and a much more, an interminable list. Another weakness relating to human and material resources, of extreme importance, and organisational and conceptual in nature, must be added to the list: the non-existence of an appropriate coordination between healthcare mechanisms and social services, which has led to negative consequences in managing the pandemic. The ageing of the population and chronicity of diseases is leading to an increase in the need to support people so they may maintain their personal autonomy. This, together with changes occurring in the family and workplace environments, should necessarily lead to organising and coordinating health and social services in such a way as to provide a comprehensive and effective response to peoples' needs, not only for treating acute cases but also for caring and recovery. Ineffective social and health care coordination, as we have already had the occasion to confirm, provokes an increasing spiral of higher dependence and greater pressure on healthcare. The time has now arrived to take decisions. Both the public and private healthcare system hospital networks are fundamentally focused on the acute patient and are not a good environment for chronicity, convalescence or recovery, despite these conditions being present in a high proportion of hospitalized patients. 1 Within today's context of ageing and chronicity, the different formulas for addressing social and health care responses have become a priority goal of different countries and the coordination, integration and complementarity between the multiple levels of intervention (social, health, public, private institutions) must be the basis for a complete management of citizens' requirements. With this in mind, in Spain, the definition of the referential framework and guideline strategies in the autonomous communities for the consolidation of a comprehensive social and health care model with homogeneous bases throughout the nation must be a priority goal. This must not be ignored or delayed any further. Social and health care is the result of the intrinsic demand for care throughout a person's life cycle. This applies to healthcare services and to care for daily life in the community. We may often find there are groups with major health and social requirements, or those not covered by an integral outlook, which make the care model ineffective. In addition to this, preventative interventions under the same continuous, comprehensive, and individual outlook would lead to a delay in the processes of physical and social impairment, having a positive impact on the viability of the system from a healthcare and economic viewpoint. The potential benefits of this new form of social and health care must be related to different objectives: -Guarantee a more rational use of resources, avoiding unnecessary hospital admissions and stays which are unsuited to the characteristics of an acute care hospital. -Improve the response capacity of care mechanisms, freeing up resources for a more appropriate use. -Act as a mechanism for risk prevention. -Guarantee care in both residential centres and in the home. The aim should be that all institutions, organisms, entities competent in the matter and professionals on the teams in both the healthcare and social care sector, should effectively manage and share comprehensive care of the people requiring services of both care systems. Setting up social and health care coordination mechanisms is not to be solely based on resource management but also on the acceptance of several basic principles of care, including the following: -People and their families as the centre of care. -Healthcare accessibility and continuity. -Continuous optimisation of quality and efficiency. -Consideration of the ethical-care principles both by professionals and organisations. -Co-responsibility for appropriate use of services. Health and social services have evolved at different rates and in different directions regarding their origin, their track records, their public-private combination and their systems of service financing and co-payment. Nevertheless, there are different initiatives in both the public and private sectors, which demonstrate great potential of joint action and the opportunities which this may provide to the system and the recipients of their actions. However, there remains a need for the initiation and development of many elements to attain true coordination of both sectors in practice. The current situation needs impetus and firm intent for social and health care coordination to become a genuine reality, placing Spain at the forefront of neighbouring countries and above all providing a response to the population's requirements. To sum up, a more human and satisfying, people-centred setting -one which is aware of the current financial reality---would be the driver of opportunities. It would create a competitive environment, be the producer of new employment niches forming part of the centre of development to begin to recover what has been lost during these months, in terms of health, good care and economy. We have to do things differently, more efficiently as regards cost and provide more comprehensive care for people. Today's financial situation has provided us with the opportunity to stop taking for granted social and health care coordination to demanding firm action that may and must be based on that coordination. The healthcare system is increasingly more complete and effective in providing acute care but needs to be re-directed in providing longterm and chronic care. At present the social system has a good procedural base and some of the necessary tools to procure correct non-health intervention, both for prevention and dependence care situations. However, it has not historically played a major role in this environment. Both sectors require a common, shared path for the sake of efficiency and a greater and higher return on their actions. Joint action, based on the working experience in both sectors is now warranted more than ever, without this implying a loss of identity for either of the two systems. The increasing ageing of the population and a higher survival rate to the most prevalent diseases in the National Healthcare System are reasons why administrations have for some time being trying to guide their structures and initiatives towards a personalised and comprehensive social and health care. In this regard, from an organisational viewpoint, steps have been taken by national state and autonomous community administration. A good example of this is the union of health and social services in several autonomous communities, although it is not essential for achieving the goal of coordination. What is essential is working together in a straightforward manner, without mistrust, to improve services to citizens and their families. This, together with the different initiatives proposed by the insular, provincial, and local administrations for a satisfactory response to the population's changing care demands are signs that we are moving in the right direction. In Spain, the need for appropriate coordination between health services and social services has been the subject of different analyses, studies, and even parliamentary agreements. In the parliamentary area, the first of these is the Commission for Analysis and Evaluation of the National Health System 2 (Abril report), and the Agreement for the consolidation and modernisation of the National Health System, 3 although the concept of social and healthcare was defined for the first time in the National Health System Cohesion and Quality Law, 4 in this case with the consideration of the provision of the National Health System, although this provision has not been furthered in the corresponding Decrees of the Common Services Portfolio of the National Health System. Furthermore, the area of dependence has been developed in both the White Paper, 5 and in the actual Dependence Law, 6 which establishes the principle of collaboration of social and health services in provision of services to the uses of this system. This was again analysed in another White Paper, in this case that of the Social and Health Coordination in Spain. 7 On a statewide level, despite these regulations, reflections, and studies, not much advancement has been achieved from a legal standpoint. There have been some initiatives, including the National Health System chronicity strategy, 8 of 2012, the Document of coordination and social and health care of the Healthcare Advisory Board 9 of 2013, the basic Document for Comprehensive Social and Healthcare 10 of 2015, a draft document which was not approved but which achieved broad consensus among all the sectors involved and the Government of Spain and the autonomous communities, and lastly, the Neurodegenerative Diseases Strategy 11 of 2016. At an autonomous community level and given their health and social services management competences, advances have been far greater, albeit not uniform, in both defining the model and the speed of introduction. A few interesting experiences have already been introduced into the heart of these services. Often peoples' needs are not covered by a comprehensive service, but managed on an individual basis by different organisms, thereby creating an ineffective and often confusing care model. At this point, the role of primary care and hospital care nurses is vitally important for coordination between care levels and social services, and for case management. It is therefore necessary to create a social and health care model and coordination which includes provision of long-term care, convalescence, rehabilitation of recoverable functional impairment and palliative care, both in hospital and home environments. To do this, prior definition of the following should be made: -A catalogue of health and social services to be directly managed by professionals. -Joint protocols of action, for an approach to both resource networks, the establishment of coordination mechanisms, the design of shared actions and the strengthening of joint professional actions, through tools and case management. methodologies. -Referral procedures between sectors, which are of particular importance for the continuity of care, the formal design and validation of referral mechanisms and proto-cols between professionals of the different care levels and sectors. -Planning strategies for hospital discharge for patients who were hospitalised or institutionalised to guarantee that a comprehensive evaluation of their needs and those of their environment is made, a care plan established and that they are provided with home care in keeping with their discharge, identifying and prioritising patients who are at the highest risk of re-admission and/or decompensation. Recognition of the competence of both the health and social care services and the need for a better use of resources for each situation must be the starting point. The aim must be to put the needs of the person first and provide a comprehensive response of services and resources in the most efficient manner possible where cost/benefit and care quality are the keystones to action. There can be no more excuses. Too much has been written and spoken about coordination of social and health care, but the reality is that we lack a coordinated care system. The bases must be set for the definition of a care and coordination model aimed at defining and developing the following points: -The profile of people with social and health needs. Without the united and committed action from all agents involved in public, private and tertiary sectors, and essentially its professionals, it will impossible to achieve the necessary catalysts for change with which to build a peoplecentred social and health care and coordination, avoiding the growing spiral of higher costs, greater dependence and greater healthcare pressure. Joint action is now even more justified, if this should be possible, and based on the experience of accumulated work in both systems and the lessons learned during the worse possible moments of the pandemic. Now is the time to implement actions from different areas -political, legislative and financial -to initiate the creation of a common regulatory framework that specifies and modernizes the catalogues of social and health provision; the development of procedures of social and health coordination between primary and hospital care; the joint planning of health service beds and social and health care services; the creation of new social and health care jobs and services within the different autonomous communities; the training of teams and of multidisciplinary protocols; the promotion of self-care for people with chronic diseases, making the most of the opportunities offered by information, communication and imaging technologies; a reform and ordination of financing systems, and the regulation of user participation in the cost of social and health care services. The health system and the social system form a substantial part of the protection and assurance model of the Spanish Welfare State. Spanish society has greatly advanced with their development and is greatly committed to them for its present and future sustainability, despite the cyclical economic crises affecting it and the economic effects deriving from the current pandemic. Against this backdrop, the adoption of a social and health care and coordination model provides a two-fold opportunity: on the one hand that of optimizing public and private resources aimed at the care of people who require long-term care, with chronic diseases, or in situations of dependence, and on the other, that of advancing towards more effective people-centred care. This would form the basis of a new care culture, unfortunately largely currently absent, with advances of the Welfare State in Spain that have taken place in other sectors, such as the healthcare sector, social services, pensions, and dependence. Joint and committed action from all intervening agents would achieve the necessary changes leading to the construction of an effective, coordinated and people-centred social and health care system model. Encuesta de morbilidad hospitalaria Comisión Parlamentaria para la revisión del Sistema Nacional de Salud y las tendencias de su entorno en el momento actual y cara al futuro. Recomendación 53 a . Madrid: Congreso de los Diputados Informe de la Subcomisión Parlamentara para la Consolidación y Modernización del Sistema Nacional de Salud. Recomendación 3 a . Congreso de los Diputados Artículo 14. BOE núm. 128, de 29/05/2003 Instituto de Mayores y Servicios Sociales. Libro Blanco de atención a las personas en situación de dependencia. Madrid: IMSERSO de Promoción de la Autonomía Personal y Atención a las personas en situación de dependencia. Artículo 3. BOE núm 299 de 15/12/2006 Libro Blanco de la coordinación sociosanitaria en España Servicios Sociales e Igualdad Grupo de trabajo Comunidades autónomas y Administración General del Estado. Documento Base para una Atención Integral Sociosanitaria. Borrador Estrategia en Enfermedades Neurodegenerativas del Sistema Nacional de Salud