University of Maastricht, 2005, pp 264,
ISBN 90 9019417 7 (dissertation)
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For people with dementia and their carers, integrated care promises much. This is an area where gaps in services, poor-quality care, insufficient information and systems failures are all too common. But will integrated care deliver any improvement? This is a book that allows readers to get beyond simplistic notions of integrated care by concentrating on the way in which pushes for integrated care have to address already complex organisations and convince busy professionals that changes are positive. It does this by exploring dementia care systems in England and the Netherlands. Susanne Kümpers' book is essentially her doctoral thesis: itself an endeavour of integration as she undertook fieldwork in two areas of England and the Netherlands.
Like many published theses this is a collection of articles submitted for publication or already published. These articles, containing both data and analysis, form the core of the book but are accompanied by a reflective commentary on the context of the research in Chapter 1 and a summary of its key points for policy-making and organisational development. Her collaborators include Arno van Raak, Brian Hardy and Ingrid Mur, who worked in particular on the data and discussion of the influence of institutions and culture on health policy.
Chapter 2 of the seven chapters provides a rationale for the use of neo-institutionalism as a conceptual framework in which to understand how the policy of integrated care is being steered at local level and translated into local professional activity or organisational change. Contrasting a fairly centralised system, such as the UK National Health Service and its partners in local government, with the looser and wider networks of the Netherlands allows for a greater understanding of what ‘steering’ means. Context is not quite all, but it is clearly highly influential. In dementia care, for example, Kümpers identifies the importance of the social model of dementia in England and the way in which the needs and rights of people with dementia are given priority (in theory, of course, but also in the words and behaviours of professionals). In contrast, she considers attitudes to people with dementia as more paternalistic in The Netherlands and thinks these are evident both in professional and public focus on families' or carers' needs and in the strong support for residential care. In a context where residential care is not in short supply, where it is seen as appropriate and where the needs of carers are prioritised this makes sense. It does, of course, alter the local care economy.
One of Kümpers' many interesting points is that knowledge transfer is often missing in debates about integrated care. In dementia care one key area where knowledge transfer can lead to better care is that of the primary and secondary interface. Kümpers notes that day to day care of people with dementia is often undertaken by people who do not have substantial training or expertise (she might have added that they are also likely to be badly paid). Integrated services need to address how they will promote a transfer of knowledge and she identifies five models. These include outreach, where expert help is provided, specific links between teams or services, the placement of a specialist in a team or setting, shared services and local opportunities (round tables) to discuss complex cases. Kümpers does not suggest that any one of these models is more successful, but she does set out what might be some of the indicators of success, such as a culture of trust and mutual respect.
This book makes a claim that to understand and compare two different state systems, a ‘stranger’ to them both does this best. However, colleagues in both settings also appear to have been useful guides. Kümpers argues that this degree of objectivity helped her tease out the systems and put her in a better position to consider both fairly and objectively. Her main point, however, is that if we are to understand a complex phenomenon such as integrated care it is necessary to understand the context in which such a policy goal is devised and implemented.
This book is likely to be most relevant to policy makers or academics with an interest in the area. It is sad to say that it may be less of interest to people working in dementia care services. This is not because dementia care is policy free, more that it is so complex an area that many simply look locally and take the policy and organisational world for granted. As Kümpers demonstrates, this leaves policy making somewhat confused and driven by other imperatives.