Clear managerial accountability but lack of clear professional accountability

This section explores the regulation and supervision of the IPCC role and the impact of these arrangements on patient care. The IPCCs were relatively

autonomous in the work that they did. Their managerial accountability was clear (despite frequent changes to their managers – see p.7). During the first part of the study, they reported to the operations managers. During the second part of the study, they reported to the senior nurse. However, their position and uncertain status in relation to the interprofessional team meant that their professional

accountability was not clear. In terms of impact on patient care, this meant that no- one took responsibility for supervising them in their work with patients, and that patients did not have a clear avenue for professional redress in the case of poor conduct.

6.2.2.1 Managerial accountability clear but supervision minimal

The IPCC job description reflected that they were responsible and accountable to the operations managers (or, later in time, the senior nurse). All interviewees and focus group participants knew who the IPCCs were managed by. The IPCCs’ managers reflected this responsibility in the interest they took in the role, and in the lead they took in management tasks such as appraisal.

I have just now IPR’d28 them all and they all get job satisfaction from what they do. One of the key things they find satisfying is their interactions with patients and relatives. (Manager, 15070, Int)

The IPCCs’ managers reflected that the one formal check of IPCC performance was at the weekly meetings with their manager where they discussed the detail of patients whose discharge had been delayed beyond clinical fitness.

They will come to me for advice if they need it but you know, as they develop their skills and have got more experienced and just encountered the situations more than once and even amongst themselves, they can overcome a lot of the problems themselves very easily with a bit of minimum support. Although sometimes, I have to be truthful, I don’t see them from one Friday to the next. (Manager, 15070, Int)

What we do with the [IPCCs] is we monitor them by meeting them weekly and by getting them to specify what patients are delayed, you’re sort of checking that the outcome is the same for all of them even if their methods for getting there are slightly different. (Manager, 07059, Int)

The IPCCs’ Managers trusted them in the work that they did and allowed them a great deal of autonomy.

Some of it does go on trust and that could be difficult, if you didn’t trust them…I think managing them does take a flexibility of mind and a trust that they are getting on with something. (Manager, 11128, Int)

These accounts by managers indicate that they did not supervise the IPCCs closely. The weekly meeting was used as the main performance check for how the IPCCs were doing. Their managers clearly did not see a role for themselves in directly assessing the IPCCs in their daily work.

6.2.2.2 Professional accountability to nursing claimed but not clear

In spite of the fact that they were now engaged in work that had previously been carried out by practitioners with a professional training, the IPCCs did not have a clearly specified line of professional accountability in their job description or elsewhere. This was a function of the role’s flexibility and was problematic for some colleagues whose accountability functioned within a unidisciplinary structure:

Social Worker: What's their accountability like? Who are they accountable to - do they have any accountability? Do you see that as a problem though, or not?

IPCCs’ Manager: Well, it depends where you see the role. If you see the role as being administrative, then there's hundreds of other roles similar in terms of accountability. The difficulty is that there is boundary problems encroaching into professional boundaries - that's what we've got to try and work at getting right. (Focus group extract, 05039A)

IPCCs described themselves in a support role to a range of professions and therefore did not fit into any one of the current groups of registered staff:

I suppose I feel like when I introduce myself to a patient I will say ‘I’m [name], I am the care co-ordinator for the team of doctors that are looking after you’. That is what I do, that is what I am employed to do. Nurses phone and I go up and they give me referrals, so I am working for them as well and the social worker that I work with she will phone me up for information. Although that is how I perceive my role as working through that particular team of doctors I don’t see that I just work for them. (IPCC, 07128, Int)

This lack of fit with traditional groupings is a key reason for the lack of clear professional accountability. Registered workers are accountable to the public through their registering body for the quality of care they deliver and for the quality of care delivered by individuals to whom they have delegated work. Firstly, it is unclear whether or not the work that IPCCs carried out could be classified as delegated. The findings described in the previous chapter that the nature of IPCC work included leadership over interprofessional colleagues and independent decision-making challenge the notion of IPCCs as simply taking on delegated work. Secondly, the lack of clear accountability to just one staff group makes defining their ultimate professional accountability problematic. Thus, the position and uncertain status of the IPCCs in relation to the interprofessional team meant that their professional accountability could not be clearly specified.

In relation to discharge planning, Trust policy names nursing as responsible for discharge planning. In their interviews, the IPCCs reflected accountability to nursing in discharge matters:

From a care co-ordinator’s point of view, I mean although obviously we work with all the professionals, you know, physio, social worker, OT, and obviously the nurses on the ward and the nurse that’s actually in charge of that patient’s care. I mean at the end of the day, we don’t do anything that isn’t documented or communicated or passed on to the ward, and the particular nurse or person that’s in charge of that ward. So at the end of the day, the actual patient discharge would be down to that nurse who’s actually looking after that patient, because we would have forwarded all the information we’ve got onto that person, whether it be services have been set up by the social worker, OT’s been in and, you know, and that we’ve actually been given the final say that the patient’s able to go, and we’ve re-instated services or sorted out the transport, etc. So the accountability on our part would be the actual nurse that’s looking after that patient, you know, the actual person. (IPCC, 15020F, FG)

This view was backed up by the managers, but there was doubt expressed that nurses understood their responsibilities in this regard:

They report to the senior nurse for their overall work but it’s a

combination. They don’t report to the senior nurse every day on what they’ve done but they report to the ward nurses about their role but I’m not sure that the ward nurses understand their role properly. (Manager,

15020G, FG)

Some nurses supported the claims made by the IPCCs:

A lot of [the IPCC] roles are things that were traditionally nurse responsibilities in terms of co-ordinating, being a lynch-pin, all those things, but from the way I’ve seen the scheme work with [the IPCCs] I’ve worked with, they’ve never approached a patient without involving a nurse prior to that and they are always really sensitive to the fact that you’re nursing that patient (Nurse, 28049, Int)

One ward manager, however, did not feel comfortable about being held

accountable for the work of the IPCCs, while a staff nurse interviewed was not clear where her responsibilities lay in relation to their work.

In the recent nursing discharge policy that the hospital has authorised, one of the very first statements and one of the biggest problem areas, it says that the named nurse is responsible for the co-ordination of the patient’s discharge, and that’s where the problem area comes. How can we be responsible for the co-ordination of the patients’ discharge if we do not have access to the levels of information which the IPCCs have? What I’m saying is how can we be responsible for something we are not actually doing. We are not doing the discharge co-ordinating any more so how can we be responsible for it. [The IPCCs] are doing a good job of it but we are being held accountable for it. (Nurse, 15020F, FG)

Researcher: Are there situations where the IPCCs are collecting social information, maybe on your behalf. I mean do you then feel the need to verify that?

Nurse: Um, No I don’t feel the need to do that, but I don’t know if I should or not, but possibly I should (laugh). There would be, sort of no point and that would kind of nullify their assessment (11059, Int)

So the claims by IPCCs that they were accountable to nurses for discharge planning matters were not supported by all of the nurses interviewed. In addition, managers felt that nurses may not understand their responsibilities in this regard. If nurses did not recognise the accountability they held, it seems unlikely that any

responsibilities that accountability might bring would be recognised by these nurses. These responsibilities include ensuring competency for delegated work. It is clear that at least some of the nursing staff did not feel a responsibility for

supervising the IPCCs in their work. This may have had an impact on the quality of care received by patients.

The flexibility attributed to the role of the IPCC had pervaded so far that it seemed down to individual IPCCs and nurses what arrangements they made for ensuring the quality of care. This flexible attitude, responding as necessary to each episode as it arises perhaps represents the ultimate in policy guidelines that encourage flexibility. However, it also undermines other government aims to make health care practice more transparent, consistent and accountable.

The lack of clarity about the IPCCs’ professional accountability that resulted from these arrangements had a potentially significant impact on patient care. Firstly, no one had taken responsibility for professional supervision of the IPCCs, and

secondly, patients and families had no avenue for professional redress in the case of poor conduct of an IPCC.

The next section uses observation data to re-examine manager and practitioner accounts of the issues of competency and accountability, and to further explore the impact of the IPCC role on patient care.