Reviewing the early literature in relation to intermediate care services, the way of working, noted above, was expected of clinicians employed within them, with a greater emphasis placed on flexible practices, transcending professional boundaries to undertake integrated working (Pearson et al 2015). In addition, there was also a greater expectation of closer partnership working between health and social care services.
Realistically though, integration between organisations does not always readily equate to integrated practice at an operational level.
In spite of this, the requirement to work collaboratively within
intermediate care services reinforced the relevance of this type of service to seek out sufficiently rich qualitative data to respond to the research questions of the study. Within this section a historical overview of the emergence of intermediate care and clarification of the criteria for patients to be accepted onto the service, is provided to support the rationale for this.
The intermediate tier comprises networks of services whose remit is to address the functional needs of individuals who have experienced a
sudden and acute deterioration in their medical or psychological condition, through supporting them either in their own home or in community based residential facilities in contrast to an acute hospital environment. Service users referred to intermediate care are therefore expected to be medically stable or medically predictable, as interventions are provided to help them to adapt to a change in their functional status (DH 2009, Young et al
2015) through programmes of rehabilitation.
Intermediate care services were therefore developed, not as a substitute for admission to an acute hospital bed, but as an alternative for those who did not need this type of intervention (Young and Stevenson 2006, Glasby et al 2008, Thomas and Lambert 2008). A referral to an
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need, would involve cross professional working using shared
documentation, practices and protocols and would usually be provided on a short-term basis (DH 2001a).
To supplement existing health and social care provision, intermediate care services developed in response to demands faced by acute hospitals
which were highlighted in the findings of the National Beds Inquiry, reported in Shaping the Future NHS (2000). This indicated the extent of pressures within the hospital sector, documenting that the health and social care systems of the time were not meeting the needs of older people. It reported that two thirds of general and acute hospital beds were occupied by people aged 65 and older, who, as a result of taking longer to recuperate from their illness, were perceived to contribute to pressures on services through, what was termed “bed blocking”. The inquiry found that had alternative community based services been available, approximately 20% of acute bed days could have been saved for the population surveyed (Martin et al 2007). There was therefore an expectation that the provision of these additional services would lead to cost savings and an improved flow of patients from admission to
discharge. As a result, the development of intermediate care services was promoted to shift the emphasis away from acute hospital admission to those who met the criteria for these new types of services.
To assist with determining how these services operated, criteria were developed highlighting the provision of intermediate care services as being to maintain people in their own home through preventing
unnecessary hospital admission, facilitating early discharge from hospital and reducing the need for long term residential care (DH 2001a, DH 2001b, Stevenson and Spencer 2002, Thomas and Lambert 2008, DH 2009, McClimens et al 2010, Young et al 2015).
However, in spite of the publication of these criteria there was a lack of consistency in how intermediate care services developed (Grant et al
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2007), with them evolving in different ways in different areas. An effect of this is that due to this diversity and complexity of intermediate care
services, measuring the effectiveness of them has proved to be
problematic (Martin et al 2007, Thomas and Lambert 2008). The lack of prescribed consistency in how intermediate services operate has, though, allowed them to develop in different ways, across a regional and local context, dependent upon the needs of the population within those areas. This reinforces Nancarrow (2004, p. 143), who suggested that a “typical” intermediate care team is unlikely.
Intermediate care services were considered to act as a middle tier of provision, being positioned to operate seamlessly between acute hospital and primary care settings (Young et al 2015), as well as social care, private and voluntary sectors and providing an alternative to hospital admission (Moore et al 2007).
Whilst cost savings within acute hospitals were an impetus for the development of these services, a subsequent DH report (2002),
suggested that they could also assist in improving the quality of care for those using these types of services, by relying on the implementation of co-ordinated, joint working between health and social care, with an emphasis on improved integrated working.
The shared assessment framework, generic competencies and shared roles within these types of services therefore reinforced them as relevant within which to explore interprofessional collaboration.
2.8 Summary
This chapter has provided a historical overview of the emergence of interprofessional collaboration and how it has been constructed over the decades, with political drivers placing a great deal of emphasis and expectation on staff to work differently. It has reviewed the literature available at the start of this study, recognising the gaps in this and in
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particular the limited number of studies that have investigated the concept of interprofessional collaboration within intermediate care settings.
Within this chapter there has also been the recognition of the lack of consistency in terminology and definitions used within the context of interprofessional collaboration which has led to ambiguity of meanings and has impacted on the development of the interprofessional arena of knowledge. To overcome this, within this study, a definition of
interprofessional collaboration has been offered to provide clarity of understanding of the author.
This chapter has therefore situated the knowledge available upon which the study was based, exploring the experiences of participants working collaboratively within intermediate care settings. The following chapter will complement this foundation by providing insight into the methodology determined as most appropriate to undertake this study in order to
53 Chapter 3 – Methodology
Introduction
The previous chapter explored the preliminary literature review of the phenomenon of interprofessional collaboration within the context of
intermediate care settings. It confirms the existence of a gap in research relating to the exploration of the interpersonal relationships and social processes which contribute to the creation of collaborative working and how it is sustained. This chapter will provide the justification for why the methodological approach of Constructivist Grounded Theory was chosen as being most appropriate for use to investigate this further in this study. From its foundation in the 1960s there has been an evolution of Grounded Theory, with divergence from the original version. A historical overview of this and comparisons between the different variations will be offered as part of this discussion. In doing so consideration to the role of Symbolic Interactionism, as theoretical perspective, in informing the study will also be undertaken. This reinforces why the emphasis on the construction of subjective interpretations of reality, through interactions with others, is relevant for this study.
Recognising the integral role of the researcher when undertaking the study, reflexivity has been exercised throughout to provide transparency of the decision-making process in determining the methodology, taking into consideration my own philosophical stance which subsequently influenced the ontological and epistemological perspectives.