Abstract
Despite the increasing policy focus on integrated dementia care in the UK, little is known about the opportunities and challenges encountered by practitioners charged with implementing these policies on the ground. We undertook an extensive, mixed-methods analysis of how a contemporary multidisciplinary dementia pathway in the UK was experienced and negotiated by service providers. Our pragmatic mixed methods design incorporated three types of research interaction with practitioners: (a) Semi-structured interviews (n=31) and focus group discussions (n=4), (b) Practitioner 'shadowing' observations (n=19), and (c) Service attendance and performance metrics reviews (n=8). Through an abductive analysis of practitioner narratives and practice observations, we evidenced how inter-practitioner prejudices, restrictive and competitive commissioning frameworks, barriers to effective data sharing and other resource constraints, all challenged integrative dementia care and led to unintended consequences such as practice overlap and failure to identify and respond to people's needs. In order to more successfully realise integrated dementia pathways, we propose innovative commissioning frameworks which purposefully seek to diffuse power imbalances, encourage inter-provider respect and understanding, and determine clear lines of responsibility.
Highlights
The methods framework included: semi-structured and structured interviews, focus groups, practitioner ‘shadowing’ and a quantitative review of service attendance and performance metrics. Adopting and adapting these methods ‘organically’ meant that researchers aimed to validate and challenge findings through evidence emerging from the multiple sources of data throughout the study (Morgan, 2007), e.g., shadowing observations and service attendance and performance metrics could be used to inform interview questions for both people affected by dementia and service providers, as well as challenge practitioners’ answers and other initial findings
Throughout the review, people and carers affected by dementia spoke highly of the expertise, compassion and commitment of dementia practitioners involved in their lives
These, coupled with the strains imposed by austerity, meant that the dementia pathway under review had evolved into a collection of disjointed services which, after initial diagnosis and signposting, prioritised crisis management over crisis prevention
Summary
‘Without integration at various levels, all aspects of healthcare performance can suffer. While current integration strategies are centrally guided, frameworks for delivery are non-prescriptive and encourage geographical regions to draw on the needs of local people, communities, as well as pre-existing care provision and commissioning structures (e.g., NHS England, 2019). A further challenge in our understanding of contemporary integrated care partnerships and systems is that our endeavours to evaluate effectiveness are focused on implementation experiences at the leadership, strategic and structural levels (such as, senior NHS, local government & third sector management; e.g., Alzheimer's Society, 2018a, 2018b; Charles et al, 2018; Ham, 2018). The mixed methods framework in question, included: interviews and focus group discussions; practitioner ‘shadowing’ observations, and service attendance and performance metrics, which were used to explore the barriers to effective integrated and collaborative practice for older people mental health services, as well as other statutory and third sector dementia service providers.
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