This themed section has at its heart reflections on the development of policy of, and for, information in health and social care over the last ten years in both the UK and Australia. It addresses a set of concerns often overlooked within social policy, namely the use of information and information systems as tools by organisations, policy makers and practitioners in the modernisation or transformation of public services, including in this case health and social care. Not long ago, in both countries, information was perceived as a panacea for the problems of integrating care services between health and social care organisations and these organisations and the patient, client or user of services. The authors focus upon England and Australia and contrast them briefly with other countries in Europe where the state plays a range of roles in the provision of health and social care. Under New Labour in the UK, there were significant investments in Information and Communications Technologies (ICTs) as a means to modernise and manage the National Health Service (NHS) (Connecting for Health) and social care for children and young people, most recently in the context of Every Child Matters (including the Integrated Children's System (ICS) and ContactPoint) in England. In parallel, in Australia there have been a series of developments, including HealthConnect and the Personal Electronic Health Record (PCEHR), and most recently a national disability insurance scheme (NDIS). These national initiatives have often led to high-profile failures on a titanic scale. Similarly, in the local implementations in the UK and Australia, ICT appears to have also failed to live up to the promise and is rarely scaled beyond initial pilots or pathfinder projects. The role of information is often implicit in debates about the role of New Public Management (NPM) and performance management of the state (for instance, Boivaird, Reference Bovaird2012; Lowe Reference Lowe2013). Alternative explanations include the work of Berg (Reference Berg1999), May et al. (Reference May, Rapley, Moreira, Finch and Heaven2006), Greenhalgh et al. (Reference Greenhalgh, Potts, Wong, Bark and Swinglehurst2009), the Editorial team for the themed section (Baines et al., Reference Baines, Wilson and Walsh2010; Wilson et al., Reference Wilson, Martin, Walsh and Richter2011, Cornford et al., Reference Cornford, Baines and Wilson2013; McLoughlin et al., Reference McLoughlin and Wilson2013) and others on the socio-technical nature of information in healthcare (for example, electronic patient records) and innovation in health and social care (such as telecare), and broader understandings from the information systems literature from notions of drift in systems requirements (Ciborra et al., Reference Ciborra, Braa and Cordella2001), on service infrastructures (Hanseth and Montiero, Reference Hanseth and Monteiro1996), and the role of information in the governance of the state (including the work of 6, Reference Six2004; Dunleavy et al., Reference Dunleavy, Margetts, Bastow and Tinkler2006; Osborne Reference Osborne2010).
Our own research observations and recent experiences suggest that there is now a significant risk of policy makers, service organisations and practitioners moving from a position of ‘dangerous enthusiasm’ (Gauld and Goldfinch, Reference Gauld and Goldfinch2006) to becoming overly sceptical about the deployment of information systems to support their goals. Witness, for example, continuing attempts to put the brakes on the financial legacy of the ill-fated national programme for IT in the English NHS and the current efforts to find a way out of the PCEHR debacle by the incoming Federal Government of Tony Abbot in Australia. Our contributors assess the policy and practice implications of information (and information systems) deployed to improve health and social care at various levels in both countries. Current explanations of the policy debates are limited by the particular context of the implementation or monological focus of the analysis either from solely technocentric or solely policy and practice perspective. By drawing on a wider set of interdisciplinary work and using international comparisons, the authors and editors seek to offer a range of alternative insights and frameworks to reach a better understanding of when, where and how government policy initiatives go awry when it comes to information. Taking such a nuanced and reflective approach to understanding the framing and roles of policy making of, and with, information in the contexts of health and social care, reveals new pathways to thinking and shaping policy in this key area. This is important in order to support improvements in services for a wide range of those in society. We have sought to address the questions of why these implementations in England and Australia (with their shared policy making histories) appear to have failed to live up to the promises. Key here, it appears, is an emerging sense that technology implementations in complex policy areas at significant national scales are bound to fail. This, combined with continuing lack of sophistication on the part of policy makers when deriving policy, means that some of the assumptions about the nature of the implementation of ICT and its effects need to be revised. Our Themed Section makes a contribution to areas that are relatively underdeveloped in social policy and practice literature, namely the role of information and information systems in policy changes and the ways in which these affect organisations and practice and vice versa.
Relationships with and to information in policy and practice: mind the gap
The review article offers a brief comparative history of the approaches to the application of information systems in England and Australia. Baines et al. document ways in which divergent national political and administrative structures in health and social care have led to problems of scaling and fragmentation in the effectiveness of these policy developments. They go on to interrogate these aspects of recent history to assess the strength and limitations of policy-making processes and understandings of information. Despite the fact that the two countries have a language in common and have followed broadly neoliberal welfare policies, there remain significant differences in the organisation and delivery of their health and social care systems. The exchange of ideas between them has continued through a shared history of experimentation, most recently in the shaping of the information agendas around personalisation. In both countries, the role of information is often positioned within debates about the health and/or care records, performance management and accountability of health and social care providers. There is a tendency to treat information as being unproblematic and ICT as a magic box which produces information that can be used to inform decision-making processes.
French and Stillman's article examines how the issue of data interoperability is nested within the particular needs and culture of the community welfare sector in Australia, with a particular review of research activity conducted by the researchers in the State of Victoria. The difficulties of reconciling a traditionally narrow and technical view of interoperability with welfare values and practice is discussed. Notwithstanding the difficulty, there are certain social-technical effects occurring, including what can be called an ‘informationalisation’ of welfare in response to the impact of ICTs on welfare practice. Other themes, such as the emergence of ‘data double’, the effects of mobility, and bricolage are also discussed as manifestations of the current changes, tensions and emergent symbioses between technical and welfare culture. Some suggestions are made for further action and investigation.
Hill's article explores the explanatory power of structuration theory as a way to work through the issues of the implementations of policy in local government and the work of social workers (in this case personalised budgets). She posits the challenges met by local authority social work departments and social workers in the interpretation of national policy into local work practice using the development of an assessment tool for adult social care. The problems encountered are described through the lens of structuration to reveal the difficulties faced by practitioners, in particular when the policy and responsible organisations seek to prescribe the work through the implementation of information tools, thereby reducing the agency of practitioners.
McLoughlin et al. show that even relatively sophisticated ICT deployment and design approaches need to afford detailed understanding of the ongoing changes to the care conversations involved in the practice of delivering client-centered care. The effect here is to create a set of ‘requirements’ that can be understood as services to govern and manage the informational environment. This opens up the possibility of an environment to support co-ordination of services as well as the provision of the recording and data collection at the practice−client interaction.
Garrety et al. illustrate that technologies, far from being neutral, provide a means through which social life and work life are developed, sustained, challenged and/or reconfigured in the pursuit of health policy goals and reform. By recognising the powerful but contested claims around the distinctive qualities of information and information systems, they assess the accusations and concerns of large-scale failure. This is positioned within the context of more business-like practices and increasing demands for bureaucratic accountability, against wider notions of intentions and values in the delivery of health and social care, including increasing debates around personalisation and the role of the patients or clients in relation to their records.
All four articles have foregrounded issues around the practices of information and the changes in relationships that result when policy seeks to use information systems as means of implementation. In their article, French and Stillman draw on work carried out in the State of Victoria in the context of welfare where the meaning of inter-operatability of information led to unforeseen changes in the social and organisational relationships required in the delivery of welfare. Hill's article reports on the ways in which macro policy agendas, such as personalization, are refracted through local government organisations and systems re-design, and the effect on social work practices and the re-distribution of roles in the setting up and administration of personal budgets for adult social care. McLoughlin et al.'s contribution describes the challenges faced by those seeking to co-ordinate care and the relationship tensions between ‘knowing’ clients or ‘knowing all about’ the clients. Garrety et al.'s article shows how the explicit restructuring of a healthcare system and its tools (such as records, for example) cuts across the historical and implicit structuring of the system (the relationships between doctors and patients and the roles they play in the system).
Recent social care policy in the developed world (including Australia and England) has promoted transformational change in the design and delivery of local services. One of the ways in which this has been envisaged is through a requirement to enable greater choice and control for service users with the expectation that these changes will deliver increased efficiencies, more effective personalised care, making better use of public funds and resources. In order to achieve these changes, local organisations have engaged in attempts to reengineer their business processes, review front line practice, develop new operational tools and revise their information systems to support and deliver these new approaches. This article draws on a case study undertaken in one local organisation as it began to implement its response to these expectations. Drawing on Giddens’ structuration theory, it explores how the macro agendas described by policy and legislation are translated into local perspectives and then further refracted through the lens of operational practice, shaping the business tools which deliver the change. The primary challenges lay in changing the institutionalised approaches of front line practice, introducing new business systems for the allocation of personal budgets and enabling service users to have greater choice and control over the support they received. The evidence suggests that there needs to be a better understanding of how the expectations of policy are interpreted, and potentially distorted, through their translation into local practice, and of the role that information and information services play in enabling, or disabling, the delivery of those expectations at the front line.
Future challenges
In England, the continued policy focus on increased or better integration of health and social care is often cited as a pre-requisite for the implementation of improvements in care co-ordination. However, it not always clear what is meant by ‘integration’. The notion of integration, highlighting the range and variety of uses of the term, including policy, commercial, managerial, professional/clinical, technological and lay discourses regarding the way in which health and social care are ‘joined-up’. The point here is that, in an increasingly mixed economy of provision (both in spatial and organisational provider terms), the limits of ‘integration’ as the only strategy in each of these domains is increasingly unsustainable. Integration projects (past and present whether in England (for example, Personal Budgets for Adult Social Care, Connecting for Health, Whole Systems Demonstrators for Telecare or ContactPoint for Children) or Australia (HealthConnect, PCEHR or NDIS) have had relatively limited success in terms of their stated objectives, highlighting instead the significant differences in accounting and recording practices between the different parts of the health and care services. Such differences have evolved over many years and are subject to diverse policy cycles, meaning that the ICT structures and infrastructure have accreted and contributed to the complexity they were intended to solve. We are only just beginning to understand the socio-technical challenges (including legal and professional) of moving information between and the roles and responsibilities of patients/clients in relation to records (Jenkings and Wilson, Reference Jenkings and Wilson2007; Wilson et al., Reference Wilson, Walsh and Vaughan2008; Greenhalgh et al., Reference Greenhalgh, Potts, Wong, Bark and Swinglehurst2009; Rigby et al., Reference Rigby, Hill, Koch and Keeling2011; Best et al., Reference Best, Greenhalgh, Lewis, Saul, Carroll and Bitz2012; Ellingsen and Monterio, Reference Ellingsen and Monteiro2012; Garrety et al., Reference Garrety, McLoughlin, Wilson, Zelle and Martin2014). Based on the work compiled in this themed section, we question the assumption of the current choice of integrationist approaches to ICT policy in complex contexts as the solution to these problems, proposing alternative ways of theorising about information and information systems in care contexts. We would stress the benefits of more ‘loosely coupled’ systems, focused in terms of a number of desirable objectives (for example, innovation, safety), which focus on the need for inter-organisational services to support joining-up that allow professionals and managers to exercise judgment, and local care communities to govern whilst supporting the appropriate use of information to support conversations of care (see the Useful Sources section, for instance www.fame-uk.org).
