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Give the people what they want

July 5, 2015

Person-centred care is something I hear a lot about these days. As summarised in a helpful little booklet from the Health Foundation, it takes its cue from the idea that it is the relationship between patient and professional that lies at the heart of care. Crucially, that relationship should be one ‘in which health care professionals and patients work together to understand what is important to the person; make decisions about their care and treatment; identify and achieve their goals’ (p.8). Care, in other words, works outwards from what matters most to the one receiving it.

It’s been said that labelling your prejudices ‘common sense’ is just a user-friendly way of denying them. If that’s really the case, then here’s someone who’s happy to come clean right now: to me, person-centred care is a no-brainer. It’s such an obvious model that I don’t even know why we need to discuss it. A more natural question would be why on earth you wouldn’t start with what matters most to the patient?

One answer is vested interest. In the years after its creation, the NHS was accused of being the fiefdom of powerful professional groups – particularly medicine. But since the 1980s, (and with renewed urgency since the crash of 2008) the dominant political narrative has been that of the NHS as an inefficient and insatiable ‘bottomless pit’ that needs to be ‘capped’ by the introduction of competition, targets and efficiency savings. (Other interpretations are available. In a report produced last year by the respected Commonwealth Fund, the NHS sat at the top of the league of health care systems of developed nations, scoring highly on both efficiency and value for money).

For politicians of a certain stripe, constant portrayal of the NHS as something that needs to be ‘brought under control’ by containing costs, managing risk, demonstrating value for money and meeting targets is of course very convenient; it allows them to trumpet privatisation and the introduction of market economics as solutions to the ‘problem’. But, as well as giving impetus to a different sort of vested interest, this is also a narrative that seeps into, and profoundly affects, the health care professions. None more so than nursing.

Nursing occupies a position at the interface between patients and ‘the system’. Indeed, on a continuum with ‘person-centred care’ at one end and ‘system-centred care’ at the other, the place where nursing occurs could be seen as a bellwether of what really matters in the NHS. And for those who champion person-centred care, the signs are not good. With little resistance or debate, ward-based general nurses have become the de facto administrators of prevailing NHS philosophy.

By that I mean that – punctuated only by drugs round and the odd procedure – most nursing time is now spent responding to ever-more urgent management demands for accelerated ‘throughput management’, risk assessments (even though of unproven effectiveness), and page after page of documentation – with no thought to how formulaic or irrelevant much of it is, as long as it is done. To me, this situation bears all the hallmarks of a system that privileges the perpetuation of itself over the needs of those it is meant to serve.

Politicians would no doubt argue that my person-centred/system-centred continuum is actually a false dichotomy because patients are, by-and-large, also taxpayers, and as tax-payers, top of their agenda is value for money. Because of this, it becomes possible to paint the pursuit of value for money as a kind of person-centred-care. Examples of this can be seen in Jeremy Hunt’s recent pronouncements about the agency spend (‘It’s outrageous that taxpayers are being taken for a ride…’) and prescription drugs (‘this will…remind people of the cost of medicine’).

Clearly, it’s a definition that’s a long way from the one proposed the Health Foundation, but the government appears to have taken its recent victory at the polls as confirmation that it is the one the electorate prefers. Recognition of this would certainly go a long way towards explaining post-election decisions such at the axing of the NICE Safe Staffing Committee.

Trapped within the implacable logic of this new orthodoxy, the prospects for vast swathes of are caught in a double bind. On the one hand, adherence to the model of person-centred care proposed by the likes of the Health Foundation is now entirely dependent on the morality and courage of individual nurses and nurse managers; it is almost a subversive act. On the other hand, meanwhile, individuals who are perceived not to be giving nice, warm, person-centred care – to which lip-service continues to be paid – will be seen as personally culpable.

In this bleak picture, I suppose it’s some comfort to remember that not everyone comes out a loser. Jeremy Hunt at least can draw comfort from knowing that he’s given people what they want.

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