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Person-centred care and the CQC: are we heading for a culture clash?

Don Redding
Don Redding
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Is it enough to ask for health and social care services to be 'caring' and 'responsive' (and what should these terms mean)?

Are service user control, empowerment and decision making a fundamental aspect of provision, or a 'nice to have'?

These questions are raised in the post-Francis atmosphere of re-regulating our services.

Francis proposed a common set of fundamental standards of care, to be used by all services and all regulators. These should be simple, easily understood by the public and service users and, if breached, should open up strong enforcement action including prosecution.

It's an understandable logic. But does it threaten the wider progress of person centred care?

A consultation from the Care Quality Commission, under new management and with a brief to rebuild the inspection system, indicates some of the risks. The CQC proposes five simple questions about care quality. The two on patient experience are: 'Is it caring?' and 'Is it responsive?'

Taken together, these domains appear to mean that people should be listened to, respected, and provided with compassionate care. All admirable, but all paternalistic. And not in alignment with the progress made towards putting people at the centre of the management of their heath and care.

Most recently, the report of Don Berwick's safety advisory group emphatically insisted that safe care in a learning culture rests on the full involvement of patients at every level from their individual care to the governance of the system. Nothing in the CQC approach indicates they share this view.

Berwick was adding to a raft of policy and regulatory approaches that has been built over recent years around service user involvement such as the duty of all doctors (in Good Medical Practice) to work in partnership with their patients, sharing decisions with them.

The NHS Constitution says we have the right to full information about treatment options, and to participate in decisions. The Narrative for Person Centred Coordinated Care, at the heart of the national system drive for 'integration', expresses the aspirations of service users to own and control their care. The ethics and values of the social care system insist on maintaining the maximum independence and autonomy of people with needs.

The 2012 Act requires NHS commissioners to 'promote the involvement of each patient in decisions', and the Mandate for NHS England gives it an objective to 'dramatically' increase the knowledge, skills and confidence of people in managing their health – advances for which National Voices and the Health Foundation campaigned together.

Strikingly, among the first and best legislative expression of these aspirations are the 2010 regulations for providers under which the CQC operates. Regulation 17 includes requirements to support service user independence, choice, self care and shared decision making, predating the current government’s expressed policy support for 'no decision about me, without me'.

These regulations are about to be rewritten to incorporate a new set of fundamental standards and a more easily triggered regime of prosecutions for breaches.

So could the Francis recommendations, and the preoccupation with hospital care, safety and compassion, actually be backward steps that signal to providers and other system leaders that we are returning to all-out paternalism? National Voices has entered a strong critique of this approach in our submissions to the CQC consultation.

At this point, before a welter of further consultations begins, there is a need for some fundamental rethinking:

Are service user involvement, independence and control, universal values and standards across the health and care systems, supported by commissioners, providers and regulators alike?

Or we are heading for a major culture clash as social care and some parts of the NHS promote a systematic shift towards person centred care, while others prioritise avoiding prosecution by maintaining a few core standards, that happen not to include the full involvement of people in their care and treatment?

Don Redding is Director of Policy for National Voices, the health and social care charity coalition. He was formerly head of policy and communications at Picker Institute Europe and a health and social care journalist.





 
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Comments
Very well said Don. Francis completely ignored submissions to his committee pointing to the connection between active patient engagement and increased safety and it looks as if the CQC is about to do the same.
Sometimes I wonder if we are not all becoming a bit confused.

There are various types of patient, with a myriad of different needs. To understand how best to be of assistance, we must be able to listen and understand what is required of us.
. Starting at the bottom rung, Virginia Henderson clearly and simply defines Nursing:
"The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible." Tomey, A. M., & Alligood, M. R. (1998). Nursing theorists and their work (p. 102). St. Louis: Mosby.
THAT is nursing as I knew it. Note that "a peaceful death" was a Nurse's function, and since that has been removed, there have been numerous cases taken to court for the" right to die". I shudder at the cost. The nurse was neutral: the nurse would only act in the best interest of the patient was tacitly understood.. And until the 80's, I believe this to be true. Lose that trust, and you lose the "unique function".


As far as patients go, there is the acute patient, who cannot take control over their own care, and frequently require a little paternalism. They need to feel safe and secure, knowing that someone can respond who is compassionate and empathic. Someone listening and caring in this situation is essential..
We were taught to treat each patient as if they were a relative: brother.sister, parent or grandparent. That got us started on the compassionate route: and once you have learnt it, it is not difficult...

Then there is the long term patient, with a chronic condition,who must learn to self manage and become an expert,t For any condition, the key is in good management, and if the patient can self manage, the NHS will run as efficiently and cost effectively as possible.
This requires education, mentoring and support. The Clinical Leader requires to become fully engaged, and demonstrate imagination and innovation when dealing with problems. This encourages participation and decision making and patient empowerment.
This is a different scenario entirely, with totally different needs, yet the Person centered aspect remains.
In the second scenario, acceptance of the patient as an expert is more difficult, until we have understood that the patient is not there to obey our orders. We are there to listen to his/her problems, and solve them together.
It turns the picture upside down, and many have a problem with it..We must think differently: we are no longer experts.
We do not know how much we do not know.
That is scary.
We will ONLY know when we listen to those who do - the patients.
Training is important, but working in the wards, culture very quickly takes over. We need to break the culture cycle to have the slightest prayer of solving our current crisis.
I found Don's post interesting and Linda McLean's response equally so. I think she's right that we need to be careful not to view all patients the same way, particularly through the lens of people managing long term conditions. I am currently analysing data on experiences of end of life care. There is the world of difference between the experience of someone with (say) MND who is coming to the end of life having had good support to live with that condition at home, who has all sorts of systems already in place; and the experience of an elderly person suddenly diagnosed with (say) advanced cancer who is sent off to die at home with virtually nil support and a desperate need for a well-organised package of basic nursing care. And there is no doubt in my mind that the interviews I am analysing - done for for the patient experience website www.healthtalkonline.org in 2010-2011 - reveal some woefully poor standards of care in hospital and community nursing. Holding providers to some basic fundamental standards here would help in my view.
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