THANKS BUT NO THANKS!
There is a scenario frequently used by visual comedians that opens with an older, infirm lady standing at a busy crossroads looking a little glum as she watches the traffic whizz past. Our hero (Benny Hill, Norman Wisdom), assuming that she is trying unsuccessfully to negotiate her way to the other side, takes her by the arm and merrily frogmarches her there. Setting her gently down and beaming at her, he stands back expecting grateful thanks. Instead, he is met with a barrage of abuse and repeated thwacks from her handbag and walking stick. The woman of course had had other intentions: she wanted to go across the other road or in the opposite direction, or she was standing waiting for her friend. Whatever the reason for her irritation, the point is — the last place she wanted to be was where she ended up.
This story highlights the problems of well-meaning people (in our case care professionals) failing to take into account the real needs and goals of the people whom they are trying to help. It’s extraordinary in this day and age that we still consider actually taking note of the views of patients to be such an innovation.
PERSONAL RESPONSIBILITY AND PERSON-CENTRED CARE
Since 2008 we have been trying to change the way our workforce delivers care in Islington by ensuring we commission services supporting and promoting a more personalised and collaborative interaction with the residents using the health and social care system.
The change isn’t easy and involves that heartsink phrase: ‘culture change’. As commissioners we tend to overuse such phrases and they lose some of their emphasis. It’s important to remind ourselves that changing the way people work and interact with others can be extremely difficult, and the cause of a great deal of mutual anxiety.
We believe it isn’t unreasonable to expect residents to take on some of the responsibility for their own wellbeing and work with their care professionals. In order to grasp this opportunity, they must be provided with the education, support, and tools to undertake this shared responsibility. We acknowledge that this concept might be a new one for both professionals and patients, and expecting a whole workforce to suddenly move away from a paternalistic approach to health care and treat patients as experts in their own care can be unnerving to say the very least.
But if this change is to happen the whole system needs to be committed to the approach, and the people driving the change are the commissioners. No single method is correct but, equally, no single method will ever be enough. The basic requirement is a shared commitment from all organisations and the clinical leadership to drive the new approach forward.
DRIVING CHANGE FROM THE GROUND UP
At Islington Clinical Commissioning Group (CCG), we refer to ourselves as a ‘patient-centred care organisation’ and I believe we are a little further down the road towards this goal than many other organisations.
The most important thing for us has been a commitment from the CCG and the council, and we are lucky enough to have some extremely charismatic and committed leaders, at both clinical and commissioning levels. This is crucial to any shift in attitude and needs to be in place before you begin. Professionals must be secure in the knowledge that they have approval in order to start changing the culture and to be confident this is a strategic approach.
Once the commitment is in place from people passionate about care and support planning you have won the first battle, though the way ahead will undoubtedly present further skirmishes. Our commissioning approach to embedding person-centred care in Islington is to not concentrate it in a single area but to try to make it ‘business as usual’ across the whole health and social care setting.
We have a range of initiatives that we are using to influence professionals across the whole system. In 2013, for example, we started to systematically embed care planning in primary care by implementing the Year of Care programme, which was incentivised through a Locally Commissioned Service. This approach has now morphed into a more bespoke coaching skills training package directly informed by an assessment of individual practices’ actual training needs. As long as those implementing the changes see improvements to patient care and wellbeing, alongside their own job satisfaction, it matters not that there is no single implementation process. In fact, if change is coming from all angles this is a signal that you’re getting it right and the message is being broadcast and received across the whole landscape.
There are naysayers who will complain there isn’t sufficient evidence to show that it works, but there is in fact a wealth of evidence.1 Even in situations where evidence is thin, there has to be a point when you acknowledge that, ‘it’s just common sense to treat people as grown-ups and as experts in their own health conditions’.
We need to step back from our compulsion to do things for people and learn to work with them instead. A good starting point would be to ask the elderly lady at the crossroads where she actually wants to go before assuming the direction in advance and risking a good thrashing!
Footnotes
Phil has worked at Islington PCT/CCG for 12 years in a variety of different roles. He now leads on long-term conditions and self-care. He has been responsible for implementing the ‘Year of Care’ programme across the borough — now being expanded to cover all LTCs. Phil is also one of the RCGP Collaborative Care and Support Planning champions.
- © British Journal of General Practice 2016
REFERENCE
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