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Why I shudder when I hear the term 'person centred care'

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When I was doing my junior medical rotations, in preparation for the clinical examinations for the Royal Colleges of Physicians, there would always be the scary assessment of ‘communication skills’.

This is long before the time of the current #mynameis campaign in the NHS.

Having introduced yourself to the patient, one of the first things you’d be examined on is your exploration of the patient’s “beliefs, concerns and expectations.” The aim of the medical consultation was to prepare a management plan, given the time constraints, given these aspirations from the patient.

In reality, we all know the nonsense of being able to deal with all of a patient’s issues within a ten minute timeframe. People living with conditions, such as dementia, have had long time to reflect on the nature of their conditions and how impact on their lives.

The power imbalance in the doctor-patient relationship, I do not wish to deny, can potentially be a problem. For an example a medical patient’s wish to ‘live better with dementia’ can easily become a GP’s wish to solve a problem (s)he thinks (s)he can solve – like a modest improvement of memory through a drug.

For example, I violently object to Doctors seeing people as nameless entities, with no background, simply as a list of medical problems.

In life, I believe strongly we should actively seek out what people can do too.

Ultimately, I feel we are all persons, and that we become patients when we become ill. I think personhood is all about embracing a person’s past and present, and his or her relationships with everyone else; this should have been an aim of healthcare professionals all along.

I happen to be proud of being  a ‘Dr’ only because I endured (so I perceived) quite a lot of stigma from being banned from the Medical Register during my problems consequent upon alcohol abuse. In fact, I deliberately avoided calling myself ‘Dr’ even though I knew I was perfectly entitled to, on the grounds of having completed a doctor of philosophy (“a real Doctorate”).

In hospitals, it can be useful also to be a ‘Dr’ to save a lot of time. I am only saying this as I have seen circular discussions on ‘abolishing hierarchies’ in the “new model NHS”, and I can say for a fact that I never had an ‘attitude’ from being any sort of Doctor. In hospitals, it can be useful for patients to differentiate yourself from other health professionals.

With being a Doctor comes a lot of baggage too, like always being on best behaviour 24/7 outside of your job, or not giving any advice to complete strangers despite people asking for advice. That is, rather, an honour of professional regulation.

But I feel that the term ‘person centred care’ requires explanation. If it is not patient centred, what else is the healthcare system revolved around?

It could be “relationships” centred, and this takes away the rather individualistic approach. Or it could be “family centred”, in that you can make decisions jointly and severally with whole families. But no terms are ideal – some people can have few relationships, and/or no family.

However you define ‘person centred care’, it is not only liable to being a bandwagon, but liable to be a performance reductionist metric imposed by non-professionals on professions to ‘improve quality’, when the whole world knows that many healthcare professionals desire time, space and resources do the job.

When I chat with a friend of mine living with dementia I do not see as ‘person centred care’, merely just being a good support hopefully. Likewise, if we have ‘dementia friendly communities’, I genuinely wonder who else we are being friendly or unfriendly to.

It’s become dreadfully easy for ‘person centred care’ to trip off the tongue.

But a few basic ‘messages’ somehow appear to have become drowned out – such as health and wellbeing not merely the absence of illness.

Kate Swaffer once joked about ‘purse centred care’ in a now seminal article “There is Big Money in dementia” (click here).

And after all you can set your criteria for your brand of purse centred care is like, trademark it, flog it; but this would defeat the whole ethos of the intentions of the work of Tom Kitwood.

Whatever “person centred care” is to managers or others, we don’t seem to be doing a good job in achieving it according to the Health Foundation. We all have different takes on the notion. As with anything else, I suspect, however, too many cooks spoil the broth.

 

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  • Rosie Bolton

    If you found the communications skills assessment tough Shibley you should have some sympathy for me who was muddling through the same assessments with undiagnosed autism!

  • That makes me shudder even more Rosie! Massive sympathy!!

  • Could someone please tell me what other sort of care there is?

  • abetternhs

    Hi Shibley,

    I’m trying to review the person/patient centred (centered?) care literature and have come across 2 themes. One theme focusses on patient-professional relationships, (Mead and Bower 2000, Hudon et al 2010, Epstein 2010 etc) and the other focuses on coordinated healthcare systems (National Voices 2014, Health Foundation 2014/2015) The former are more concerned with pedagogy and philosophy (e.g. how do we make healthcare professionals more patient centred?) and the latter (NV in particular) seem more concerned with tools (e.g. how can technology help to make healthcare more patient centred?)

    I’m interested in how to make healthcare professionals more patient-centred with is really challenging: Bombeke 2010 has done one of the best studies and showed when students lack self-efficacy, when they face barriers (time pressure, tiredness) or when they are surrounded by non-patient-centred role models and are overwhelmed by powerful experiences, they lose their patient-centred focus. The importance of the ‘professional as person’ was key to their ability to provide ‘patient/person-centred care’

    Person-centred care therefore requires BOTH the care and treatment of health-professionals as people which enables person-centred relationships, AND systems that are attentive to patients’ needs. It won’t happen if caring for professionals results in systems that are bad for patients, for example the EWTD and the loss of continuity of care.

    The opposite example is that we tried a system of running surgeries continually from 8am to 8pm to make appointments more flexible for patients, but staff became incredibly stressed because they had much less opportunity to meet with each-other and discuss patients they were worried about.

    There are enormous and exciting possibilities to make healthcare more patient/ person centred, but they must ensure that human and structural elements are attended to,

    Warm wishes,
    Jonathon

  • Excellent comment – many thanks, best wishes shibley

  • Thanks for this, Shibley. I have always understood the phrase “person-centred care” to be an acknowledgement of failure on the part of the healthcare system.

    When Katherine Bredin and Tom Kitwood began using the phrase “person-centred care” (cf “Dementia reconsidered”, 1997:4) it was to make a distinction between good care and what would now be seen as neglect and abuse. Unfortunately, such neglect and abuse is still common, so for the time being we still need the epithet “person-centred”.

    I fear the general shuddering will continue until we have more compassionate behaviour across the whole of society, and not just in dementia care.