Person-centred care in Scotland 1 - Realistic Medicine
Can the Chief Medical Officer’s ‘realistic medicine’ help put the person in the centre of their care? Part one of Holyrood's three-part series
Realistic medicine - Aimee Wachtel/Holyrood
When the Chief Medical Officer (CMO) Catherine Calderwood published her first annual report, ‘Realistic Medicine’, in January, she took a critical eye on the relationship between doctor and patient.
“Realistic medicine is about moving away from the ‘doctor knows best’ culture. It’s about more fully involving patients in the decisions about their care,” she said at the document’s launch.
“Of course this will only happen if people are prepared to have these conversations in this way with their doctors.”
Her own conversations with clinicians followed. By spring, the consultant obstetrician admitted to Holyrood the engagement had fared better than she’d expected.
“The CMO annual report has always been a feature, I know, but this one has taken off, so what I’ve been doing is going out and about round the country, meeting not just doctors but the whole team in the NHS – nurses, pharmacists and dentists, physios – everybody’s interested in it,” she said.
Responses to the report saw some lively discussions and found themselves onto social media. The document was praised at home and abroad for its focus on culture and ‘shared decision-making’.
Scotland’s interest in putting the patient at the centre of their care is not new. The agenda has come increasingly into the spotlight since the inquiry led by Robert Francis QC into failings of care at Mid Staffordshire NHS Foundation Trust was launched in 2010.
While issues of patient safety, quality of care and leadership naturally became the focus of his report, just as important to the public narrative were discussions about how dignity, compassion and respect could be better protected in the relationship with services.
Person-centred integrated care became the holy grail for health strategy, and was referred to as the ‘House of Care’, a model which focuses on the general needs of the individual rather than on individual diseases.
In 2011 the Scottish Government’s 2020 vision built on work by Campbell Christie, and put the term ‘person-centred’ into NHS Scotland’s lexicon.
By 2013 the government’s definition of person centred was: “Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.”
And the latest National Clinical Strategy puts person-centred as one of the priorities for reform of health services in Scotland, building on ‘Realistic Medicine’.
However, culture of course is about behaviour and language, and is notoriously hard to shift. Just ask anyone involved in the integration of health and social care.
Shared decisions come from two active parties, suggested Calderwood in ‘Realistic Medicine’. Time constraints, she said, reinforce “medical paternalism”, where clinicians decide what is in the best interests of the patient, while “people often happily cede control and entrust themselves into the hands of their professionals.”
Calderwood understands the importance of language. Patients, she suggests, should be referred to as people.
“I certainly also feel it’s shifting the way people are talking. I’ve got a kind of strapline, which is people not patients. People now keep correcting themselves when they talk about patients,” she told Holyrood.
“The patient has this whole other life and if you call them a patient, you narrow them down into that little box, and actually, it’s far better to think of them as the person they are the rest of the time. I think there’s a shift, we’re starting to shift conversations.”
However, conversations, of course, are two-way. What did Calderwood hear back from those clinicians she engaged with?
“I haven’t said, ‘this is it, everybody needs to just do it’. People are coming back and saying one of the problems is time. ‘We have increased workload’.”
And according to the latest workforce projections from health boards, that workload is not going to ease up in the next year.
A projected rise of 440 nurses and midwives across Scotland masks the fact 2,200 posts remain unfilled, as demand for services grows.
Furthermore, Fife, Lothian and Shetland project decreases in their nursing workforce, while NHS Lanarkshire predicts a fall in staff numbers overall.
A recruitment and retention crisis has also hit general practice with many family doctors due to retire. This has led to the Scottish Government offering an incentive to trainee GPs to live in more remote areas of the country.
Time constraints are not just restricted to the 165,000 staff in Scotland’s NHS, either.
Social care increasingly is part of the equation, as services are integrated and the new partnerships between health boards and councils bed in.
And according to a recent report by the trade union UNISON, four in five home care workers believe the emphasis is now on quantity over quality.
This at a time when the population is getting older and the nature of disease changing into one of living with multiple long-term conditions. In other words, people will need more, different services to help them manage their lives.
Health Secretary Shona Robison told Holyrood Scotland needs a “unique whole system” of health and social care.
“People are now living longer than ever before, which is a good thing. However, we know we need to change and improve how we deliver care if we are to have an NHS and social care sector able to support the health needs of this generation – and generations to come,” she said.
When third sector umbrella body the Health and Social Care Alliance launched its self-management fund in 2008 it was seen as innovative. This year the refreshed funds are seen as much more mainstream and embedded, according to the ALLIANCE Strategy and Engagement Director, Irene Oldfather.
“It’s really good to see it coming through a bit more,” she said.
Realistic medicine feeds right into that journey, according to Oldfather.
“It’s about how we support people to be equal partners in their own health and social care. I think there’s a big job still to be done around that.
“It’s not just working with people themselves and giving them the confidence and empowering them, but also working with clinicians and other health professionals to get them to buy in to this agenda of shared decision-making.”
The United Nation’s ‘PANEL’ approach to human rights informed much of the ALLIANCE’s work on person-centred care. PANEL stands for participation, accountability, non-discrimination, empowerment and legality, and was used in work Oldfather did for the ALLIANCE on the Dementia Carer Voices project and active ageing.
As the population gets older, the changing face of disease and care also means doctors are increasingly looking at managing symptoms as opposed to seeking a cure, which makes a conversation with the person about what they actually want from their life even more appropriate.
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