How far can we go in stretching the model that is person-centred care?
I should probably start with explaining to those who haven’t heard about it, what person-centred care means.
Person-centred care is the philosophy that within health, social or voluntary sector care, the person we are helping, supporting or enabling, is at the centre.
Pretty straightforward – you might consider it to be self-evident.
How can medicine, for example, not be person-centred?
Surely if you are going to treat someone – with medicines, an operation or some other intervention, without them being at the heart of what you do you are missing the point – yet, every day in hospitals, clinics and surgeries across the country and very likely the world, this is not how things happen.
An easy distinction is where process, that is the doing of things, overwhelms the purpose of the doing – let me give you an example.
It is three o’clock on a Saturday morning – the nurse calls the doctor who is rushing about the night time hospital, as an intravenous cannula that was placed the day before has stopped working, or fallen out. The nurse asks the doctor to come and re-site the cannula (that is a short, thin plastic tube that delivers medicine into a patient’s veins – see below) (sorry for the graphic image).
The doctor arrives, tired, disorientated, overwhelmed with demands, (yes, thanks to ‘seven’-day working – once you over-stretch the rubber band it loses its elasticity) searches for the needle box, tourniquet, plastic gloves, alcohol wipes and proceeds to seek-out a ‘good’ vein.
The patient, by now it is 330 in the morning, is fast asleep. You nudge them, apologise and proceed to look for somewhere to have a go.
In the dark, you miss, the patient perhaps flinches, cotton-wool, sticking plaster, another attempt, and perhaps another and if, the patient is very old or has been in hospital for a long time, the whole process becomes more technically difficult. Perhaps six attempts, by which point you are frustrated, and the patient is distressed – they might have dementia, learning disabilities, visual impairment, or just be unwell, and, is covered in cotton-wool.
The cannula is in. you have tested that it works and you move on to another task.
The next morning the cannula is removed as it wasn’t needed – the drip or the antibiotics are deemed unnecessary and so it goes.
Person-centred care is asking why the patient (or ideally the person) needs the cannula, and why at three am, and could they not be left to sleep for a few more hours, or could the medicine not be changed to tablets or syrup or the drip changed to a drink – a cup of cocoa for example.
The task becomes more important than the action and the reason for doing what you are doing is lost, forgotten, overwhelmed by the demands.
We tend to think less clearly when we rush, and rushing is something that happens often in the NHS, more often at night, and likely at the weekends. Remember the snapped elastic.
If we can allow some breathing space, if we can treat the doctor as a person, consider their needs, how to help them rather than burden them with more, if we treat the patient according to their preferences – what they want, what they need, what they understand, things start to unravel. The knot that is process disentangles.
Going back to the model of person-centred care, ad absurdum. How far can we go?
For a start, we get rid of visiting times – the movement of friends and family is at the discretion of the patient; people have a choice of medicines – ‘Do you want drug A, which works this way, with these side-effects, do you want drug B, with these side-effects or do you not want a medicine?’
Let’s weigh the pros and cons of tablets or waiting and watching, of tests or investigations that might or might not reveal information you may or may not want to hear.
Do you really need to come into hospital for the treatment? Could we (doctors, nurses, hospital administrators) put ourselves-out a little and see what we can do by stretching the rules, the model or the concept of inpatient or outpatient or patient?
Let us (yes, you and me, patient and doctor) collaborate, problem solve, let’s treat you as an individual, one at a time, think, consider, reflect and act.
Can you be trusted with your own health?
Can you measure your own blood pressure, monitor your own blood tests? Do you need to make an appointment at the GP surgery to have a discussion that could have taken place by text?
Could you Facetime your doctor when you are on holiday in Greece rather than having to wade through the complexities of health insurance (yes, Brexiters) and a foreign health system?
I am sometimes asked by innovative patients as to whether they could pop home for a few hours before being admitted, or perhaps come along the next day; yet, we don’t have the systems that meet these needs, we don’t have the flexibility to adapt to the variation that is essentially what it is to be human.
We have pathways and processes, we have standard doses, routines and treatments that fit A or B or C or under 65’s or those weighing less than 70Kg. We try to apply logical associations to situations that don’t make sense or are random or inexplicable.
We assign diagnoses when no one quite knows what is going on – ‘Sorry, I am not sure what is causing your pain,’ rather than standard routines – the urinary tract infections for older people who fall, the non-specific abdominal pain when the CT scan is normal, or the migraine when meningitis has been excluded.
Openness, honesty and transparency are all fundamentals of patient safety and high-quality care, they are also core to the principle of person-centred care – revealing what you know or do not know, allowing yourself to be seen as part of a team, not the team, allowing yourself a moment of humility to put your ego to one side so that you can turn to others for the answer – turn to those without as many years of ‘experience’ – towards the patients and the carers, towards the other members of the team who have the opportunity to see what you have missed.
Is this a start?
Is this a beginning?
How many times can you say that your experiences have been within the realms of equal participants in care, where you have been unable to perceive a hierarchy or a power-balance?
If those times are few and far between, let us start chipping away, nibbling at the monstrosity that is the system; the more who participate, the more people singing in the same key of ‘this is me’ the better.