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There is a scenario frequently used by visual comedians which opens with an elderly, infirm lady standing at a busy crossroads looking a little glum as she watches the traffic whizz past. Our hero, (Benny Hill, Norman Wisdom, et al), assuming that she is trying unsuccessfully to negotiate her way to the other side, takes her by the arm and merrily frogmarches her to the other side. 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, etc. Whatever the reason for her irritation, the point is – the last place she wanted to be was where she ended up.
The story highlights the problems of well-meaning people (in our case care professionals) who fail 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/service users/people to be such an innovation.
In Islington for the last few years, we have been trying to change the way that our whole workforce delivers care, by ensuring that we commission services which support and promote a more personalised and collaborative interaction with our residents who are using the health and social care system.
The change is not an easy one and involves that heart sink phrase: “culture change”. As commissioners we tend to over use the phrase and it loses some of its weight. It is important constantly to remind ourselves that changing the way people work and interact with others is extremely difficult and can be the cause of a great deal of anxiety on both sides of the interaction.
In Islington we believe that it is not unreasonable to expect residents to take on some of the responsibility themselves and to work with their care professionals to take control of their own wellbeing. In order to take that opportunity, they must be provided with the education, support and the tools to take on the shared responsibility. We acknowledge that this concept is new for both professionals and the population itself, so expecting a whole workforce to move away from the paternalistic approach to healthcare and treat patients as experts in their own care can be unnerving to say the very least.
If this change is to happen the whole system needs to be committed to the approach and the people who will drive the change are the commissioners. No single method is correct but it must also be recognised that no single method will ever be enough. At Islington CCG, we like to refer to ourselves as a “patient centred care organisation”. This may be wishful thinking but 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 top in the CCG and the Council and we are lucky enough to have some extremely charismatic and committed leaders, both at a clinical and commissioning level. Make no mistake this is crucial to any shift in attitude and needs to be in place before you can start to drive the change from the bottom up. Professionals need to be secure in the knowledge that they have the approval from above in order to start changing the culture on the ground and to be confident that this is a strategic approach.
Once the commitment is in place from people who are 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 basically not to concentrate it on a single area but to try and make it business as usual across the whole health and social care setting. We have a range of initiatives which we are using to influence professionals across the whole system. As long as the people who implement the changes at the coal face can witness the improvements to patient care, patient well-being and their own job satisfaction, it doesn’t matter that there is no single implementation process. In fact if change is coming from all angles then that is a signal that you are getting it right and that the message is being broadcast and received across the whole landscape.
There are naysayers who will complain that there isn’t sufficient evidence to show that it works, but honestly, there is actually a lot of evidence out there and even in situations where it is thin, there has to be a point when you turn and say, “It’s just common sense to treat people as grown-ups and as experts of their own health conditions”. We just need to learn to step back from our compulsion to do things for people and start to work with them instead.