Over the next three weeks we’ll be exploring our next theme ‘Care in hospital’. In week one we will be talking about Person-Centred Care.
To set the scene, we have a guest post by Shaun Maher – The Strategic Advisor for Person-Centred Care and Improvement at the Scottish Government.
- Why isn’t a Person-Centred approach to care “business as usual” and what do we have to do to make sure that is?
When people think about person-centred care they often equate it with the principles of good customer service, and whilst there is some truth in this, when it comes to the world of healthcare there is much more to being person-centred than smiling and saying “have a nice day!” Really good customer service comes about when the provider of the service or product has a good understanding of what provides value to their customers. If they fail to understand what provides value then experiences and quality will be variable. These same principles apply to healthcare. Coupled with this the common description of relational elements of care as “soft skills” can demean their importance and reinforces the view of some that these skills are nice to have, but not essential. The pressure and pace of work can often cause us to lose sight of the important fact that our work is all about people, our fellow human beings. How we, and the systems we operate in, relate to the people we come into contact with is at the heart of our work and critical to its quality.
What is person-centred care?
Person-centred care is at the heart of the NHS Scotland quality strategy, which defines it a “providing care that is responsive to individual personal preferences, needs and values and assuring that patient values guide all clinical decisions”.
How can a person-centred approach help?
One of the principle objections to adopting a truly person-centred approach is that there is simply not enough time. This objection may seem reasonable at first glance, especially in the current climate. This is worth exploring a little more deeply and in doing so we need to return to the point about good customer service being at the heart of high quality.
Failure to understand what really matters to the people who use your service and what provides value, at best results in variable quality and at worst, leads to poor clinical outcomes, harm and poor financial performance.
Where patient experiences are good, safety, effectiveness and financial performance are good. Where experiences are variable and poor, so are safety, effectiveness and financial performance. In light of this relationship we could perhaps argue that we should always start with “what really matters” and the rest will follow. The reality is perhaps that we cannot afford to neglect any of these elements and they are at least of equal importance, but perhaps person-centred approaches have been somewhat neglected until now and therefore, need some remedial attention. We cannot afford not to make time to focus on person-centred approaches to care.
Person-centred care in action
There are a number of exciting and innovative examples at home and abroad demonstrating the potential transformative power of this approach.
Swedish gastroenterologist Jorgen Tholstrup and his team adopted a person-centred approach starting with asking whether routine return visits to the outpatient clinic following treatment were good value to patients. Unsurprisingly people didn’t value sitting for half a day in his late-running clinic! Amongst other interventions, the new approach simply involved a direct phone line to a senior nurse that people could call if they had any concerns or questions following treatment. The nurse would triage the calls, deal with the ones she could and refer on to medical staff those that she couldn’t. The results were significant.
By focusing on what provided value to the people using the service capacity was released in the outpatient clinic. This in turn resulted in waiting time for referral from primary care being reduced by two thirds from around 70 days to a little over 20 days. There was also a 50% reduction in waiting time for gastroscopy; 18 days to 9 days. Because people were seeing a specialist more promptly emergency admissions to the ward reduced along with a 25% reduction in length of stay. In the new system patients achieving set physiological improvement goals increased as well as improved quality of life and satisfaction with the service.
Belinda Hacking and colleagues developed a person-centred approach with a “navigator” supporting people who had breast or prostate cancer through the decision making process about treatment options. The intervention had a number of elements, but mainly focused on ensuring that people were primed with clear understandable information by means of a personal phone call and discussion prior to a major consultation with their oncologist. They were supported to set an agenda for the meeting based on the things that mattered to them. Immediately following the consultation with the oncologist a recording of the conversation was provided to take away and reflect on. Participants were randomised to standard care or the navigator intervention.
Patients who had the support of a navigator reported less regret about their decisions than the control group, but interestingly also chose less treatment opting for less chemotherapy and less surgical intervention than the control group. Another interesting finding was that those in the navigator group who did choose intervention experienced less side effects than those in the control group undergoing the same treatment. The reasons for this were not explored.
The final example is from the USA and involves people who presented with stage IV lung carcinoma. There is no curative treatment with advanced disease of this nature and life expectancy is around 12 months, often much less. Standard care focuses on palliative chemotherapy and various other pharmacological interventions aimed at symptom relief.
The intervention in this study was “a good conversation about the things that really matter to you” as soon as possible after diagnosis. The technical description of the intervention was “early palliative care” which involved a semi-structured conversation with the individual about their personal goals and fears, as well as some of the more usual aspects of care. One half of the participants in the study were assigned to standard care and the other half received the “what matters to you?” conversation.
The intervention group fared significantly better than the control group, experiencing less anxiety and depression and fewer hospital admissions. They also opted for less chemotherapy and only 16% of them died in hospital compared to a little over 30% in the control group. There is one final finding to ponder. This group of patients had less medical intervention, less time in hospital and yet they lived 25% longer than the control group. Food for thought.
These examples, and many more besides, are telling us that modern healthcare is lacking something important. When person-centeredness is at the heart of everything we do, our core purpose if you like, then improvements in safety, effectiveness and efficiency follow on naturally. It’s not that we can’t improve without being person-centred, but we will never be as good as we could be if we fail to recognise the benefits that this crucial element of quality can contribute.
The evidence supporting the benefits of a person-centred approach is so powerful that if a good conversation about the things that matter to you was a drug I’m certain we would prescribing it for everyone by now!
- So, why isn’t this way of working “business as usual” and what do we have to do to make it happen?
Guest post by Shaun Maher – Strategic Advisor for Person-Centred Care and Improvement at the Scottish Government.