Posts Tagged 'Health'

Am I a patient?

Alan Cribb unravels the transition from an epidemiological approach to a philosophical approach to healthcare he discusses in his new book – Healthcare in transition – by examining how his identification, or not, as a patient impacts on his research.

Whilst working as an academic I tend not to identify myself as a patient. 

In the last few years one of the themes of my work has been patient-centred or person-centred healthcare, and I have just completed Healthcare in transition, a book in which I tried to tease out some of the elements of, and tensions within, this idea. But I have never self-identified as a patient in my writing and I only occasionally do so in my face to face encounters with trusted colleagues and in what feel like safe spaces to me.

In some ways this is odd. I am not simply a patient in a notional sense – like very many people, I have regular interactions with medical consultants and other health professionals, I follow a regime of treatment and I have health-related conditions that challenge my identity and frame the way I organise my life. So why not self-identify as a patient in my academic work?

“Why not self-identity as a patient in my academic work?”

Partly it is probably just about privacy or for reasons of self-protection – not to invite threatening line of enquiry from others. But it feels as if it is about something more than that. First and foremost it seems presumptuous. It feels like I have been invited to the meeting with one ticket – as a researcher – but now I am claiming to have a further ticket and am expecting to vote twice!

This sense of cheating applies however I think about what counts as a patient, and I have to confess that I am confused about this. In health services research, for example, it is now a methodological and ethical norm to worry about the inclusion of either patient perspectives or patients in some fuller sense. But there is a spectrum of attitudes and practices in response to this norm.

In some cases – and this is to exaggerate for effect – ‘patients’ is treated as a kind of self-fulfilling marginal category, such that if people happen to have any other source of relevant expertise – they are health professionals, or researchers, or activists or even heavily engaged in a peer led patient group then they will to some extent be disqualified as ‘patients’.

This attitude stems from an understandable concern that the identity of patients isn’t colonised and misrepresented by powerful voices but, at the same time – certainly in this exaggerated sense – it risks reproducing a deficit view of patients.

“I feel either disqualified or under qualified.”

At the other end of the spectrum there are strong patient voices and groups who will not only lobby for involvement in research but will themselves lead research and will challenge prevailing orthodoxies – for example, questioning not only the practices of patient involvement but also the ways in which research agendas are set and research is conducted and so on. These kinds of patient voices play an important role and can be inspirational. But there is also a danger here – again at the extreme – that the identity of patient itself becomes professionalised and owned by a few well-organised people.

The first account coincides with my worry about being presumptuous. I need to be cautious about saying I am speaking as a patient, especially with any implication that it is on behalf of other patients, when I already have a hearing as an academic.

But I am equally ruled out on the second account. I have not taken any special steps to become an expert patient; nor do I have any particular credentials to claim a quasi-professional status in this regard. For me to act as if I had would be to cheat.

In short, I feel either disqualified or under qualified. But the issue of my patient identity will not go away completely. It seems unavoidable because even not mentioning it feels like a significant choice. In some contexts there are temptations to mention it – because for certain audiences it may add a sense of authenticity and credibility. In other contexts there are temptations not to mention it – because, for example, some clinicians or others may worry about what axe I have to grind and see it as a source of ‘bias’.

How far this issue is seen to be of importance, and in what respects, is arguably a function of the kind of research we are talking about and also of disciplinary assumptions and conventions. But for anyone who thinks ‘reflexivity’ matters it does seem to be a question worth asking.

If I am being reflexive as an academic then I can treat my identity as a source of problems or limitations that need to be acknowledged, or as a source of legitimacy or authority, or sometimes as a combination of both. This seems as relevant to patient identity as to other aspects of identity. On this account there seems to be something seriously lacking in my approach to date.

Healthcare in transition by Alan Cribb is available with 20% discount on the Policy Press website. Order here for just £17.59.

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The views and opinions expressed on this blog site are solely those of the original blog post authors and other contributors. These views and opinions do not necessarily represent those of the Policy Press and/or any/all contributors to this site.

Election focus: Avoiding Another Failed NHS Experiment

In the next post in our Election Focus series, David Hunter, author of The health debate, explains that the election must not become an excuse for shelving much needed health system transformation.

David Hunter

“A possible unwanted side effect of this most avoidable of unnecessary general elections, and the accompanying purdah into which everyone has slumped, is the impact on the NHS reforms initiated by the NHS Five Year Forward View published in 2014 and its update in the Next Steps delivery plan published last month.

One can only hope the NHS Chief Executive, Simon Stevens, is correct when he asserts that ‘there is no version of reality’ in which his changes will not be needed and actively pursued. Even if he is proved right there could still be disruption if a new health secretary replaces the current post-holder, Jeremy Hunt.

Or if the all-consuming Brexit negotiations divert the government’s focus and slow down the pace of change as seems likely. Or if a new administration decides to replace Stevens. As the chief architect and champion of the changes, he is critical to their success, especially at such a delicate stage in their evolution and before they have been fully embedded.

New Care Models and Sustainability and Transformation Plans

The election comes at a pivotal time in regard to progress with the New Care Models (NCM) nested in the Vanguards initiative and the evolving Sustainability and Transformation Plans (or Programmes if you prefer) (STPs) agenda.

“…opens up the prospect of further stalemate and a failure once again to get to grips with long overdue changes to reshape the NHS for the new challenges it faces.”

In the case of STPs, Labour has stepped back from its rather foolish pledge announced in the leaked manifesto to impose an immediate moratorium on them if elected. But while the final manifesto now states that Labour will merely ‘halt and review’ STPs, the move still heralds a return to heavy-handed ministerial meddling from the centre.

As a way of running the NHS, it has rarely if ever been desirable or worked. Moreover, it opens up the prospect of further stalemate and risks failing once again to get to grips with long overdue changes to reshape the NHS for the urgent and complex challenges it faces.

What’s needed?

For the changes to succeed requires sensible resourcing and sustained commitment over a reasonable time period, both of which are already fragile under the current government. If re-elected with a larger majority it is unlikely much will change which could leave the changes in a precarious state, especially when coupled with the desperate pressures the NHS is already under both in terms of financing and staff recruitment.

So, while perhaps not putting the changes at risk in the way Labour’s proposals seem destined to do, a Conservative government with a fresh mandate need not axiomatically be good news for the NHS.

If the political outlook for the NHS changes presently being implemented looks potentially bleak or risky whoever wins, it will be incumbent on senior managers and clinicians, perhaps with the support of the Royal Colleges and others, including local government, to lead and drive the changes.

An opportunity

The Vanguards and STPs represent a chance of a lifetime opportunity to transform the NHS as it approaches its 70th birthday in July 2018. Too often in the past resistance to change has won out and the result has been an NHS which in many respects has become ossified and no longer fit for purpose given the changes in demography, lifestyles and the evidence of growing inequalities.

“Too often in the past resistance to change has won out.”

Successive inquiries and critiques of the NHS have pointed to the repeated failure to take prevention and public health seriously, to integrate health and social care, and to rebalance the health system away from costly, acute hospital care. The Vanguards initiative and STPs are confronting head-on all these deep-seated systemic problems that have persisted in the NHS for decades.

Drawing conclusions from the NCMs is premature and inconclusive. Generalising from very complex and different models and contexts is a hazardous business. But, putting these health warnings to one side, the early evidence emerging shows a passion, enthusiasm and high level of commitment to make the changes work. They are also felt to be the right way to go in terms of patient care.

Once the evidence from the local evaluations starts to appear later this year, there will almost certainly be a mix of likely successes and failures although it will take longer to assess how far the changes have actually impacted on health outcomes. It is also the case that, as the Public Accounts Committee concluded recently, STPs are a mixed bag and of variable quality. In most places, engaging local government and the public should have assumed a much higher priority at an earlier stage.

But when all is said and done, the unprecedented transformation journey on which the NHS has embarked has given permission to local areas to chart their own destinies within a national framework providing support and development know-how. It is not perfect and tendencies for old-style, command-and control behaviour to surface have to be resisted. Nor is the overall financial climate helpful or sustainable although, if one is honest, resource pressures have been an important stimulus for change.

If the changes underway can be maintained post-election and the NHS becomes a genuine health service rather than a sickness one, which it has been since its inception, then that must be the goal of all those who want the NHS to survive and should be embraced enthusiastically.

Warts and all, we should not squander this opportunity to transform the NHS so it can meet the 21st century challenges confronting it. Surely that has to be a 70th birthday present to remember.

 

The health debate by David J. Hunter is currently available with 50% discount on the Policy Press website.  Order here for just £7.49.

Browse all the books in our 50% General Election promotion here.

Find out more about impact, influence and engagement at Policy Press here.

Policy Press newsletter subscribers receive a 35% discount – sign up here.

The views and opinions expressed on this blog site are solely those of the original blog post authors and other contributors. These views and opinions do not necessarily represent those of the Policy Press and/or any/all contributors to this site.

It’s not just about the money: 5 dilemmas underpinning health and social care reform

Following on from the publication of the third edition of Understanding health and social care, Jon Glasby looks at what’s needed for long-term, successful health and social care reform.

jon-glasby-pic-2

Jon Glasby

Open any national newspaper or turn on the news and (Trump and Brexit aside) there is likely to be coverage of the intense pressures facing the NHS.

Throughout the winter, there have been stories of hospitals at breaking point, an ambulance service struggling to cope, major problems in general practice and significant financial challenges.

For many commentators, this is one of the significant crises the NHS has faced for many years, and quite possibly the longest period of sustained disinvestment in its history.

“Draconian funding cuts have decimated services at the very time that need is increasing.”

Continue reading ‘It’s not just about the money: 5 dilemmas underpinning health and social care reform’


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