The Cost v Care Dilemma


Contention: there are two opposing forces within our care professions (which include the hospitals and broader care industry) – cost v compassionate care. It is often put forward that they are incompatible. They cannot be.

The Dilemma

My previous post looked at whether the NHS and care industry can provide  “care” and how the charity sector has a single-minded pursuit towards compassionate care that could assist the public sector caring professions and should be sought out to advise on care in the medical and social care services.

Someone for whom I have a great deal of respect, Richard Murphy (through his Tax Research UK ), reminded us of a post he made back in 2011:

He reminded in a more recent blog that, in the UK, we have a National Health Service (NHS) which is highly rated in international comparisons.

This high rating (2nd out of seven major nations), was at the expense of one measure where we came 7thpatient centred care. Richard Murphy, who wrote the article shown, declares that “we trade something important here: price for patient focus.”

This shows the dilemma that we appear to face. On the one hand, we (the tax-paying public) may want public sector spending kept down (and thereby keep the taxes we pay as low as possible). On the other hand, we (the hospital-attending public) want our public services to be provided to the highest quality. What does not take place in any rational way is a discussion about the quality of service that we demand and the price we are willing to pay for it. There are reasons for this.

Government, which runs the National Health Service and regulates the rest of the medical and social care industry, has one of two political defaults. It either wants to run everything centrally – which led in the past to doctrinal key performance indicators with its huge range of unintended consequences; or, it wants competition where each hospital trust can do its own thing because they are somehow in competition.

What is not understood (because no-one at a macro-level is putting enough time to do it) is how to establish the qualitative measures that we need so that a real Care Quality Commission (CQC) or other monitors would properly be able to judge performance and adequacy with the same prestige as those who guard costs.

Who Really Cares?

I mentioned in my July post that I was Chief Executive at Willow – where we provide Special Days for seriously ill young adults. I am leaving this month and will genuinely miss Willow. It personifies charitable and compassionate care throughout.

An excellent charity, it was founded in 1999 by Bob Wilson (ex-Arsenal double winner, BBC/ITV broadcaster and now Arsenal Foundation Ambassador) and his wife, Megs, following the death of their daughter Anna from cancer. Willow provides around 1,000 Special Days a year for young seriously ill adults (www.willowfoundation.org.uk) . These Special Days provide benefits on three levels: the day itself – a respite from treatment and an opportunity to do something extraordinary with your family and / or friends; positive emotions that result from the Special Days for at least two months – described by the Centre for Applied Positive Psychology (CAPP) as “Astounding!”; the impact of the Special Day both for those in a palliative condition (where they are able to focus on the Day from the time of application) and for those in a curative condition – where the day often results in a change of lifestyle – providing a momentum to start work again, a drive to get back to family life or something new.

Willow’s stories (and Willow is about to provide its 10,000th Special Day) are many and varied.

What each story shares in common is the ability to provide something way beyond repair – even beyond care. The degree of wellbeing (as evidenced by 1000’s of stories) results in Special Day beneficiaries and their families wanting to give something back to Willow – to fundraise and volunteer – and we have now formed an Alumni Association (maybe the first in a charity) for our beneficiaries and those close to them.

This is charity-provided wellbeing which adds to the excellent repair services from the medical community and the care services of hospices. It provides a respite for families who are the traditional “carers” and an opportunity for all to spend time in a positive mind-set that we know enables beneficiaries to take advantage of whatever life has to offer.

This microcosm of our society (there are 100,000 young adults in the UK at any one time who are suffering from an illness that could require palliative care) exhibits many of the issues that we confront in our trade-off between price and care (between cost and quality).

Willow does not question the treatment that any of our beneficiaries obtain in hospitals and hospices, for example. We don’t comment on them and have no desire to do so. What we witness is the complete desire on the part of our beneficiaries and their families and friends to take advantage of something so different and so positive. That Willow provides, through charitable contributions, something so remarkable is to the good. The question is why there is such a difference between what Willow provides and what appears to be provided within the NHS and elsewhere? Is the desire to remake the NHS from a repair organisation to a wellbeing one as proposed by Norman Lamb (Social Care Minister) real? Or is the trade-off between cost and care too great?

A caring organisation – the control:care plateau

What does it take beyond government rhetoric to make compassionate  care within the public sector real? It cannot be just a phrase that is uttered by a Minister with an expectation that it will immediately be understood and implemented. Compassionate care requires the whole organisation to absorb the need as a key value – supported by processes, training and monitoring. This requires management who can embody the spirit of care and staff willing to take it on. It requires sufficient staff who have the time to provide the care that it needed – sometimes it is the time itself that provides the ability to show the care.

At Willow, we have four underlying values that shape everything we do. We aim to be:

Effective    /    Positive    /    Innovative    /    Compassionate

We aim that each person that works at Willow (whether as a Special Days co-ordinator – who works with beneficiaries and medical professionals to put on the day – to a fundraiser or someone in Finance) embodies each of these values.

  • Effective (rather than efficient) means that we add value and are seen to do so;
  • Positive means that we seek to be pro-active (glass half full);
  • Innovative means that we are continuously seeking to do things better;
  • Compassionate means that we care – and show it to our beneficiaries and to staff and to funders and to whoever else Willow comes into contact with.

So, it is a balance between the two bottom lines that I discussed in my previous post – we have to balance a proper degree of control with a proper degree of care. These are not mutually exclusive. We believe and show that the control : care plateau we have reached is a good one but that we have to continuously strive to raise our sights to a new plateau. For us, a focus on care underlies what Willow is all about.

Within the NHS, this trade off has been seen to be an “either / or”. Richard Murphy’s comment strongly suggests (and Richard never meekly suggests anything)  that the national health service has to make a choice – not a plateau of control : care but a choice between them.

This assumes that the prime requirement is to repair the physical when holistic treatment should be in place. Moving from repair to wellbeing is not just a preventative message but one where the wellbeing of a patient comes from an understanding that they have as much right to a fulfilling existence as anyone else. This does mean that the way they are treated has to be via a care policy that is not just understood but embedded and funded.

From All those Reports to Compassionate Care

The Francis Report showed that the standards of compassionate care were too often far too low. Unfortunately, the remedies that the media have focused on relate to punishment and monitoring. Great quality of care cannot be monitored in; great compassionate care cannot be sought though punishment when things go wrong.

The Berwick Report into safety in the NHS properly focused on what could pro-actively be done to reduce accidents, for example, and that purely quantitative measures (“naïve or mechanistic targets”) are insufficient and, on their own, damaging. The Report stated that the problems in care happens despite the good nature of the staff:

“Most impressive of all, perhaps, has been the consistent dedication to helping their patients among the vast majority of clinicians—doctors, nurses, pharmacists, allied health professionals, mental health professionals and many more—as well as non-clinical staff”.

From all these reports, we now have to move on. I believe there are four, crucial outcomes that include:

  • ·         the need for organisational approaches from the top – values have to embody compassionate care; they include the need for qualitative measures which may best be made around stories like in Willow’s case and a process being followed up in a number of hospitals (in Mental Health as an example);
  • ·         the need for a cost and care balance – an agreed plateau that provides in each hospital satisfactory levels of both;
  • ·         the need for innovation in care and understanding of care needs – just as important in holistic treatment as new equipment or methods of surgery;
  • ·         continuous learning and best in class understanding from wherever this can be obtained – often from the charity sector where compassionate care is the underlying value.

Moving from a sense of mutual exclusivity and away from

Costs v Care

to a

Cost : Compassionate Care plateau

Should be the new normal of 21st patient care wherever practised: no either / or but an acceptable balance of care and costs.

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