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.

Who Cares?

Whatever untold strife there is in Syria, Egypt, Afghanistan and Iraq, the undeniable and continuing news story at home is our national health service – the NHS itself and (in the wider community) social care services – especially care homes exacerbated by the government’s desire to cut costs and benefits as a result of government debts from the bank-induced recession.

In recent years, the intolerable conditions under which elderly and mentally challenged residents of social care homes were treated became clear. Attacks by staff on residents have been detailed and prison sentences resulted.

Then, in the last 12 months, publicity has focused on NHS hospitals – amongst them Mid-Staffs, Trafford and now University College in Wales. Poor standards appear to have led to deaths and misery and then a debate about how nurses, for example, spend too much time training and not enough caring, while week-ends are suddenly revealed to be understaffed and A&E (Accident and Emergency) services are under enormous strain.

So, Who Cares?

This is not just a sad reflection on critical institutions but appears to reflect very badly on ourselves as caring human beings and on whatever society we have created. Our demands are for low government spending and for maximum services as long as someone else pays. What has happened that makes us so uncaring? While this may not be on a scale like what has happened in recent years in Bosnia or Somalia or now in Syria, Afghanistan and Iraq, our insensitivities to other people have reached a sorry state – the governing State and its inability to provide the answer and the civil state that appears to be no better.

Quality of life has been subsumed in the message of “quantity of life” for so long – the pursuit of wealth as recorded in terms of money and goods – that we are failing to reconcile ourselves with the softer issues of existence. The pursuit of economic benefits has seems to have clouded out all else as we pursue ever higher GDP.

We blame government for this – but, government represent us, civil society, citizens and we get what, I guess, we deserve. David Cameron and his happiness index is a measure of the difficulties we are in – where we have to measure things before we do anything.

Measurement is a quantitative outcome of real activities. Hospital failures are deemed to be the outcome of rigid focus on targets and it is clear that we have, as a society, been totally brainwashed by the success of business and used its targeting approach to success in all other areas.

So, we set up targets for hospitals without understanding the qualitative targets that need to be set. This is the same as the setting up of government departments to quantify the value of natural capital (Natural Capital Committee at DEFRA) as that, seemingly, is the only way to guard against the complete destruction of our ecology. As a minor example, the only delight that most have in watching Antiques Roadshow is the valuation for each item – the genuine beauty of the item is sidelined as we wait for the valuer to tell us how much an item is “worth”.

We seem completely uncaring as human beings – sacrificed on the altar of quantity and unable any more to see the real quality of life.

Where is the Care?

Yet, not all NHS hospitals are death traps and by no means all medical professionals are uncaring – most aren’t. Indeed, it is likely to be a small minority that exhibits such immoralities. However, we have a developed a structure built on sand where managerialism and devotion to numbers and targets exist throughout and our obsession with quantity overrules quality.

This is why MRSA took such hold in British hospitals for so many years – because other obsessions took firmer hold.

So, where is the care? Will it come from the new agenda that is being pushed  – the wellbeing agenda? Will the Health and Wellbeing Boards (around 150 have been set-up throughout England) result in an infection of caring and quality? Will top-down direction result in a change in culture that is professed throughout.  Will the CQC be suddenly changed into a care organization? Will expert inspections be the savior? Or will the whole be an edifice, behind which politicians hide proclaiming that they did their job and it was the professionals that failed – or are we simply kidding ourselves that top-down, outside inspection and control can fix the problem.

The Caring Sectors? Chaos in Conformity.

The NHS and Care homes suffer from a culture problem and a procedures-driven mentality that eschews common feelings. NHS facilities are procedures-focused to the extent that it is amazing that breathing can be undertaken without supervision. Everything is policy-controlled and process. It is no wonder that care is forgotten. All who have it are in danger of losing it once they enter the profession – those that retain their care mentality are fighters and have to be for their morality to survive.

I have seen the evidence of this, not in a hospital but in the charity sector. – the so-called Third Sector. Charities are centres of care where the whole focus is on the cause. This key focus is driven by founders with vision and caring and with funders who buy into that care and cause agenda.

Sometimes, well-meaning Trustees bring in NHS or NHS-related people to run a charity – thinking that one non-profit is much like another. So wrong!

What often happens is that the charity is swarmed over by policies and procedures and directives and by new people brought in from outside (often the NHS) who “get” the new mantra. Soon, the charity is losing its way and its cause is forgotten in the chaos of conformity that ensues.

I believe that the charity sector (really the second sector in the caring sector as it was the precursor to government involvement) is where real compassion and caring still resides. Like a treasure-box of solace for humanity, the charity sector is built on causes and full of people that care – quality of caring and not quantities of statistics.

I have myself spent many years in the business sector, where care for customers is paramount but so is the quantifiable bottom line. Customer care leads to better profits and well-run companies know that their profits will be hit hard if customers suffer. However, care for customers means doing business well – good design, well priced goods and services, good after-sales, better call centres, smiles and the like. The aim is to make profits – one bottom line – but thorugh a complex array of inputs, outputs and outcomes.

In the charity sector, there are two bottom lines and two customers. The main one is the cause – the caring for the beneficiaries of the charity. The second is the funder – the provider of the funds for the cause and a way to break-even and grow the charity to satisfy the needs of the beneficiaries.

This balancing of the two bottom lines is crucial to the success of any charity and the care side is just as important as the funding. It comes first but is dependent on the other. Two sides of the bargain.

I continue to be overwhelmed by the people that work in and volunteer for and fund charities. From the largest like Macmillan Cancer Care and Cancer Research and WWF to the smaller ones like Willow (where I am CEO) to campaigning charities to health charities, the vast majority are focused, and relentlessly determined to make their charity successful. To do that, they have to positively impact their cause.

This is a learning tool for the national health sector (both public sector and private sector) in the UK. The challenge of wellbeing is to harness real caring into the morass of policies and procedures that entangle the NHS and the profit-motive that engulfs the care homes. Amongst the top-down rules and strategies that the Health and Wellbeing Boards adopt should be the adoption of the basic tenets of the charity sector.

The Third Sector Infiltration

What does this mean? Well, first, ensure that there are charity people on the Health and Wellbeing Boards. This means real, caring people that understand the challenges of the two bottom lines and have shown some success. Such people run and work in hospices across the country as well as service-type charities like MacMillan and many others.

Second, adopt the two bottom lines. Understand that the cause is as crucial as the finances. Just because in the public sector there is only one funder does not mean that that monopoly funder should run the organization. Being “funder led” is a sign of disaster in the charity sector. It should also be in the public sector. Sure, we want effective use of taxation in every public sector area but the balance should be in place and the only area where that balance is in place is in the charity sector.

Third, Government must take the role of the interested funder – not the shareholder. This is civil society money raised from taxation but to be used for a good cause. It is the wrong balance if the Treasury is the only arbiter. The Department of Health (and wellbeing?) is the funder and the CCG (Clinical Commissioning Groups) are the funders – can we trust them (the General Practitioners and members of other NHS organisations) to provide care objectives when they are the “commissioners” – the buyers? Who represents the citizens – civil society – the patients? Where are the patients represented anywhere? Who demands that care forms the agenda – the Health and Wellbeing Boards?

Yet, they are mainly formed of our representatives – local councilors and the like. Where is the care sector involved? The “caring professions” have, unfortunately, been tainted by the recent past – it is now a good time for the Third Sector to be properly represented in the world of care to a far higher extent than David Cameron’s vision of a caring Britain (his Big Society) where charities were lumbered with being low-cost alternatives to local authorities and hospitals. It is time for a reverse takeover – with caring in the lead.