Personalising the policy of the personalisation of care

Today there is a conference  to re-launch the NHS and social care services offer around the personalisation of care. I’m one of the speakers and will be explaining how we need to personalise change in the NHS and social care through narrative and storytelling. (You can watch by following @IPCEngland on Twitter).

Of course, personalisation of care isn’t ‘new’. Clinicians, and especially social care workers, have been developing practices that personalise care for some time. And there are now streams of practice where this has become the norm.  Personal Care budgets have been a part of mainstream social care for some time and are now growing inside the NHS. GPs are famously referred to a text book during their training that states that when a GP meets a patient it is a meeting of two experts. One of them possesses considerable medical knowledge while the other has a vast personal knowledge of their condition that the GP needs to learn how to use. Initially through taking a personal case history and subsequently by creating any treatment regime.

Similarly, there has been for some time been a policy of shared decision making where the patient is informed of all their options and has an active role in making the medical decisions about their treatment. Mental health patients – themselves so much the engine of their own improvement – have to be fully involved in any recovery.

So why a relaunch of this policy in June 2018? And what will I be arguing?

The issue is that much care is not as personalised as it needs to be. A 75 year old woman with three long term conditions is more likely to be treated as if they were three different people with three different conditions rather than as one individual with three conditions. This is not just inefficient medicine (which it is, and at a time when we are seeking greater efficiency) but it also fails to appreciate who this woman actually is as an individual. Aside from her three conditions she has a family who she loves and who love her; she lives in a community where she is known and is active – there are a wide range of other activities that are a part of her life. Managing her health as a person goes way beyond being treated separately for three long term conditions.

Given that this woman is in fact the median person that the NHS and social care are working with in 2018, then the reality that her care is not being developed around her as a person, is very important. It represents the experience of millions of people. And this lack of personalisation has a big impact not only on their experience of poor care, but also on the capability of the NHS and social care to carry out its role in our aging society.

The argument for the personalisation of care is not that it’s a nice ‘extra’, but that for it to work we need much more active patients. And for them to be more active we need to ensure that we understand and treat them as individuals. Of course many clinicians do try and do this, but some find it an addition to their core task that goes some way beyond what comes purely from the application of medical knowledge.

That is why personalisation in many parts of practice depends upon the development of paraprofessionals to help existing clinicians with this task. Last week I posted about the importance of what I called ‘health trainers’ (they go by a range of different titles) in helping GPs to develop the social prescribing offer that is so important to patients and the public. The public need to spend more time with health and social care staff than the existing categories of highly qualified staff can deliver.

Increasingly we will hear more about the policy and practice of the personalisation of social and health care, whether it is shared decision making, personal health. budgets or social prescribing.

My task at today’s conference is to talk about we can make out a case for the personalisation of health and social care.

Firstly I am returning to the idea of creating a narrative for change. This is based around viewing our work and practice as a story, so that developing a different practice will need a different story.

This narrative for personalised health and social care starts from the fact that NHS and social care staff are already doing this is different parts of existing services. Over recent years all of the strands of personalised practice have already been developed. They are not new ideas that NHS policy is pushing – they are existing practices that are already happening. Policy is secondary to practice here.

Secondly, modern medicine and social care needs active people. We need people to be active in their own health and social care both before and after they need it. The more agency that people have in their own health and social care, the better they will develop. For some, those who are very ill, this is not at all easy – but for most there is greater agency and activity to be developed. If NHS and social care services are to help encourage that agency they will have to discover much more about the specific individuals for whom who the services are needed. Suggesting to someone who is depressed that they ‘should get out a bit more’ is indeed useful advice. But recognising that that person used to be a keen gardener, or has a daughter five streets away will help uncover the mainsprings of motivation to increase that necessary agency.

So personalisation of services has a much better chance of increasing agency. I’ve published my overall draft narrative here.

My main point is that if we want to encourage staff into new ways of working, then we need to do more than just develop a new policy. Very few people do new things or change their minds because of a policy.  They do so because they are emotionally persuaded of the new. And that emotional persuasion comes from being in touch with new stories of how the new world might work.

In the last few days we have seen the power of new narratives. The Irish referendum on abortion was full of different forms of persuasion as the insightful Irish journalist Fintan O’Toole noted recently,

“The political has to be personalised. The greatest human immune system against the viruses of hysteria, hatred and lies is storytelling. Even when we don’t trust politicians or experts, we trust people telling their own tales. We trust ourselves to judge whether they are lying or being truthful. Irish women had to go out and tell their own stories, to make the painful and intimate into public property…. It is unstoppably powerful… exit polls showed that by far the biggest factors in determining how people voted were ‘peoples personal stories that were told to the media’”

If we want to develop the practice of health and social care staff, then we need to use real stories of real people that demonstrate how important change is.

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