25th November 2016

Missing Medical Opportunities and Person-Centred Limits?

Missing Medical Opportunities and Person-Centred Limits?

Social care has been moving inexorably over past decades, from a heavily medicalised model with an emphasis upon disease and disability, towards a more distinctly social model. This has led to a transformation in the way in which services are structured, organised and delivered. The clearest illustration of this being the massive programmes of deinstitutionalisation of learning disability and mental health services which continues today.

Highly centralised services based around the large old Victorian hospitals have been replaced with far more local and flexible services, capable of integrating and supporting the individual within their social world.

Welsh Social Care Model

In Wales, the contemporary vision for social care is embodied within the Social Services and Well-being Act (2014), with its emphasis upon well-being and person-centre care and support.

The use of the word ‘care’ and its replacement in the legislation with the term ‘support’ is a case in point. ‘Care’ was more closely associated with the medical approach of looking after (caring for) an individual rendered passive and inert by their medical ‘condition’ and its treatment. The language reinforces a ‘sick role’ much studied by psychologists and sociologists, whereby individuals are encouraged to adopt a passive response. Thereby allowing experts, or designated carers, to dictate the course of treatment. Once adopted, the role can be difficult to escape from and for individuals with enduring and lifelong conditions this could mean limited choice and autonomy or complete institutionalisation.

Positives and strengths

The social model, by contrast, has moved to a position of emphasising strengths, resilience and abilities - thus minimising the passivity inherent within the care concept. At its best this helps bring about highly active and engaged service users within services enabling and facilitating well-being. Also,  highly responsive and personalised packages (interventions), focused upon the wishes, aspirations and needs of the service user.

Whilst this shift is undoubtedly a good thing, it has caused me to reflect upon whether we might lose sight of the need for good medicine and proven medical interventions, because of over-focusing on individuality? Is there also still a need for service managers to assess aggregate needs as well as individual needs within their services? In order to facilitate areas such as training plans, recruitment of suitably experienced individuals, building design and alterations etc.?

Perhaps its a question of maintaining an overview as well as seeing things at a highly-individualised level. Medical science functions on the level of population norms in order to identify abnormalities of function, which become categorised as disease processes. Understanding the causation, course and outcome of disease allows therapeutic interventions which can be tested and evaluated for efficacy.

Whilst we don’t want to herd individuals into one-size treatment or care solutions, we might wish to ensure that the disease element within an individual’s totality of need is addressed, diagnosed, treated and managed effectively.

Example

Amir is an individual who presents with challenging behaviour within a residential service. The service manages the behaviour skillfully and appropriately but has not considered the possibility of an underlying illness. Conceivably he may have an underlying anxiety disorder, a thyroid illness or other diagnosable condition. However, the failure to properly investigate the cause of the behaviour means that the service is missing opportunities to better support Reg, and prepare their staff for the role which they undertake in supporting Amir.

Services which only address the individual’s wishes and presenting behaviour will miss an opportunity to treat at least one potential cause of the challenging behaviour.

Broad based model

Under the SSWA, local authorities have a responsibility for collating data for needs assessment. This suggests service providers themselves will need to input into this data collection. But with such an absorbing focus upon person-centredness, I wonder whether collating data will fall down the to-do list and become a tick-box response. Whilst person-centred is good, properly contextualised within a biological/medical and social model, it is surely better.

*All information is correct at the time of publishing

Nic Bowler

Welsh Care and Social Services Inspectorate Specialist

Dr Nicholas Bowler is a researcher and consultant to government-level [Welsh Government Review of Secure Services, 2009] – specialising in QA/compliance focused projects. He has interests in clinically relevant training, service development and research. He enjoys working with clients to support them in identifying problems and initiating projects to improve practice.

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