Awareness and kindness remain priceless

Published: 18 January 2011

Ghislaine Young writes about the paradox of providing high-quality care amidst a climate of cuts and cost saving.

Happy New Year one and all! The year 2011 promises to be a strain on all those delivering front-line care to patients. Not only are primary care trusts (PCTs) becoming reshaped into commissioning consortia – causing some uncertainty and mayhem in the process – but also hospital trusts are being told to cut costs without endangering patient care! How is that possible, you may very well ask?

Remaining committed in the face of adversity

Those of us in GP land are still encouraged to practise by numbers. By that I mean delivering Quality Outcome Framework (QOF) targets – medicine at its most reductionist! Des Spence in the British Medical Journal (BMJ), recently wrote a scathing article on what he calls ‘bad medicine’ and ‘bad general practice’, stating: ‘... the quality of care has little to do with algebra and all to with attitude.’ Yet the problem is this: how do you inspire and motivate health professionals to provide high-quality patient care without relying on renumeration and performance management?

Nurses, historically, have always been paid salaries, so it is easy to criticise GPs who are in effect self-employed and whose income is determined by delivering the Government’s health agenda. So in the coming months of cost saving, how do we remain committed to the best care our patients deserve?

The art of nursing and compassion

There is a paradox: nursing and medicine are at their very centre an art form, but one which relies on a hard scientific evidence base if we are to keep patients safe from harm. Primum non nocere (‘First, do no harm’) is the directive that ever guides our practice. The synthesis between the art and the science is the way to achieve the care and the cure, and this means not merely what we do to patients but how we do it. Care and compassion are cost neutral, so when money runs out for hospital beds, for equipment and for staff, let us rely all the more on our interpersonal skills to respond to our patients’ needs: awareness and kindness cost nothing but are priceless!

Seasonal influenza and the H1N1 virus are straining our already stretched NHS. The difficulty here is amongst the hundreds of patients who present with minor coughs and colds – how do we spot the one patient who is fast sinking into an acute, severe and possibly life-threatening illness? We need to keep our heads and our common sense and yet refrain from becoming blasé – we must remain able to recognise any patient who really needs our diagnostic skills and prompt intervention. Needles in haystacks come to mind!

Complex patients... what to do?

Another difficult scenario is dealing with patients who don’t fit into neat little diagnostic criteria: the so-called patients with ‘medically unexplained symptoms’ (MUS). The Royal College of General Practitioners (RCGP), jointly with The Royal College of Psychiatrists (RC PSYCH), has produced guidance on how to manage these often very complex patients. As ever, the difficulty is managing uncertainty and not being completely overwhelmed by our patients’ physical symptoms when, at the root of it all, there may be psychological trauma.

The guidance quotes Sir Henry Maudsley (c. 1907): ‘Sorrow which finds no vent in tears may make other organs weep’. The strategy with these patients is to listen actively to their ills and to allow them to find the words to express their feelings and their pain, and then to empower them to help themselves. ‘Our remedies oft in ourselves do lie’, as Shakespeare himself pronounced in All’s well that ends well. This strategy also means refraining from multiple referrals to other agencies and keeping medications to a minimum.

If you can bear one more quote, it is this (also taken from the MUS guidance):
  ‘It is not what you say that matters but the manner in which you say it: there lies the secret of the ages.’
– William Carlos Williams, American poet, 1883–1963.

And finally, take good care of yourselves. We have passed the winter solstice – light and the promise of spring time is on the way!