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The College reply to Francis misses the big question: a commentary on OP92

  • John Cox (a1) and Alison Gray (a2)
Summary

The College has recently published an occasional paper in response to the Francis inquiry into the care at Mid Staffordshire NHS Foundation Trust. We consider that it overlooks one key question implicit in the inquiry's recommendations: ‘Is the business model of care fit for purpose?’ We question whether the business model in its present form is appropriate for the delivery of healthcare. We suggest there is a need for greater conceptual clarity with regard to the nature of compassionate care and the meaning of person-centred medicine. We recommend that a broader moral and ethical framework is considered not only for psychiatry, but for all healthcare provision which would transcend specialty and Royal College boundaries.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Declaration of interest

None.

Footnotes
References
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1 Rayner, G, Adams, S. Mid Staffs report: Failure at every level has shaken trust in the NHS. Daily Telegraph 2013; 6 February.
2 Royal College of Psychiatrists. Driving Quality Implementation in the Context of the Francis Report (Occasional Paper OP92). RCPsych, 2013.
3 Armstrong, K. Twelve Steps to a Compassionate Life. Bodley Head, 2011.
4 Gilbert, BJ, Maruthappu, M, Leaver, L, Gray, M. Morality in the NHS Marketplace. Lancet 2013; 382: 2065–6.
5 Cox, J, Gray, A. Médecine de la Personne and the lost morality of the NHS in England (letter). Lancet 2014; 383: 696.
6 Tyrer, P. A solution to the ossification of community psychiatry. Psychiatrist 2013; 37: 336–9.
7 Raycheva, RD, Asenova, RS, Kazakov, DN, Yordanovd, SY, Tarnovska, T, Stoyanov, DS. The vulnerability to burn out in healthcare personnel according to the Stoyanov–Cloninger model: evidence from a pilot study. Int J Pers Cent Med 2012; 3: 352–63.
8 Morrison, L, Gillies, J. Dr Pat Manson and the way forward. Br J Gen Pract 2012; 62: 603.
9 McCabe, S. Where have we gone wrong? Br J Gen Pract 2013; 63: 35.
10 Gill, R. Moral Communities. University of Exeter Press, 1992.
11 Owen, D. Researcher into hubris. BMJ 2014; 348: 6.
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The College reply to Francis misses the big question: a commentary on OP92

  • John Cox (a1) and Alison Gray (a2)
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eLetters

Re: The sacred, the profane and the Francis Report

John Cox, Professor Emeritus
18 November 2014

We welcome the opportunity to reply to Professor Poole's stimulating and challenging commentary on our editorial which, even if misunderstood, has clearly succeeded in alerting the readership to the pressing managerial and moral challenges for the NHS in the aftermath of the Francis report.

The College in its six month update of its report has a further chance to unravel the complex contributing circumstances in Mid Staffordshire, and to consider not confining its recommendations to mental health services alone. The failure to put patients first and the neglect of basic quality of care standards could be replicated elsewhere (1). The task is not confined to applied scientists but involves values aswell as the personal ethics of members. Therefore in appearing to belittlethe contribution of moral philosophers, comparative religion experts and even patient groups to the consideration of the roots of compassion and tothe conceptual underpinning of patient centred care, Prof Poole is out of kilter with much local and international work in this field (2).

We would wish also to counter his suspicion that the source of our dissatisfaction with OP92 was linked to a secret Christian plot to impose our religious values on others of a different faith or none. That was far from our intent - as a detailed un-blinkered reading of the editorial would confirm. Moreover our earlier disclosures of interest were as cited,but have been repeated without first checking neither their current accuracy, nor the precise context in which those declarations were appropriate. For the interest of readers, JC remains a lay member of a Methodist Church in Cheltenham; AG is now an associate priest in the Church of England, and the Centre for the study of Faith, Science and Values at the University of Gloucestershire closed last year.

Rex Haigh and colleagues, on the other hand, are correct to have identified our implicit awareness that the values of the therapeutic community, the understandings of the need for healthy environments respectful of the person - and the grasp of group processes - have each conditioned our search for solutions to the current NHS impasse. The excellent work undertaken by the College's Centre for Quality Improvement (CCQI) was referred to in our editorial and in the College response. It is much to be hoped that the CCQI will increasingly be more integrated with the other College structures in Prescot Street, so that its impact onroutine medical work in acute hospital care (such as intensive care, a GI cancer service or a primary care community unit) can be facilitated. Thelack of uptake of the CCQI's projects in the NHS (other than the Quality Network for Perinatal Mental Health Services, which is conspicuously successful (3)) is, in the context of the Francis recommendations, a causefor much concern and may be symptomatic of the current malaise.

We thank both correspondents for prolonging this timely and importantdebate. We conclude by declaring an interest in the hope that the College,in tandem with other national organisations, will seek for a majority opinion about the nature of these key structural issues in the NHS - including the fitness for purpose of the competitive business model - and also facilitate a greater understanding of the conceptual (biological, philosophical, ethical, humanistic and religious) underpinning of the nature of health, the process of healing and the primacy of the person.

References:

1. Dewhurst NG, Jones MC, Wilson JA . Time to refocus the NHS on Quality and Dignity of patient care: RCPE response to Mid - Staffordshire.J R Coll Physicians Edinb 2013; 43; 3-6

2. Miles A , Mezzich JK. Person centered Medicine; advancing methods,promoting implementation. International Journal of Person Centered Medicine. 2011,vol 1,3,423-425.

3. Solomon S, Thomson P. The Quality Network for Perinatal Mental health Services. Centre for Quality Improvement. Royal College of Psychiatrists, 2010

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Conflict of interest: Revd. Dr Gray is a Non-Stipendary Associate Priest in the Church of England.

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The sacred, the profane and the Francis Report

Rob Poole, Professor of Social Psychiatry
26 October 2014

In December 2013, the Royal College of Psychiatrists published an occasional paper responding to the Francis Report, OP92. In an editorial (1), John Cox and Alison Gray stridently criticise the document. In contrast, I believe that OP92 strikes exactly the right tone and that the actions it sets out should be strongly supported. All members of the College should read it (it is available at the College website). It succinctly relates principles to the actions that the College is taking.

I suspect that that the source of dissatisfaction for Cox and Gray lies in the following passages in the document: "Responses to inadequate or abusive practice tend to emphasise the practical, ethical or moral failings of individuals. These are relevant, but, alone, statements of the importance of compassion, patient-centred care and the duty of candour are unlikely to prevent further scandals. Inadequate and abusive care arises in response to situational forces and a variety of behavioural cues" (OP92, pages 4-5).

"We need to take on board the lessons of the Milligram (1974) and Zimbardo (Haney et al, 1973) experiments, namely that ordinary, decent people will behave badly in environments that are not designed to help them to behave well" (OP92, page 5).

This touches on a systemic and empirical understanding of the problems in British healthcare delivery, which is exactly the appropriate approach for applied scientists to take. However, Cox and Gray seem to prefer a model of moral decay, which they want addressed through urgent dialogue between the College and the medical profession in general on the one hand, and religious leaders and thinkers on the other. They introduce this suggestion through the rhetorical device of an allegation that OP92 fails to address the inadequacies of the "business model" in health care. This criticism is in any case inaccurate; OP92 includes an implicit critique of the entire system and the clinical environments it creates, as can be seen in the passages I have quoted. It is disappointing that Cox and Gray declare no conflict of interest in their editorial. Four years ago, in a letter to this journal (2), they supported a call by Robert Higgo and myself (3) for the College to establish a Working Party on Psychiatry and Religion. Their declaration of interest in that letter was as follows: "John Cox is a Christian from the Methodist Tradition. Alison Gray was recently ordained Deacon in the Church of England", and their affiliation was stated as "Centre for Faith Science and Values in Healthcare, University of Gloucestershire". Cox and Grays' religious faith may well help them to adhere to their own moral standards. They have every right to understand things that go wrong in the world in terms of morality and religious faith. These are personal matters. The suggestion that the Royal College of Psychiatrists should take such a position is wholly inappropriate and wrong. The College has important institutional roles concerning ethics and proper professional behaviour, which are part of its overall raison d'etre: to maintain and improve standards of care for patients. These roles would be utterly compromised by dabbling in morality and religion. If the College were to take a position on individual morality informed by religious thinking, we would enter a morass of schism and conflict. This would do nothing to protect patients. Three years ago, concern was raised that the ostensibly anodyne College Position Paper (PS03) 'Recommendations for psychiatrists on spirituality and religion' would be taken as permission to breach professional boundaries with respect to religion (4). The vast majority of psychiatrists successfully avoid inappropriate inter- digitation of faith, belief and professional practice. It will not be just the atheists who will find Cox and Grays' editorial worrying.

References:

1. Cox J, Gray A (2014) The College reply to Francis misses the big question: a commentary on OP92 Psychiatric Bulletin 38:152-153.

2. Cox J, Gray A (2011) Proposed College working party on psychiatry and religion The Psychiatrist 35:118.

3. Poole R, Higgo R (2010) Psychiatry, religion and spirituality: a way forward The Psychiatrist 34: 452-453.

4. Poole R (2011). "Praying with a patient constitutes a breach of professional boundaries in psychiatric practice: Author's reply". British Journal of Psychiatry. 199: 518.

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Conflict of interest: I am an atheist

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