‘I'm beyond caring’, a response to the Francis Report: the failure of social systems in health care to adequately support nurses and nursing in the clinical care of their patients

Lord Francis was commissioned to look at why the serious problems (between January 2005 and March 2009) at Mid Staffs Foundation Trust were not identified sooner and the appropriate action taken. Lord Francis was also asked to outline what lessons could be learned to enhance patient care. The report was delivered on 5 February 2013 and contained 290 recommendations. The key message was that the National Health Service needed to put the patient first and everything else should flow from that principle. Poor standards of care should not be tolerated and staff would be expected to speak out when they felt patient care was being compromised. Lord Francis also recommended that there should be one regulatory body and that the role of the Care Quality Commission was to be reviewed.     

Spiritual advisors and old age psychiatry in the United Kingdom

This survey investigates the role and views of NHS spiritual advisors across the United Kingdom on the provision of pastoral care for elderly people with mental health needs. The College of Health Care Chaplains provided a database, and questionnaires were sent to 405 registered NHS chaplains/spiritual advisors. The response rate was 59%. Quantitative and qualitative analyses were carried out. Spiritual advisors describe their working patterns and understanding of their roles within the modern NHS, and their observations of the level of NHS staff awareness of the importance of spiritual issues in the mental health care of older adults. They provide insights into possible negative and positive perceptions of their roles at a service level, and contribute suggestions of topics relevant to shared education between pastoral care and clinical services. This survey further highlights ethical and operational dimensions at the point of integration of the work of spiritual advisors and multidisciplinary teams.     

QALYs—A Threat to our Quality of Life?

ABSTRACT QALY calcuations are currently being considered in the UK as a way of showing how the National Health Service (NHS) can do the most good with its resources. After providing a brief summary of how QALY calculations work and the most common arguments for and against using them to set NHS priorities, I suggest that they are an inadequate measure of the good done by the NHS because they refer only to its effects on what will be defined as the 'patient community'. The benefit of the NHS to the wider community is best regarded as a public good—everyone benefits from the general belief that the NHS is there to provide care for those who fall into a state of medical need. QALY ideology threatens this belief because it gives efficiency a higher priority than caring in response to need. It is a fallacy that a QALY maximising health service will be a greater good to society, because this sort of quest for efficiency threatens the caring basis of the Welfare State as such.     

Chapter Four of Evangelii Gaudium: The Social Dimension of Evangelization

This contribution summarizes the four major sections of Chapter Four of Evangelii Gaudium, and offers reflections about the papal text. It concludes with Pope Francis’ proclamation that the kerygma is at the heart of evangelization, but that the gospel message has necessary social implications. Chief among those implications are treating the poor with justice and building cultures of peace through social dialogue. Francis is not the first to say these things, but he brings a genuine modesty to expectations about the role of the Petrine ministry within the process of evangelization. He also brings a direct and urgent style to articulate the centrality of the social dimension of evangelization.     

Community‐oriented primary care: a multidisciplinary community‐oriented approach to primary care?

Developing more of a local public health focus, and involving local communities in Great Britain in health care decision‐making, are key aspects of the radically changing face of primary care. Community‐oriented primary care (COPC) is an international model for innovative primary health care delivery historically applied in developing or deprived communities, but increasingly seen as having broader relevance for a wider range of primary care settings. COPC has a long history of development in deprived communities, it is still however seen as innovative. It fits the current requirements of clinical governance and the ‘Modern and Dependable NHS’, but does its long history also provide information about it's pitfalls? COPC is promoted as an approach that is applicable to community mental health problems, community psychologists can provide the expertise to facilitate addressing community mental health in COPC programmes. This paper describes the COPC model and highlights the relevance of the COPC philosophy and the problems of its implementation for community psychologists in primary care. Copyright © 2001 John Wiley & Sons, Ltd.     

Council-Based Approaches to Reforming the Health Care Response to Domestic Violence: Promising Findings and Cautionary Tales

Councils are commonly formed to address social issues including intimate partner violence (IPV). Research suggests that councils may be well positioned to achieve proximal outcomes, but that their success may depend on contextual factors. The current study compared providers and health care settings at two points in time to explore the degree to which the Health Care Council achieved proximal outcomes in the health care response to IPV, including: (a) providers' reported capacity to screen for IPV, (b) providers' beliefs about IPV as a health care issue and about the IPV screening process, (c) providers' screening behaviors and (d) organizational policies and protocols to encourage screening. This study, while preliminary, provides support for council-based efforts to stimulate change in the health care response to IPV and also highlights the central role that organizational environment plays in shaping desired outcomes.     

Counselling — Why not? A qualitative study of people's accounts of not taking up counselling appointments

The aim of this research was to explore the reasons behind people's decision not to take up a counselling referral. A qualitative study was carried out, using semi‐structured interviews and written responses. The investigation was based in NHS primary care counselling services in a GP practice in the North of England. People who had been referred for counselling by their GP, but did not attend any counselling appointments, were interviewed or invited to submit written comments. Many people talked about the courage it took to ask for help. The referral itself was sometimes therapeutic as it legitimised their distress. The GP's response affected people's decisions. Waiting time and what happened during waiting was important. Some people had their own resources, which they used actively, seeking other sources of help; others were more passive, their lives changed around them. Other factors that contributed to non‐engagement were being referred in a crisis; lack of knowledge about counselling and mental distress; and concern about stigma and its impact on work. Perceived waiting time was the most significant factor for participants in this study, but most people had a combination of reasons for not engaging. Support from the GP, information about the service and being given a realistic expectation of waiting times, may help people feel better able to access counselling services.     

The Lost Voice: How Libertarianism and Consumerism Obliterate the Need for a Relational Ethics in the National Health Care Service

This article analyzes the contribution Christian ethics mightbe able to make to the ethical debate on policy and caregivingin health and social care in the United Kingdom. The articledeals particularly with the concepts of solidarity and subsidiaritywhich are essential in Christian social ethics and health careethics, and which may be relevant for the ethical debate onhealth and social caregiving in the United Kingdom. An importantargument in the article is that utilitarian and market-drivenpolicies in the National Health Service (NHS) and the socialcare system have marginalized the position of the elderly andhave seriously impoverished the quality of care for the elderly.The neglect of the elderly and other vulnerable groups is alsothe result of widespread consumerist attitudes among patientsand of libertarian models of noninterference which are affirmedby a public ethos of self-sufficiency and counter-dependency.Those who need care dare not make their need known to othersand ask for help, while simultaneously those who could helpare so intimidated by the public affirmation of privacy andnegative rights that they do not dare to offer help except ifthis is explicitly demanded. This distant and standoffish attitudeis in an important way responsible for the fact that the voiceof those in need is altogether lost to the public forum. Christianethics puts much emphasis on responsibility and solidarity withthe needy other but is not able to have much impact on the deliveryof care in a secularized society and health care system likethe NHS. Nonetheless, Christianity still has a powerful andrespected voice, by speaking up for those who cannot speak forthemselves, such as the elderly and the handicapped. Christianscan find allies in the ethics of care and other relational approachesin health care ethics in order to combat libertarianism, consumerism,and utilitarianism.     

The Maternal lineage: identification,desire and transgenerational issues

In this paper I argue that close attention should be paid to the changes that have been taking place in the National Health Service over the last 15 years as a result of governmental initiatives. The identification of the direction that the recent health reforms have been taking should allow us to draw significant conclusions regarding the possible fate that the NHS is facing in the not‐too‐distant future. The introduction of the internal market in health care, the Private Finance Initiative, private Diagnostic & Treatment Centres and Foundation Trusts may indicate that the privatization of the NHS has begun in earnest. The relevance of such considerations to all NHS workers and users needs to be appreciated, as it may go some way towards answering the important question of what kind of NHS we will be having and using in the future. The implications for the NHS in general, and for psychotherapy services in particular, of the insidious but invasive process of privatization inherent in the ongoing changes in the structure and funding of the NHS are discussed.     

When does duration matter in judgment and decision making?

Research on sequences of outcomes shows that people care about features of an experience, such as improvement or deterioration over time, and peak and end levels, which the discounted utility model (DU) assumes they do not care about. In contrast to the finding that some attributes are weighted more than DU predicts, Kahneman and coauthors have proposed that there is one feature of sequences that DU predicts people should care about but that people in fact ignore or underweight: duration. In this article, the authors extend this line of research by investigating the role of conversational norms (H. P. Grice, 1975), and scale-norming (D. Kahneman & T. D. Miller, 1986). The impact of these 2 factors are examined in 4 parallel studies that manipulate these factors orthogonally. The major finding is that response modes that reduce reliance on conversational norms or standard of comparison also increase the attention that participants pay to duration.     

The relationship between existential-phenomenological and cognitive-behaviour therapies

The tendency of GPs to cap the number of counselling sessions offered to their patients in primary care has led to an ongoing debate about the effectiveness of time-limited counselling and brief therapy models. the advantages and disadvantages of brief as opposed to open-ended models of counselling in primary care need to be considered from the point of view of the client, the counsellor and the GP. Given that outcome research shows no difference between the two methods, a cost-benefit analysis would indicate that, for the majority of cases, time-limited counselling works very well. But there is still a minority of clients who do need open-ended therapy, and their needs are not being served by the present NHS system. Counsellors should therefore not be debating for either brief or open-ended style in primary care, but should be organizing themselves into expanding the service to give GPs the choice of both approaches.     

CORE-OM mental health norms of students attending university counselling services benchmarked against an age-matched primary care sample

Whilst concern has been expressed at the increasing severity of the mental health of students, there has been very little research on this growing population outside of small, single institution studies. The aims of this paper are to provide CORE Outcome Measure (CORE-OM) norms for the psychological health of students across multiple sites receiving university counselling, and benchmark these against an age-matched sample of people receiving treatment in NHS primary care settings. Results indicate that students using university counselling services show severity levels only marginally lower than young people presenting in primary care, with the differences being at a functional/relationship rather than a symptomatic level and with levels of risk to self being similar. This suggests that university counselling services deliver a service to people who closely resemble NHS primary care clients in terms of severity and risk to self.     

Negotiating time: the significance of timing in ending inpatient work

This paper discusses work with young people during their stay on an NHS psychiatric inpatient unit, especially focusing on the end of treatment and the appropriate timing of discharge into the community. When approaching the end of an admission, various factors are considered that seem particularly relevant to the decision of when a young person may be ready to leave and cope with the transition back to life outside the unit. Indications of medical stability, in patients where this has been an issue, is a factor of prime importance. Other important factors include family functioning; the availability of adequate ongoing local CAMHS support for the child and family; suitable school provision; and the identity of the child within a peer group. The reality of NHS resources and the demand for inpatient beds is another pressing consideration. The young person's own motivation emerges as crucial at this stage – towards the end of treatment – not only in terms of what is said, and therefore evident verbally, but also through signs of internal shifts in the child that indicate a capacity to re-engage with life outside in a lasting way. Decisions about when to stop are taken with all this in mind and when the decision does not seem straightforward, it can provoke considerable anxiety in the multi-disciplinary team. Clinical material from psychotherapy with a young adolescent boy with anorexia nervosa is used to illustrate some of the dilemmas.     

‘You have to treat the person,not the mouth only’: UK dentists’ perceptions of communication in patient consultations

Effective communication between patients and health professionals is a key component of patient-centred care. Although there is a large body of literature focusing on doctor-patient communication, there has been limited research related to dentist-patient communication, especially presented from the dentists’ perspective. The aim of our study was to explore UK dentists’ perceptions of communication in their consultations, and the factors they perceive may influence this. We conducted semi-structured interviews with eight dentists in UK dental NHS practices. Thematic analysis revealed three themes (‘Treating the whole person’, ‘Barriers to patient-centred communication’ and ‘Mutuality of communication’), which reflected the dentists’ perceptions of their own communication during consultations, the patients’ interaction skills, attitudes (and characteristics that may affect them), and external factors, such as time constraints, that can influence dentist-patients’ encounters. These in-depth accounts are valuable, in that we see what dentists perceive is important, obstructive and facilitative. They report using a patient-centred approach in their everyday dental practice; however this is often difficult due to factors such as time constraints. Although they emphasized that the patient has an active role to play in the communication process, it may be the case that they also need to play their part in facilitating this.     

An in-depth observational study of an acute psychiatric ward: combining the psychodynamic observational method with thematic analysis to develop understanding of ward culture

The question of how to create benign organisational cultures in health care is a topic of particular concern in the UK at the present time. The current study aimed to further understanding of complex health care cultures in the National Health Service (NHS), with a focus on an acute adult in-patient psychiatric ward. The psychoanalytic observational method was used for this purpose. The first author conducted six-hour long observation sessions on the ward at weekly intervals, writing detailed process recordings after each observation to take to a supervision group for discussion. The six presentations of observational material and the responses of the supervision group were audiotaped and transcribed. These data were then analysed thematically. The picture that emerged was of a fragile ward environment in which staff appeared fearful of engagement with patients, there was a sense of confusion regarding roles and decision-making processes, and the nursing team felt burdened by responsibility, isolated and anxious about criticism from outside. Contemporary developments within the social defence paradigm are applied to these findings in the context of the intense pressures currently facing staff in the NHS.     

Health Risk Behaviors and Their Relationships to Health Care Utilization Among Veterans Receiving Primary Medical Care

This paper reports the findings of a behavioral health risk screening form and examines the interrelationships among behavioral risk factors and health care utilization. Participants were 1,000 veterans who completed a brief self-report questionnaire assessing affective distress and behavioral health risk factors while they waited to see their primary care provider. Participants reported a mean level of affective distress in the mild range on a scale of 0 to 20 (M = 6.4, SD = 4.95), and 22.4% reported moderate or high levels of affective distress. Fifty percent of the sample denied alcohol use; 5% of the men and none of the women reported a pattern of use that met established criteria for at-risk drinking. Twenty-six percent of the sample reported current tobacco use, 45% acknowledged concerns about diet and/or weight, and 54% reported concern about pain. These factors were largely significantly intercorrelated and several were related to indices of health care utilization. It was concluded that veterans receiving health care in primary care settings report significant levels of affective distress and other health risk behaviors and that the presence of these factors is associated with increased use of the health care system. These data encourage increased efforts to identify these factors and to develop behavior change interventions.     

Is the Catholic Church in America Experiencing Internal Secularization? Priests’ Assessments of Pope Francis and the Condition of the Church

This study addressed internal secularization in the Catholic Church by testing the role of several factors in priests’ assessments of the state of the Church in the United States, priests’ views of whether the Church's situation is getting better or worse, and their attitudes toward Pope Francis. Comparisons with identical questions fielded in 2002 revealed a striking pessimistic turn among priests over the last two decades. In addition, regression analyses using the 2021 Survey of American Catholic Priests revealed that “in-house” factors—namely, attitudes toward Pope Francis and perceptions of how well bishops have restored confidence in the Catholic Church following the sexual abuse crisis—most powerfully predicted priests’ current pessimism. On top of this, politically conservative priests and priests ordained more recently tended to be most critical of how Francis is handling his duties, signaling a pronounced tension inside the Catholic Church over religious authority, a defining feature of internal secularization.     

Psychological type and attitude toward Christianity: a replication

A sample of 149 university students completed the Francis Psychological Type Scales together with the Francis Scale of Attitude Toward Christianity. The data indicated that university students classified as Feeling Types hold a more positive attitude toward Christianity than those classified as Thinking Types. These findings replicate the 1999 report of Jones and Francis.     

Reply to: Roberts

In his critique of my views on supererogation, Rodney Roberts (Philosophia, 2014) claims that I treat care ethics as having a more general moral validity than other care ethicists do. He also claims that the kind of sentimentalism I espouse doesn’t sufficiently emphasize sentiment and then goes on to question what I say about supererogation. But in fact other care ethicists also think care ethics can cover the whole of morality, and my sentimentalism emphasizes sentiment just as much and as little as that paradigm sentimentalist Francis Hutcheson does. Further, the critique Roberts makes of my view on supererogation doesn’t allow for the full range of possible cases of supererogation.