This post is about some follow-up on the NICE guidance in palliative and supportive care. Non-British readers perhaps need to know that NICE (the National Institute for Health and Clinical Excellence) is the government body that collects research and views about what is effective in various healthcare services, advising government bodies that purchase them. Social workers have been concerned about its discussion of psychological support. In most hospices, social workers do a lot of this. Of course doctors and nurses also do it and probably do most of it, but they tend to pass on the complicated and time-consuming bits. NICE did not really deal much with social work. This was partly because it is a healthcare biased body that gives priority to healththink. Most people involved would have thought that it was fine to neglect the fact that most palliative care patients have been receiving social care services for years before they end up connecting with a hospice. It is also because a similar body (SCIE, the Social Care Institute for Excellence) should do this, but wasn’t commissioned at the same time to do the same thing for social work in end of life care. They don’t do joined up thinking at the Department of Health on social care because they have a healthcare mindset.
The National Cancer Action Team has been pegging away for ages at operationalising the NICE Guidance. It has finally got around to psychological support, which it issued a consultation paper about, and of course it continues to pursue the NICE line. This has hyped social work concern although the consultation is about the measures that peer review teams will apply to cancer networks. These are the multiprofessional committees that coordinate palliative care services in each area, so they’re hardly at the frontline or organising services and the measures actually offer quite a fair bit of flexibility. They are the sort of guidelines that say ‘You’ve got to have this, that or the other plan’, but don’t really tell you what the plan should be.
Whatever, to work out the guidance on psychological support the NCAT has picked up the NICE approach which, not unreasonably, was to ask psychologists what they thought and of course they came out with the idea that anything called psychological should be be done by psychologists. So NICE set up four levels of psychological care, in which, rather sniffily, people such as nurses and social workers can do the two lowest levels of, although they need to be trained and guided by the wise, and the upper levels can only be done by psychologists, or, in the case of level 3 those who have been made a bit wise by being given extra tuition by the specially wise.
In case you haven’t worked it out, in the previous paragraph wise = qualified in psychology or psychiatry. You’ll have gathered that I’m not all that sure that a qualification on psychology gives you that much more competence in responding to people’s life problems or the problems of the world than rather similar qualifications in other related fields (or possibly just developing yourself as a competent human being, but that’s another story). There’s a whole range of knowledge out there and different qualifications give you a purchase on different bits of it.
This kind of specialisation produces sillinesses among all professions. As an example of a psychological silliness I am inclined to quote the British Psychological Society’s publication on psychology in palliative care. This is a classic example of professional imperialism, claiming that the whole world is to be understood as a psychological problem that only psychologists know how to do something about. One role of psychologists in palliative care for example is said to be: ‘Dependency issues, such as fear of leaving the hospice/hospital, etc.;’ (BPS, 2008: 17). They’re welcome to dependency issues, a term which I regard as an offensive way of labelling people as psychologically inadequate for being dependent on others, which we all are. On the substantive point, though, most people who fear leaving hospital or hospice quite legitimately worry about how they’re going to cope with a major illness in their own homes, and they also fear losing their own home and having to go into some ghastly nursing home (they’re not all ghastly, but people fear this move). It just brings psychology into disrepute to call these widely-experienced and legitimate fears ‘dependency issues’. Then seeking to justify psychotherapy to resolve them takes the biscuit. The much more sensible social work approach is to sit down with patients and their relatives, find out what their problems are and organise the services or help them make decisions that remove the problems that raise the fears on the first place. Psychologists don’t do that because they only work with the patient, or their family, they don’t go on to sort out practical problems, or they do that by opassing it on to social workers. I say ‘get a social worker in the first place’. See BPS (2008) The Role of Psychology in End of Life Care. Leicester: British Psychological Society.
One of the problems with the NICE approach is that in reality there are very few psychologists around in palliative care and most of this work is done by social workers.Consequently, it tends to be closely intertwined with social care responses to issues, as you see with the ‘fears on leaving hospital and hospices’ example. It is senseless to set up a whole series of practices that rely on a limited set of ideas associated with one small and not very important profession, that seek to exclude other small and not very important professions.
Another problem is that, because palliative care is not a mental health or psychotherapy service, the main focus is not on psychological problems. Some people (I’m thinking here of Randall and Downie, 2006) have argued that patients and certainly their relatives, who are not anyone’s patients, have not given informed consent for psychological, social and spiritual interventions and all people really need is a nice kindly doctor to assuage their worries. This is a medical silliness similar to the psychological kind. However, it does make the legitimate point that we should be cautious of psychologising or sociologising common humanity. And, says he, delinquently, medicalising it too. See Randall, F., & Downie, R. S. (2006). The philosophy of palliative care: Critique and reconstruction. Oxford University Press.
The NCAT measures, and the NICE guidance, contains a really expert piece of professional imperialism by the psychologists, which says if it’s psychological call a psychologist. NCAT should have applied their minds to it and realised it’s not just psychological, it’s also a lot of other things. It’s all to play for, of course, because even if NCAT falls for this, the measures are only about how cancer networks organise themselves, not about services. So what social workers have got to do is stick up for themselves, get themselves on the committees and fight for reality as they understand it, just as the psychologists have done for reality as they understand it. Playing the game means joining the team.
Consequently, for the St Christopher’s response to the consultation I have drafted a comment that starts off by saying this:
| St Christopher’s Hospice has a strong commitment to providing effective psychosocial support in palliative care, and has recently been involved in research, including random controlled trials, to explore effective psychological care. It views the formulation of this guideline with concern, and considers it contrary to the basic objectives of palliative care, public policy, to the possibility of achieving effective management of psychosocial care in palliative care services and contrary to the available research evidence.
The main issues are as follows: |
1 Psychological and social support are closely intertwined in palliative care and measures for psychological support should not be seen in a way that prioritises one or the other.
2 Public and professional policy seeks to break down divisions between professional groups and emphasise flexibility in multiprofessional working. However, these measures are written in such a way as to create professional division.
3 The effective management of a multiprofessional service requires the utmost flexibility in the deployment of, often scarce, staff.
4 Palliative care, and cancer services more generally, are not settings for psychotherapy or psychiatry; their objective is integrated multiprofessional care. Most patients and their carers do not require psychotherapy to respond to personal and social issues that affect them. They prefer their main team to help, rather than being referred to specialists. The Hospice has found that a liaison psychiatry service with clinical psychology available on referral for psychotherapy is the most effective model. |
