Argue the Toss: How can you introduce perspective-balance into multi-agency working ?

This one doesn't fit so well, with an either/or format: it seems to require a more interwoven approach.

Lots of people write about multi-disciplinary teams and 'joined-up working' these days, and I have two questions:

1) How, within a multi-disciplinary team (MDT), do you arrange for 'behavioural balance' ?

2) How do you arrange for the lay perspective - that of patients, family carers, etc - to be properly represented within any guidance or 'agreements' created by the professionals within an MDT ?

I am using MDT to mean a team of ONLY professionals - that is how most authors use the term (with the D meaning 'professional discipline'; nurse, doctor, etc).

I'll start with 2).

The Shape of Caring review was recently published: it looked at how nurses and HCAs should be trained to meet the future needs of the NHS. The report used 'themes' and the first theme is:

Theme 1: Enhancing co-production and the voice of the patient

The report says things such as:

'The best healthcare is focused on the specific needs of patients and their families. In the future, patients are likely to be much more knowledgeable about their medical conditions and how to stay healthy, as well as wanting to become more involved in care planning and decision-making. At the same time, many patients will become
more vulnerable and carers will need to be more involved

...

One of the most popular themes within the evidence submitted was integrating the patient voice into education and training. The review learned of excellent initiatives where patient groups are embedded in the process, and these patient/carer voices have enriched curriculum development, implementation and delivery.'

My own 'special interest' - end-of-life behaviour when the patient is in his or her own home - is particularly complex in terms of 'perspective integration': before the patient dies, you can have the GP, the relatives, district nurses and social care staff all trying to support the patient, and immediately post-mortem it is often the case that paramedics and police also become involved. Not only do these groups of professionals have different levels of understanding, but they also have different objectives (especially police). If there is a formal attempt to 'join these people together' it will be in the form of something I will call a CPR/VoD policy (CPR is cardiopulmonary resuscitation, and VoD is verification of death) - and these policies are almost always created by groups of professionals, which might have canvassed the views of lay groups, but which usually operate without laymen actually sitting inside the policy creation group. I wrote about this in something I put together quite soon after my mum's death, where I commented that unless there are patients and relatives WITHIN THE GROUP WHICH WRITES THE POLICY, the policy will inevitably 'be perspective-biased' [towards the professional perspectives].

I think the inquest into the deaths of 96 people in the Hillsborough tragedy 'throws some light here'. While I was writing this piece, it was reported that:

'The police officer in command at Hillsborough when 96 people were killed in a crush called for police dogs instead of ambulances, even after he realised he was facing a medical emergency, not an incident of disorder.'

The inquest was examining this, along the lines of [using my phrasing] 'if you could see people were dying, why does it seem to some of us now, that at the time you still 'saw the situation' as crowd disorder and control instead of as 'a serious medical emergency' ?

I seem to remember that the 'famous footage' of a single ambulance driving onto the pitch, was added to by the crew subsequently saying that 'we were told by the police to not enter the stadium - but we ignored that, because we knew people were injured and dying in there'.

What I think goes on here, is the answer to the question frequently posed by the BBC Radio 4 'Today' team, to some unfortunate person after a 'scandal' of one sort or another which seemed to involve 'very bad behaviour by professionals' - the question is:

"But why does it take a review to realise that the staff were doing the wrong thing - why wasn't it blindingly obvious to them, at the time ?"

The answer, seems to be that increasing 'professional expertise' is accompanied by a 'distortion of the professional's mindset away from 'neutral' towards 'what fits our objectives'' - so at Hillsborough the police 'saw in front of them crowd disorder' but most other observers see 'fans dying from crush injuries, because bad crowd management had led to terrible overcrowding in some sections of the ground'.

So it is interesting that the Shape of Caring review mentioned 'embedded':

'The review learned of excellent initiatives where patient groups are embedded in the process'

That review is talking about training - but unless the 'user voice' is also embedded within service design, the professionals who design services will almost inevitably fall prey to 'perspective bias', even if they try to avoid that. The problem, is that 'what a person 'sees as important'' depends on the person's background and past experiences, and the person's objective: even if a group of people are looking at the same situation, they all 'see' different things.

I can now move on to 1).

It isn't possible, to work out where a 'neutral balance' between different professional objectives and perspectives rests.

It is possible, to be fairly certain that the balance will definitely be in the wrong place, unless ALL of the professions in the MDT are involved.

In effect, an MDT without embedded lay service users, will involve professionals haggling with each other about 'where the right balance is', and whatever they end up agreeing, the 'user perspective' will almost certainly be under-weighted.

I have in the past described this as 'the professionals all fighting with each other to get under the umbrella, and in the process pushing the laymen out into the rain !'.

This is VERY DIFFICULT to resolve, especially if 'legal issues' are involved - most professionals are pretty poor at 'legal issues' and most laymen will be even worse, and to properly argue the 'lay position' a layman needs to have read enough professionally-authored material, to 'have an idea of what the professionals believe'.

So I don't know, how to solve this one: effectively you need to somehow embed within professional MDTs, specialist laymen, who have done a lot of 'homework' but who have retained the 'normal user perspective' - that type of layman, is I suspect rather thin on the ground.