Pushing poverty off limits: quality improvement and the architecture of healthcare values

BMC Medical Ethics

Alan Cribb¹  Polly Mitchell¹  Vikki Entwistle²  Guddi Singh³ 

[1] Centre for Public Policy Research, School of Education, Communication and Society, King’s College London, Waterloo Bridge Wing, Franklin-Wilkins Building, Waterloo Road, SE1 9NH, London, UK;Health Services Research Unit and School of Divinity, History and Philosophy, University of Aberdeen, 3rd floor, Health Sciences Building, AB25 2ZD, Foresterhill, Aberdeen, UK;Mary Sheridan Centre for Child Health, Guy’s and St. Thomas’ NHS Foundation Trust, 5 Dugard Way, SE11 4TH, London, UK;

关键词: Healthcare values;    Healthcare quality;    QI;    Quality improvement;    Social determinants of health;    Poverty;    Screening;   

DOI  :  10.1186/s12910-021-00655-x

来源: Springer

【 摘 要 】

BackgroundPoverty and social deprivation have adverse effects on health outcomes and place a significant burden on healthcare systems. There are some actions that can be taken to tackle them from within healthcare institutions, but clinicians who seek to make frontline services more responsive to the social determinants of health and the social context of people’s lives can face a range of ethical challenges. We summarise and consider a case in which clinicians introduced a poverty screening initiative (PSI) into paediatric practice using the discourse and methodology of healthcare quality improvement (QI).DiscussionWhilst suggesting that interventions like the PSI are a potentially valuable extension of clinical roles, which take advantage of the unique affordances of clinical settings, we argue that there is a tendency for such settings to continuously reproduce a narrower set of norms. We illustrate how the framing of an initiative as QI can help legitimate and secure funding for practical efforts to help address social ends from within clinical service, but also how it can constrain and disguise the value of this work. A combination of methodological emphases within QI and managerialism within healthcare institutions leads to the prioritisation, often implicitly, of a limited set of aims and governing values for healthcare. This can act as an obstacle to a genuine broadening of the clinical agenda, reinforcing norms of clinical practice that effectively push poverty ‘off limits.’ We set out the ethical dilemmas facing clinicians who seek to navigate this landscape in order to address poverty and the social determinants of health.ConclusionsWe suggest that reclaiming QI as a more deliberative tool that is sensitive to these ethical dilemmas can enable managers, clinicians and patients to pursue health-related values and ends, broadly conceived, as part of an expansive range of social and personal goods.

【 授权许可】

CC BY