A guest blog by Paul Higgs, Chief Veterinary Officer, CVS
Contextualised care. Who would have thought such an innocuous phrase could cause such uncertainty and controversy! This conversation began many moons before the Competition and Markets Authority announced their review. However, as communication, client choice and client experience are in the CMA’s areas of focus, contextualised care has become central to explanations of what a pet owner should experience.
This article may well contain some controversial opinions. I hope so, as debate and discussion are the best way for us to reflect and improve. So let’s put some cards on the table! I am the Chief Veterinary Officer for CVS and I am an internal medicine specialist. Cynics might say my opinion is biased. My client experience may be narrow (yes, I still work in clinics) and my motives might be influenced by my role. Yet, I have been a proud member of this profession for just less than 20 years, spending nearly a quarter of that time in primary care practice, half in referral practice and the most recent quarter in clinical leadership positions. I can tell you that the challenges in the consulting room and clinical decision making are the same, no matter which consulting room we are in.
Anyway, enough of that for now. I want to start with what contextualised care is not. It is not the opposite of “Gold Standard”. For starters the “Gold Standard” doesn’t exist – I can’t believe we are still having conversations reminding each other that we shouldn’t be using the term. We should be way beyond that! In the complex world of healthcare where no single case can ever be the same (the clinical context) and with the lack of powerful data in our evidence bank, we can rarely ever say that something is definitively the best way of doing something, but we need to be able to say “given everything I understand about you and your pet I believe this is the best thing to do”. If the term “Gold Standard” has any place for me, it would be accounting for the full context of a case and creating shared-decision making with the owner is the “Gold Standard” approach to consulting.
Contextualised care is also not the equivalent of veterinary medicine on a shoestring. That is a dangerous route for us to go down; many of the public conversations, podcasts and blogs on this topic are written with a focus on money, with charities leading on the discussions. Don’t get me wrong, I fully respect and admire the experiences of the charity sector and it is critical we include their unique insights into the outcome of financial distress on owners and the welfare of their pets. Yet this focus suggests to me that as a profession we still haven’t found a way to explain the wider reach of the contextualised care approach.
A pet owner’s financial freedom to make decisions about their animal is only one element of the context of a case. Accounting for the influence of finance is a part of contextualised care that should never be missed as getting this wrong will inevitably result in a frustrated, disappointed or suspicious owner. Yet contextualised care is neither a race to the bottom or a way of escalating cost unnecessarily. It is how we balance animal welfare, financial choice and the other innumerable factors that influence an owner’s decision on a care plan. It is doing the right thing for that animal and their owner, at the right time, in the right way in the full context of their needs. That isn’t always the cheapest; the most expensive approach is often not the right thing for the animal; taking initial shortcuts to keep costs down can result in increased costs overall if the gamble doesn’t pay off. All of this is very hard to achieve without lived experience and real empathy for the owner.
“We already do it: don’t be so patronising!” is one of the more common responses in any conversation about contextualised care. It’s true, we do. There is little doubt in my mind that every vet and every nurse in the profession uses information from the owner about their needs and desires to influence the care plan for an animal. Clearly there is something missing or we wouldn’t be having the conversation.
It also concerns me that there is competition for ownership of what contextualised care is and a desire to have intellectual property over what the process looks like. I stated recently that you can simplify what contextualised care means in the consulting room. I hate the thought that contextualised care will become a consulting “paint-by-numbers” checklist, as this will lead to inflexibility, inauthenticity and could achieve the opposite of what we need. I believe that the best way to deliver contextualised care is to develop genuine rapport and empathy with owners, to humanise them and for them to humanise us. In my opinion, the only way to do this is to be your authentic self in the consulting room; and you can’t do this with a “paint-by-numbers” consulting style!
Let me clarify my opinion; the concept of contextualised care is complex. The layers of socio-economic influences; animal welfare; clinician, team and practice capabilities – all endless! But if we make the action of contextualising care complex we won’t be able to achieve it in a consult and also achieve all of the other critical elements. For this reason, the action has to be simple and it is critical that the pet owner understands that we are doing it – and what it means for them!
There has to be a reason why some pet owners believe they weren’t listened to and don’t perceive the value in our consultations. This is why this is a conversation worth having, despite the fact that I believe all vets and nurses are accounting for owners’ needs and desires. Just because we do account for some needs it doesn’t mean we are accounting for the right ones and just because we are accounting for them it doesn’t mean that the owner realises it!
It is critical that we don’t get bogged down in the science but think about the outcome we and the owners need from contextualised care. .
I believe that the outcome needs to be the creation of shared decision-making where the owner truly understands how and why the information they have told us has influenced the care plan for their pet. We can do the best asking and listening and accounting for owners’ wishes in the world, but if the owner doesn’t recognise this and feel ownership of the decision then we have not closed the circle on the contextualised care consult. If we can do that, the owner can be deeply involved and invested in the plan of action, such that they understand that their needs and beliefs about the needs of their pet have influenced the plan alongside our clinical knowledge and expertise.
A final comment, contextualised care is incredibly hard to deliver without lived experience of what happens when you divert from the textbook. Those of us with lived experience have a responsibility to our colleagues to share this in our practices though mentorship and peer support to enable the whole team to be able to support our pet owners’ decisions.
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