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Recording Skills in Safeguarding Adults: best practice and evidence requirements

Nigel Crisp, one of the contributors to the Commission report featured in the Editorial for this issue, provides an illuminating personal perspective in this book. After serving concurrently as Permanent Undersecretary at the Department of Health for England and CEO for the National Health Service, he was asked by Prime Minister Blair to look at ways in which the UK could use its accumulated expertise and experience to improve health in developing countries. Crisp concluded that the UK and other rich countries also had much to learn from the ingenuity and innovation of poor countries unconstrained by western history, conventions and institutions. Scientific medicine alone, he argues, cannot continue to improve health. We need to understand how to make best use of ever-improving scientific knowledge and technology as part of a paradigm shift towards a global perspective. The factors, says Crisp, which led to many improvements in the 20th century are so invested in maintaining and developing the old models of delivery and behaviour that they make it difficult to create new ones and become part of the problem. Attempts at reforming health systems in richer countries have concentrated on getting the best out of the existing model, improving existing arrangements, incentivising doctors differently and making more productive use of equipment and facilities. But Crisp believes that the world is shifting as young professionals in the rich countries align themselves with leaders in the poor to turn the world up side down, not with modern medicine but with an understanding of society which seeks to apply findings from the natural and social sciences with profound implications for the way in which clinicians behave. Yet the rich and powerful countries still control the levers of power in the world. They export their ideas and ideologies of health to poor countries alongside their aid, introducing their beliefs about western medicine, organising health care and getting things done, as they exercise unconscious superiority, set the agenda and overpower. Exporting health care workers from poor to rich countries is, for reasons which Crisp explains, a relatively small part of the global crisis in the health care workforce. Quite simply, not enough healthcare workers are being trained, but what sort of healthcare workers does the world need and want? Should poorer countries have the same staffing structures as richer? Many are training people for the job that needs doing with reference, but not deference, to the established health professions. Do richer countries need the traditional model and can they still afford it? Changes in staffing structures accelerate as cost pressures bite. Every country, Crisp asserts, must have a safe minimum level of health workers to meet the needs of its population consistent with international codes of practice. Massive increases in education and training are essential with the rich supporting the poor, but it is inconceivable that every country will be able to staff itself as the richer countries do. We need to change the design of our healthcare systems and workforce, to understand what technology can do when trained human time will be ever more at a premium. The picture that Crisp paints is, however, far from simple. Lesser trained workers need support from higher trained and to know when and how to refer to them. The mid-level workers of today aspire to be the nurses and doctors of tomorrow. The square has to be circled; a major increase in the number of ancillary workers in the UK was accepted without demur when government concurrently set and met ambitious targets to increase the number of nurses and doctors.