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Getting back to basics: on the need to define care in analyses of care
  1. Roxanna Lynch
  1. Correspondence to Roxanna Lynch, Swansea University, Singleton Park, Swansea SA2 8PP, UK; roxannajesselynch{at}

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In their insightful paper, Newdick and Danbury1 explore some of the issues that they identify as having contributed to the failures of various institutions within the NHS to provide adequate levels of clinical care to their patients. This commentary acknowledges that many of the issues highlighted by Newdick and Danbury may plausibly be said to form part of the explanation of why failures of care—such as those identified within the Mid Staffordshire NHS Foundation Trust and the Bristol Royal Infirmary—occurred. However, it will be argued that any analysis of care (in the context of the NHS or elsewhere) will remain suboptimal in the absence of a clearly articulated and plausible definition of ‘care’.

The claim that a clearly articulated and plausible definition of care is necessary to a successful analysis of care (and institutions that purport to be caring) is motivated by the assumption that the meaning of care is neither self-evident nor uncontentious. If what is meant by the term care is assumed to be neither self-evident nor uncontentious, so-called analyses of care that fail to define care will remain obscure. The obscurity of such analyses is a result of their failure to identify what it is, exactly, they are analysing.

Newdick and Danbury's paper discusses the possible reasons behind serious failures of care within the NHS. However, they fail to stipulate what it is they mean by care. As a result of this failure, it remains obscure what exactly they think a ‘failure of care’ is and, subsequently, how such failures could be avoided. For example, Newdick and Danbury identify the fact of clinical attention being diverted away from patients and towards other concerns, for example, financial pressures as a factor that can plausibly be said to have contributed to failures of care within the NHS. However, it is argued that in the absence of an understanding of what is meant by care it remains unclear why a clinician's choosing to focus on financial issues instead of patient welfare would be at odds with providing adequate care. This is because ‘adequate care’ may be interpreted as requiring that the long-term financial health of institutions is insured in order to secure their future ability to continue to provide some level of provision for patients.

Newdick and Danbury are not, by any means, alone in omitting to define what it is they mean by care. Such omissions occur in perhaps more surprising places. For example, in the report2 of the findings of the public inquiry into the Mid Staffordshire NHS Foundation Trust, many of the recommendations reflect the belief that adequate patient care should be a priority within the NHS. Statements such as ‘there needs to be a relentless focus on the patient's interests and the obligation to keep patients safe and protected from substandard care’2 support this claim. However, nowhere in this report is care defined. The problems caused by this failure to define care can be summed up in the following question: how are readers of the report, particularly those charged with responding to its findings, to properly implement its recommendations in the absence of an explanation of what is meant by care? The anxiety is that a failure to articulate what is meant by care leaves the implications of analyses of care—such as those undertaken in Francis' public inquiry—regrettably open to interpretation.

One response to these anxieties could be to argue that what is meant by care—although not self-evident or uncontentious—is not so obscure as to leave it entirely open to interpretation what it is that someone may be demanding when they demand ‘better care’. It could be argued that people have a basic or intuitive understanding of care that is sufficient to enable them to carry out accurate analyses of caring practices/institutions. For example, such a basic or intuitive understanding of care could plausibly be said to assert that care involves the meeting of basic needs in a manner that is not offensive to the recipient of the care.

Alternatively, it could be argued that what is meant by care in the context of discussions of the NHS can be ascertained from other sources, such as the NHS Constitution.3 The argument would run, then, that what is meant by care in the context of the NHS is adequately stipulated elsewhere and so there is no need for other authors (such as Newdick and Danbury or Francis) to reiterate the definition. Neither of these responses is considered plausible.

It does not seem that basic or intuitive definitions of care could be either sufficiently clear or robust to protect both givers and recipients of care from substandard or harmful ‘care’. This is because such understandings of care may leave many issues unaddressed. For example, such a basic or ‘intuitive’ understanding of care as was highlighted above fails to clarify certain central issues such as the issues of what constitutes a basic need, who has the authority to say which needs are basic, how it is to be decided to what extent basic needs should be meti and what types of behaviour can be plausibly be said to be offensive, for example, are acts of paternalism necessarily offensive? Such basic understandings of care are, then, not fit for purpose. This is because in failing to provide parties to relationships of care with a workable understanding of what they can reasonably expect from acts of care, they fail to identify what care is in a way that is useful to people seeking to operate within the bounds of the term.ii

The idea that care is adequately defined elsewhere in the context of the NHS—for example, in the NHS Constitution—is rejected for the same reasons that basic or intuitive accounts of care were rejected above: namely, the definition of care provided is not fit for purpose. The closest that the NHS Constitution comes to defining care is in claiming that the basics of quality care are ‘safety, effectiveness and patient experience’.3 However, in failing to elaborate upon what is meant by, for example, effectiveness or patient experience, the brief description of the basics of quality care contained within the NHS Constitution is uninformative and unclear at best. For example, to what does ‘effectiveness’ refer? What sort of experiences is it believed that patients should be having? These issues are left unaddressed.

In summary, it seems that there is a clear need for authors who seek to address the issue of care to provide a clear and plausible definition of what it is they mean by care. It is argued that in the absence of such a definition it will remain obscure to readers exactly what it is that is being examined and what the implications of the results of such examinations might be.

A final point: it is wondered whether, (in spite of the potential circularity of the claim), the NHS's failure to clearly define what it means by care could itself be a contributing factor in failures of care within the NHS and an indication that the NHS does not care about care as much as it claims to.



  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • i A similar point regarding the need to provide clear answers to questions such as ‘to what extent do physicians have responsibilities to promote the welfare of their patients’ is made by John Saunders in his excellent commentary on Newdick and Danbury (see reference 4).

  • ii It is assumed that a definition should serve the purpose of providing an understanding of the definiendum that is sufficiently robust so as to remain usefully coherent in the face of challenges to the limits or compatibilities of the term.

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