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

Polly Mitchell* (Corresponding Author), Alan Cribb, Vikki Entwistle, Guddi Singh

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract

Background
Poverty 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).
Discussion
Whilst 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.
Conclusions
We 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.
Original languageEnglish
Article number91
Number of pages13
JournalBMC Medical Ethics
Volume22
Issue number1
Early online date13 Jul 2021
DOIs
Publication statusPublished - 13 Jul 2021

Keywords

  • healthcare values
  • healthcare quality
  • QI
  • quality improvement
  • social determinants of health
  • poverty
  • screening

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