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David Oliver: Will robotic automation solve social care?

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4854 (Published 21 November 2018) Cite this as: BMJ 2018;363:k4854

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Re: David Oliver: Will robotic automation solve social care?

David Oliver is concerned by the call made by Ara Darzi, surgeon and former health minister, for 'full automation' of 'repetitive tasks' in health and care services, expressing scepticism about its purported benefits and warning that ‘we should never forget that health and social care is a people business and that those people might prefer more, not less, human contact.’ In response, Toby Prescott and Julie Robillard argue that while robotic automation is not a ‘solution’ to social care, it can nonetheless contribute to improving lives.

We agree that robotics may be a useful avenue to explore in the provision of care. However, we wish to stress the human aspect of high quality care. We find many of the ways in which care work has been characterised in the debate to be of concern, and we question the ways in which the provision of care is often presented by robotics advocates as involving ‘repetitive tasks’ ripe for ‘automation’. In general, work targeted for automation is routinely described as ‘dull’, ‘low skilled’, and even ‘menial’.

Our team is carrying out a programme of ethnographic research that involves detailed observations of the bedside care ward staff (nurses and healthcare assistants) provide for people living with dementia (a key demographic for the consideration of robotic assistance) during a hospital admission (1, 2). We note that our findings are from hospital settings of the acute ward but nonetheless are of relevance to the consideration of care in general. We strongly believe that this care is highly skilled, and that routine everyday interactions including the provision of personal care, medication, mealtimes, observation rounds, and continence care, are in fact often very varied, involving nuanced, finely negotiated interactions between ward staff (nurses and healthcare assistants) and patients. There are also great differences between such interactions for the provision of different types of care. There may be some tasks which could be ‘automated’ but currently, it is unclear to us how essential care could be taken over by robotic automation. It may be argued that robotics may free staff for the ‘human side of care’, but this makes the implicit assumptions that this is something over and above the routine everyday care work that takes place within hospital ward. The humanity of care and the communication with individuals takes place within the myriad encounters between patient and carer.

Moreover, our research (and the wider field of research examining the organisation and delivery of care) demonstrates again and again, that the emphasis on ‘efficiency’ which so often derives from the wider institutional drivers of tightly timetabled delivery of care to patients at the bedside, can frequently be counterproductive, for example with speed and efficiency often producing anxiety and confusion in patients and stress and burnout in staff. Robotics and its potential must be examined in the context of these wider social and institutional drivers underlying the challenges and priorities of delivering high quality care to patients.

Considerable weight to the impetus to explore robotics in social care can arise from awareness of the numbers involved. There is a shortage of nurses and other caring staff, with difficulties in filling vacancies and retention, together with an increasing population in need of various forms of care. However, whilst this is not in dispute, focus on this as a ‘numbers’ problem can seduce us into an attitude of ‘nurses and carers in short supply’: ergo, ‘fill the gap with robots’. This may focus our vision away from examining the systemic reasons behind the mismatch between carers and need. Whilst we are anxious not to oversimplify, our research indicates that there are systemic barriers to the provision of good quality care to people living with dementia within hospital settings which may also feed into the stress and burnout that contributes to poor staff experiences. Focusing on exactly what is happening in the highly complex human interactions between staff and patient in their social context, is a key to understanding both how robotics might assist, or might not be useful, as well as contributing to a greater understanding of some of the reasons underlying the challenges of delivering high quality care and of supporting and retaining highly skilled care staff.

The need for careful design in the development of social care robotics has been noted. We believe that this must include consideration of the complexity of the delivery of care within the wider social and institutional contexts, because this can help to reveal the complexity of these very human interactions, and help to shed light on the broader factors contributing to the challenges of care provision that those working in robotics wish to help address. Above all we must consider the different factors that contribute to the quality of care. Quality of care encompasses not only safety and effectiveness, but importantly, it must be delivered with humanity. Focus on the very concept of ‘automating’ care may, if we are not careful, lead us astray.

References

(1) Featherstone, K., Northcott, A., Bridges, J., Harrison Denning, K., Harden, J., Bale, S., Hopkinson, J., Tope, R., Hillman, A., and King, M. MemoryCare: Investigating the management of refusal of care in people living with dementia admitted to hospital with an acute condition – An Ethnographic study. Health Services and Delivery Research (HS&DR) (In press)

(2) Featherstone, K., Northcott, A., Bridges, J., Harrison Denning, K., Harden, J., Bale, S., Hopkinson, J., Tope, R., Hillman, A., and King, M. (2018). Summary Results: An evidence based investigation examining the care people living with dementia receive following an acute hospital admission. [online] London: Stories of Dementia. Available at: http://www.storiesofdementia.com/2018/04/research-report.html

Dr Katie Featherstone
Reader in Sociology and Medicine, School of Healthcare Sciences, Cardiff University
Dr Paula Boddington
Senior Research Fellow, School of Healthcare Sciences, Cardiff University
@storiesdementia
@Drkfeatherston
@PaulaBoddington

Competing interests: No competing interests

24 November 2018
Paula R Boddington
Senior Research Fellow
Katie Featherstone
School of Healthcare Sciences, Cardiff University
School of Healthcare Sciences Cardiff University 13th Floor 35-43 Eastgate House Newport Road, Cardiff CF24 0AB