Conceptualising Cultural Competence in the NHS

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Chapter 2

2.1 Terms of reference and Scope of Study

The terms of reference for this work are primarily linked to professional experiences and other factors mentioned in the previous chapter. The commissioning department is mostly concerned with designing and procuring services for the community. The continuing healthcare department is mainly staffed by nurses who work in partnership with social workers. We participate in treatment reviews and care planning which means that we do not commission for the whole but for the individual. Planning for a community of diverse people most of whom are elderly and affected by long term conditions requires all those involved to be sensitised to the cultural needs represented in the locality.

Cultural competent commissioning like value based commissioning is an emerging concept that seeks to improve the outcomes of commissioning and service delivery. Its practice requires cultural competent skills and a support process that can be delivered in the form of a framework that guides commissioners as to which skills are needed and which principles and guidelines should be applied when working to design MH services for older people. The readers of this study must note that it is not so much a question of what our culture or values are but an acknowledgement that we all cultural beings first and our biases must not compromise our ability to work within those of others. The significance of this is that tangible values that shape the way people live and express their perspectives of ill health should be factored into the commissioning of health or social care services so that the care received is meaningful.

A study by Leininger, 1988 introduces a theory of nursing (caring) from clinical experiences. Culture as a wholistic concept was reported as the missing link in nursing knowledge and practice. All professionals are asked to understand the variations in cultural values (Carter, 1991). Commissioning organisations serve communities but professionals are yet to understand the full impact of the values of society on the values of the organisation (Sagiv and Schwartz, 2007).

This study is timely to the government’s current NHS, Social Care, Public Health and Well-being reform programme; it represents an opportunity to contribute to the task of highlighting the relevance of conceptualising cultural competence in the NHS. This is an important study not just relative to the quest to improve services for older people but also in light of the outcome of the Staffordshire NHS Trust Public Inquiry. It is contended that cultural competence is what Sir Francis (2013) referred to in his response to the Trust failings. His recommendations included a request for a culture change in the NHS. The report put the concept of culture, and specifically hospital culture, at the centre of the debate about improvement in the NHS. Specific statements are evident of this fact as follows;

“While the theme of the recommendations will be a need for a greater cohesion and unity of culture throughout the healthcare system, this will not be brought about by yet further “top down” pronouncements but by engagement of every single person serving patients in contributing to a safer, committed and compassionate and caring service.” (The Mid-Staffordshire NHS Foundation Trust Public Inquiry, 2013, p18)

This maintains the vision set out in “High Quality Care for All” which advocates for:

“An NHS that gives patients and the public more information and choice, works in partnership and has quality of care at its heart.” (Darzi, 2008, p7).

The scope of this study considers the challenges and opportunities for commissioning cultural competent dementia services and takes the opportunity to attempt provide the kind of new knowledge that can add value to the National Framework for commissioning dementia services (NICE guidance) and other relevant documents from other relevant bodies.

It will be true to say that the task represents an ambitious undertaking as there is an expectation that there may be successful negotiation and influence over long standing policy and practice within a commissioning agency such as the NHS. The history of the NHS is that of an organisation that has long standing practices of commissioning services for a mono-cultural society (one size fits all).

It is intimidating to consider what it will take to successfully get the NHS and other health bodies (CQC, DoH and NICE), to fully consider the relevance of cultural competence to commissioning. What we do know is that it will entail the recognition of the different values held by those engaged in making health and social care decisions. The requirement by agencies will be to act on these values in the planning and implementing services that are culturally relevant to service users (Heginbotham, 2012).

This study expects to produce a set of principles and or criteria that can be applied to current NICE guidelines for commissioning dementia services; the Delphi Study-validated evidence aims to make current guidance/framework culturally competent.  This effort may amount to a valid contribution towards highlighting cultural competence as a quality outcome for all older people’s services. The expectation is that this might address issues such as imbalances in the quality of services available, the negative reasons why caregivers do not access services, and the fragmented care experienced by those affected by dementia (Nolan et al, 2002, Brodaty et al 2005, Markle-Reid 2001, Phillipson et al 2013, Morgan et al 2002, Lim et al 2012 and Tanji et al 2005). While the above are experiences shared by many elderly people and their carers, it is particularly those of a BME background that most cultural competent interventions are targeted at, hence this might be the first time that a cultural competence study is focused on older people and the role played by health and social care service commissioning.

This study presents a summary description of dementia with no attempt to embrace or subscribe to any one of its theoretical perspectives of which there are many. The aim is to give the reader a depth of background information (cogent facts about dementia) and an appreciation for the passion of the researcher in relation to the vulnerable group that is the elderly affected by dementia. I attempt to share what might be considered a holistic approach to understanding dementia as a condition that should be considered in the context of what service users need on an individual basis (values/culture). I aim to evidence how including an understanding of cultural diversity might improve how we treat and care for the elderly affected by dementia or other mental health conditions.

This work also provides a brief critique of current policies affiliated to older people’s services; these are the National Older Services Framework and the Dementia Strategy. Both policies are still far removed from moving the dementia discourse into the culturally competent arena.

2.2 Overview of the Research Question(s) and Objectives

This section elaborates on the main research questions and offers an insight into the how the research method objectives are linked to the questions and overall research methodology.

To describe the challenges of culturally competent commissioning a working definition has been offered to describe both the practical and theoretical demands on commissioners and providers. This means that it is necessary to establish the values, opinions, experiences and knowledge of commissioners and providers. There is an expectation that the responses of participants will contribute to an understanding of the challenges and opportunities for culturally competent commissioning. A summary of the queries are as follows:

1. Which criteria do participants consider crucial to cultural competent


2. To what extent do participants feel they can influence the practice of cultural

competent commissioning and how can they influence the practice?

3. To what extent can the NHS be considered a culturally competent organisation?

4. How culturally competent are participants?

5. To what extent do participants feel that cultural competence should

play a role in the commissioning of services?

6.        Do participants consider any of the services that they receive, design or deliver to

be culturally competent?

7.        Do participants feel that cultural competence is an important concept?

8. How do participants describe or define cultural competence.

The in-depth interview phase focuses on exploring responses from participants in relation to their personal definitions, principles and opinions about cultural competence. These will be further subjected a content analysis enquiry in readiness for further consideration by the Delphi study approach.

The research question is related to concerns that go beyond findings which assert that both culture and social class influence treatment choices (Wright, 1991). This would mean that culture must influence the way services are designed and the way treatment and social care is commissioned and delivered.  As with Value based commissioning (V-BC) the concern is not so much about understanding every single culture in the population and incorporating every single nuance. It is about understanding how the cultural values expressed in the population play an important role in people’s lives and how these nuances much be given due attention in designing meaningful models of care/services. The theory is that in engaging with these premises commissioners can reasonably expect to successfully create accessibility, equity of access improved services and compliance with treatment.

The study further pertains to a belief that older people have a culture that amounts to a sum total of their value system which in turn plays a part in shaping their perceptions of ill health, how they might report symptoms and how they live their lives. For this reason culturally competent commissioning is more than a matter of understanding the influences of culture and the nuances of old age, it is about using cultural intelligence to make available the best treatment and social care services, ensuring seamless experiences of care and support and keeping a significant focus on dementia prevention initiatives.

Culturally competent policies have the capacity to ensure the availability of culturally appropriate services and corresponding culturally appropriate workforces (Cross, 1989, Lynch and Hanson, 1992, Weaver 1999, Van Den Bergh and Crisp, 2004). Given the number of cultural competent studies available it is disappointing that cultural competence has not acquired a hallmark status of quality, hence the significance of this study.

It appears that unlike in America the concept of cultural competent frameworks are still very much an emerging field in the UK (Betancourt et al, 2002). In America, Betancourt et al, 2002, stated that the emergence of cultural competence is recent, and part of a strategy to reduce disparities related to access to quality healthcare. They further describe efforts to modify hospital culture to keep up with changing demographics. The description of efforts to define cultural competence beyond transcultural nursing and mental health care are also still evolving (Betancourt et al 2002) and pace setting in the UK where we have recently chosen the term Value Based Commissioning in place of cultural competence. Cultural competence is a term much more entrenched in American practice where most of the research relied on in this work takes place. Despite its popularity in America, it is sometimes confusing to understand if its main driver is economic or necessary improvements in health issues pertaining to minorities. So far cultural competence has been used by health businesses to take up larger shares of the health insurance market. It has also been used to help reduce healthcare disparities (Carter-Porkras and Dogra, 2005).

In the UK it can be argued that the relevance of cultural competent care is entrenched in the Mental Health Act 2007 wherein the following matters are referred to as being crucial to informing decisions that are made in relation to MH services. These include:

1. Respect  for patients’ past and present wishes and feelings

2. Respect for diversity generally, including, in particular, diversity of religion, culture and sexual orientation;

3. Minimising restrictions on liberty;

4. Involvement of patients in planning, developing and delivering care and treatment appropriate to them;

5. Avoidance of unlawful discrimination;

6. Effectiveness of treatment;

7. Views of carers and other interested parties;

8. Patient well-being and safety; and

9. Public  safety

The cultural values of commissioners are relevant in the procurement of health or social care service; this is certainly the assertion of those who belong to the V-BC school of thought (Heginbotham, 2012). We know that these values affect the ability of providers and commissioners to effectively work within the cultural context of service users. This expectation or requirement is a well-researched contention of experts like Campinha-Bacote, 1999 (p.2003).


The main aims of the proposed research project are the following:

1. To investigate the challenges of commissioning culturally competent dementia services.

2. To consider the opportunities that exist for commissioning culturally competent dementia Services.

3. To develop a culturally competent dementia service commissioning framework.

4. To contribute to the commissioning arena in relation to the commissioning of culturally competent dementia services and care.

5. To make the commissioning of culturally competent dementia services a priority criterion within outcome based commissioning.

6. To publish and disseminate the findings and recommendations of the project.

This study uses survey questionnaires, in-depth interviews and a Delphi study as components of a mixed method study to produce data to respond to the research question(s). The survey questionnaire is designed with collaboration from commissioning colleagues to ensure that the right queries obtain the appropriate kind of information. Emerging themes and ideas form the survey phase are the premise on which the in-depth interviews questions are based. The final phase is a Delphi study which will be used to further validate the results of the in-depth interviews and survey responses that amount to statements of cultural competent commissioning principles. The mixed method research objectives will achieve the following:

• Gain an understanding of the personal views of participants in relation to cultural Competent commissioning

• Assess the level to which participants practice any level of cultural competent commissioning

• Assess the level to which participants might influence cultural competent commissioning practices in their individual roles

• Assess the personal cultural competent experiences of participants when using   NHS services.

• Obtain and collate the opinions of participants in relation to their definitions of principles or criteria that should underpin cultural competent commissioning or service provision

• Obtain and collate a consensus profile of the criteria and principles capable of developing a culturally competent commissioning framework.

2.3 Definitions of Cultural Competence

Cultural competence is a movement that has evolved from efforts to reduce racial and ethnic disparities in healthcare in America.  The sources of disparities are often complex and multifactorial and do not differ much from one setting to another therefore the American experience may not be that different from the UK. Saha et al, 2008, state that ‘the principles of cultural competence are rooted in efforts that precede the high visibility of inequalities and disparity’. The definition of cultural competence along with its principles are still emerging in the UK (Papadopoulos, 2006).

There are numerous definitions of cultural competence, each of which depends on the perspective of the author and the setting. Bhui et al (2007), defined the concept as a ‘set of skills or processes that enable the health care professional to provide services that are culturally appropriate for the diverse populations they serve’ (p.4).

A review of the literature found definitions by a few researchers, Lopez (1997) asserts that a defining characteristic of the culturally competent mental health service provider is cognitive flexibility or problem-solving skills.  In more recent times Papadopoulos, 2006 defined it as ‘a process one goes through in order to continuously develop and refine one’s capacity to provide effective health care taking into consideration people’s cultural beliefs, behaviours and needs.   Cross as et al, 2009, described the concept as a set of congruent behaviours, attitudes and policies that come together in a system or amongst professionals enabling that system or those professionals to work effectively in cross-cultural situations. Other definitions included cultural competence as a demonstrated awareness and integration of three population-specific issues: health related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy (Lavizzo-Mourey and Mackenzie, 1996). Roberts et al, 1990 defined the concept as a programme’s ability to honour and respect those interpersonal styles, attitudes and behaviours both of families who are clients and the multicultural staff who are providing services. Cultural competence has also been defined as the ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences (Cooper et al, 2002). Betancourt et al, 2003 agree that CC is accomplished by recognition of the importance of social and cultural influences on patients, considering how such factors interact and devising interventions (treatment and social care) that take such issues into account.

The common thread of these definitions is that of a problem-solving and improving quality dimension. Expanding the definition further, Betancourt et al, (2003) and Sue and Torino (2005) offer a definition covering organisational and system-level activities. Overall these definitions speak to this current study in that the level at which cultural competence is required in commissioning may be at organisational and systemic levels where strategies evolve into practice.

The definitions stated earlier have an emphasis on performance at delivery (provider) level and not much of an emphasis on the important elements of commissioning which are service design and specification, assessment of needs, budgets and the procurement of services. There is a focus on cultural competence training in the literature but there is also very limited consensus on the validity of the various cultural competent interventions or training schemes in use. This has been the evidence from research studies looking at the impact of training, one study by Clarke, (2010) found participants of a multicultural training course still felt that they still lacked adequate multicultural competencies following training. A study of health care provider educational interventions recommended that future research needs to focus on determining which teaching methods and contents are most effective ( Beach et al, 2005). In agreement with the Beach study Chipps et al, 2008 carried out a systematic review of the literature in relation to training for health professionals in community-based rehabilitation settings and found positive outcomes for most programmes however the reviewed studies had small samples and poor designs. They recommended that future studies that are methodologically rigorous are needed given the paucity of studies and lack of empirical precision in evaluating effectiveness.  Despite the above findings of dissenting views and studies that describe points of convergence and divergence they all widely agree that CC is a set of problem-solving skills learnt over time. In summary, cultural competence is a crucial tool for professionals as diagnosis, treatment and the reporting of symptoms are influenced by cultural beliefs (Jackson,1993; Broome, 2006).  The suggestion is for health staff to be adequately trained to meet the needs of culturally diverse patients (Campinha-Bacote,2003; Leininger and MacFarland, 2006  and Mahoney, 2006). Aside from cultural competence aiding the understanding of service users it also promotes empowerment as it enables negotiation, facilitation of dialogue and compliance (Langer, 2002; Caper, 1994).

2.4 Literature Review

The literature review process yielded a significant amount of material for analysis as it was difficult to keep to predetermined boundaries. The search was based on specific search criteria that allowed comprehensive collation of relevant studies with the purpose of establishing a comprehensive understanding of cultural competence  and how it can be applied to the design and commissioning of services.

Search Criteria and Strategy

Findings within the literature specific to cultural competent commissioning or service design practices were meagre probably due to the fact that in the health arena cultural competence studies are mostly linked to BME service delivery, training and the education of nurses and based in America.  Within the UK context cultural competence was not found as a term applied commissioning however studies included in the review are those related to the UK phenomena of Value Based Commissioning (Vb-C). Its focus is to support balanced decision making within a framework of shared-values practice based on mutual respect and relies on good progress rather than pre- set right outcomes for practical effectiveness (Fulford et al 2012).

Heginbotham and Newbigging, 2013, give a definition of VBC as

……..the practice of recognising and acting on the differing values held by all those engaged in making health and social care decisions, in order to plan and implement health and social care   culturally relevant and appropriate, clinically and economically effective, and addresses need in a way that reflects the values of those using and providing care. (Heginbotham and Newbigging, 2012, p.ix)

There was paucity of appropriate cultural competent studies related to commissioning, this meant that inclusion and exclusion criteria were fluid to enable the identification of as many relevant articles. Some studies (BME related studies) were only marginally related but it was assumed that as many of the issues and findings captured also affect the elderly in terms of health disparities or access and quality they could be included. Also included in the literature are any studies of cultural competent models and those that focus the evaluation of their application within MH health services and training. Criteria chosen were based on the issues to be discussed, the research questions and the concept of cultural competence, dementia and commissioning older peoples services. They were applied as follows:

The American literature reveals other important drivers of cultural competence; these are related to insurance and diversity management (Dreachslin, 2007). The purpose here is for larger American insurance companies to oblige health services to stimulate cultural competence so that insurance companies can increase their market share in diverse communities. Cultural competence has in many ways become a business tool for driving profit in health related businesses, in recent times businesses have gone to the extent of including systemic cultural competence interventions as part of contracting language (Betancourt et al 2002).

The literature reveals that the health care (delivery) community were one of the first to place value on the usefulness of cultural competence in reducing disparities (Campinha- Bacote, 2002; Purnell and Paulanka 2008; Paez et al 2009; Starr and Wallace 2009.

The paucity of cultural competent commissioning information hampered the literature review process though there were studies relating to Value Based Commissioning (VBC), this current study will accept that the 2 are interchangeable to a certain extent. Their definitions are different but their focus is similar.

A working definition of cultural competent commissioning is about using the cultural competent knowledge from the service user population to inform the commissioning of services that meet the specific needs of individuals. The idea is that services should not be a generalised fit.  Based on the limited UK-based research this literature search is designed to enable an examination of the literature in relation to the role and relevance of cultural competence in commissioning for quality dementia. It is a suitable course of action given that the aim of this study is to improve services for older people affected by dementia by suggesting they should be culturally competently commissioned. The process of commissioning is itself relates to the procurement of dementia health and care services. It also involves the assessment and understanding of a population’s health needs, planning, securing and monitoring of services commissioned. It is important to note that the quality of culturally competent services will very much be dependent on the skills of commissioning professionals. There is no formal training for commissioners or a requirement for a cultural competent skill set or training, this might explain why there is paucity in the availability of theoretical literature on the components of commissioning.

The literature contained numerous studies relating to the reduction of health care disparities/ethnic minority health care but very few had any bearings on design, development and the procurement of services. The intention of the search was to look for factors that speak to the challenges of implementing culturally competence in commissioning practices. This was necessary to consider the implications for cultural competence among health care commissioners.

The databases used include text books and grey literature, Medline, Proquest, PubMed/NCBI, Wiley online, SAGE and the MDX library resource for journals and the Google scholar search engine. I also did a search of reference of references had the advice of academic supervisors and had access to British Library journals and a number of textbooks.

A decision was made as to the time frame of published literature to be included to keep the search to studies carried out or completed in the last thirty years. This was about ensuring coverage  of the estimated emergence of addressing health disparities and inequalities with cultural competence (the history/evolution of CC).

The literature search was carried out using single and combined keywords; culture, cultural competence, value based commissioning, evaluation of cultural competence, cultural competence in healthcare or mental healthcare, cultural competent models, historical perspectives of cultural competence, definition of cultural competence, commissioning, dementia care, older peoples dementia care, dementia strategies for care, reducing inequalities and disparities.

The reasons for using the selected keywords were, first to consider the emergence of concepts, the ways in which definitions were developed and operationalized as solutions to problems investigated by previous works. Other reasons included identifying and describing any issues other researchers considered important, limitations of their studies and recommendations. This mode of operation assists to consider how judgements of these findings could apply to this study and enables cognisance of findings that defer from my epistemology. The extraction of data was considered according to how well it identified as having a relationship with the overarching research questions and capacity to justify or add value to the study.

The first major challenge of the literature review process was the lack of current research in relation cultural competence as applied to older people health service commissioning or dementia. Although there were no studies investigating or evaluating the application of cultural competence to commissioning dementia or older peoples services there were studies that considered Relationship-Centred approaches (Nolan et al 2006). Searching for studies specific to cultural competence in commissioning older peoples services was about attempting to continue where other researchers had left off, justifying my study, and applying any relevant aspects to answering the research questions.  I made assumptions that there would be a significant body of research relating to designing cultural competent commissioning models or tools for addressing cultural competence in service designs.  I found studies and definitions in relation to the delivery of health care a significant number of these studies cited Camphina-Bacote, 1994, 1998a, 1999. There were many pioneer studies focusing on the contemporary tools and practice of mental health care demands on the role of culture in the mediation of psychopathology and service delivery to BME populations. These studies include work by Stauss & Mang 1999, Sharma et al. 2009, Campinha-Bacote 2002, Papadopoulos, 2004, Harris 2010, Betancourt et al. 2003, Henderson et al. 2011, Johnson et al. 2006, Abbe et al. 2007 and Deardorff 2009.

This study intends to speak for older people in general though findings may address other service areas. This is because all services are accessed by marginalised groups of which older people are some of the most vulnerable. BME’s and older people seem to have less than optimal experiences of quality healthcare, referenced studies are further listed further on.   Although a significant portion of my literature search is extracted from studies which link BME health care improvements to cultural competence the focus is on the need to commission culturally competent services for older people affected by dementia. As the experiences of both groups can and should be addressed using culturally competent tools, perhaps findings from one can be related to the other? Furthermore, this study’s findings can also be related to the value of cultural competence in providing person-centred health and social care services. This notion is related to a recent study investigating the role of cultural competence in delivering patient centred care in the midst of a cultural conflict (Campinha-Bacote, 2011). The significance of this relates to the general consensus within anthropology, psychology, sociology, psychiatry, public health and social work regarding the role of sociocultural factors in the aetiology, epidemiology, manifestation and treatment of mental health disorders of which dementia is one.

It is not possible to discuss cultural competence in the delivery of dementia/mental health care and not mention the role of those responsible  for training the professionals and the professionals who deliver care. First, training providers have a responsibility to ensure that MH nurses are equipped to provide culturally appropriate care in any setting (global care). So far studies have reported that this is not the case as studies have reported nurses feel inadequate of the challenges within diverse communities, and some reports of nursing curricula not being compliant to teaching cultural competence  (Reeves and Fogg, 2006; Rodriguex, 1997; Leininger, 1994; Miller et al, 2008 and Koskien et al, 2009). Questions have been asked of the quality and role of undergraduate nursing education to equip a culturally competent workforce to deliver relevant care ( Centre for Mental Health et al 2012; DoH, 2005  and NIMHE 2003). Koskien and others took up the challenge and emphasised the need to respond with training that educates and produces culturally competent professionals (Koskinen et al, 2009; Chenowethm et al, 2006 and Mahoney 2006). Despite the importance of culturally competent nursing professionals to an increasing diverse world population, many of whom experience lapses in MH studies have revealed an inconsistency in the training content (Hildenberg and Schlickau, 2002 and Dogra and Pokra 2005). Recommendations from a study by Hildenberg and Schlickau were for the improved preparation of students for transcultural nursing. This would be in keeping with responding to the belief that people from different cultures have varying beliefs about disease aetiology, diagnosis and treatment (Jackson, 1993 and Broome, 2006)

2.5 Leading Concepts, Definitions and Theories in the Literature

The study of the role of cultural knowledge in shaping illness goes back many years as there has also been a substantial tradition of cross cultural research describing beliefs and practices associated with mental health disorders in different societies (Westermeyer, 1976). As an African it is my reality that every ethnic tribe in my country of origin has a different yet similar cultural belief system and method of approaching mental health illness. It therefore stands to reason that I might express a bias that supports the role of culture and cultural competence in designing and delivering services. Day and Cohen, 2000 described there being a role for culture in designing environments for people with dementia. Laroche et al, 2004 agreed when they reported findings on culture playing a role in service quality perceptions and customer satisfaction.

In 1989 Cross et al defined cultural competence as a set of congruent behaviours, behaviours, attitudes and policies that come together as a system, agency or among professionals enabling that system, agency or those professionals to work effectively in cross-cultural situations. He and his colleagues coined the term cultural competence in 1989 while working with children suffering from severe MH disorders. Tse et al (2005) took a slightly different take on it  and described it as ‘the ability of individuals and systems to respond respectfully and effectively to members of all cultures, races, classes and ethnic backgrounds and religions in a manner  that recognises, affirms, and values the cultural similarities and differences and their worth’.  The goal is to use cultural competent tools to create person-centred care that is meaningful to the user. That makes cultural competence a component of patient centeredness (Engebreston et al, 2008), which was originally defined by Balint in 1969 to explain the need for patients to be understood as unique human beings.  Both definitions advocate respect, place the patient and their values at the centre of care and introduce an element of empowerment into the patient-physician dynamic.

There is evidence in the literature that patient centeredness existed before cultural competence which didn’t begin to appear consistently in literature (possibly due to lack of research) till after 1989. So far, it has been included in curricula for training nurses and other medics, informed programmes to enhance service improvement and considered as a means of reducing health care disparities in America (Betancourt et al 2003, Anderson et al 2003, Brach and Fraserirector, 2000, Chin et al 2007, Lie et al 2011, Campbell et al, 2011, Qureshi et al, 2008 and Khanna et al, 2009).

Within the literature there is general consensus of a need for health care practitioners to recognise the role culture plays in health seeking behaviour, ethnic minorities’ perspective of disease, the description of symptoms and the ability of service users to comply with treatment. We also know that with the advent of previously mono-cultural societies becoming multicultural, health practitioners are experiencing a different level of complexity in caring for people of different cultures. This has resulted in practitioners having to examine their own understandings of culture, culture awareness and ethnocentrism (Leninger 1995, Camphina-Bacote 1999, Papadopoulos 2006).

2.6 The Complexity of Cultural Competence

It was important to use the literature review to understand the complexity of culture competence given that there is a significant level of research findings reporting its complexity, numerous definitions, applications and dissenting views. Its complexity causes it to be described as multidimensional, contentious and in high demand especially in the mental health care arena, these issues are discussed further along. The contentions have been the product of debates that have led to many dissenting views which centre on its relevance, use, training evaluation, outcomes and definitions.   Examples of studies confirming varying levels of contention include the following:

• Nadan, Y., 2017. Rethinking ‘cultural competence’ in international social work. International Social Work, 60(1), pp.74-83. She argues that the common understanding of ‘cultural competence’ from the so-called essentialist perspective is inadequate.

•  Kumas-Tan, Z., Beagan, B., Loppie, C., MacLeod, A. and Frank, B., 2007. Measures of cultural competence: examining hidden assumptions. Academic Medicine, 82(6), pp.548-557, the study concludes that existing measures embed highly problematic assumptions about what constitutes cultural competence. A further weakness is that they ignore the power relations of social inequality and assume that individual knowledge and self-confidence are sufficient for change.

•  Kleinman, A. and Benson, P., 2006. Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS medicine, 3(10), pg 294, The issue raised by this study is that of a major problem with the idea of cultural competency suggesting culture can be reduced to a technical skill for which clinicians can be trained to develop expertise (Delvecchio,1995). They blame the problem on the medical definition of culture which contrasts significantly from the original anthropological definition. Having assumed that culture is akin to ethnicity, nationality and language, in dealing with patients of a particular ethnicity the medical professional is apt to act according to a series of cultural competency do’s and don’t’s (stereotyping).

• Sue, D.W., 2001. Multidimensional facets of cultural competence. The counselling psychologist, 29(6), pp.790-821. Sue asserts that calls for incorporating cultural competence in psychology are hindered for a number of reasons: belief in the universality of psychological laws and theories, the invisibility of mono-cultural policies and practices, differences over defining cultural competence, and the lack of a conceptual framework for organizing its multifaceted dimensions.

• Wong, Y.L.R., Cheng, S., Choi, S.Y., Ky, K., LeBa, S., Tsang, K. and Yoo, L., 2003. Deconstructing culture in cultural competence: Dissenting voices from Asian-Canadian practitioners. Canadian Social Work Review/Revue Canadienne De Service Social, pp.149-167. This study acknowledges the significant growth in culturally competent practice among social work and health professionals over the past decade. The researchers share concerns of a dissent nature regarding the conceptualization of culture in most writings stating the failing of cultural competence to recognize the fluid boundaries and political character of culture.

These examples showcase the many levels of complexity attached to the implementation and development of the cultural competence discourse. Further examples of dissenting models include those of Purnell, (2000), Papadopoulos, Tilki and Taylor (2006); Camphina-Bacote, (2001) and Wong et al (2003). They expound on the complexities of deconstructing culture in cultural competence, asking for recognition of the elusive, contextual and political character of culture. They also argue the need for a critical approach to cross-cultural practice that involves identifying power as central to how we all understand culture and negotiate culture’s multiple narratives and meanings.

Caminha-Bacote et al (1995) contend that cultural competence is a critical factor in nursing research, claiming that cultural competence must be linked to the need for an appreciation of the number of ethnic minorities that will be accessing services in future. Research would help deal with the corresponding expected challenges to health care professionals. O’Brien et al (2006) conducted a study on the self-assessment of cultural attitudes and the competence of clinical investigators to enhance the recruitment and participation of minority populations in research. Their aim was to discover the strategies necessary to enhance the abilities of study investigators to relate and communicate effectively about health and clinical research within minority communities. They found that the majority of participants were reasonably culturally competent, however areas remained in which proficiency needed to be enhanced and recruitment of participants in clinical research required improvement. They also found an acceptable level of respect and reasonable knowledge of the cultures of most patients for whom participants provide care and conduct research. They however reported that there is still a need for continued cultural sensitivity and competency training to enhance the understanding of certain aspects of minority cultures, groups and international relationships, perceptions of disease and wellness.

Engebreston et al, 2008 looked at cultural competence in the era of evidence-based practice and maintain that it is a concern for contemporary health care delivery and has ethical and legal implications aside from the challenges posed by the abstract nature of the concept (Engebreston et al, 2008). The study looked at making cultural competence relevant to clinical practice by linking a cultural competency continuum that identifies levels of cultural competency to well-established values in health care. This, they reported ‘situates cultural competence and proficiency in alignment with patient-centred care. From a commissioner’s perspective, specifications for such a service would need to include key performance indicators such as patient satisfaction, improvements in medication compliance rates, accessibility and seamless experiences of good care.

Overall the literature review is an attempt at further justifying the need to apply cultural competence to the commissioning of older peoples services (dementia) or other services. My positionality on the issue is based on my knowledge of older people’s services through the lens of a commissioner of older people’s health services which include memory services, psychiatric liaison, support services and social care.

In the American context the struggle for the validity of cultural competence is a continuous exercise, it has for many years been accepted and used as a tool for addressing health disparities in a bid to reduce them and improve access to services by ethnic minorities. In the field of psychotherapy and counselling, cultural competency has been used to understand a number of desirable phenomena such as validating ethnic match between therapists and clients; it is also associated with treatment outcomes. There are still questions in relation to cognitive match between therapists and clients, in terms of whether there is a predictor link to outcomes and whether clients who use ethnic-specific services exhibit more favourable outcomes than those who use mainstream services (Stanley, 1998).

In terms of the evolutionary perspective for cultural competence, Burchum, 2002 described the problem of a need for conceptual clarity for effective communication related to the concept.  O’Brien et al (2006) conducted a study on the self-assessment of cultural attitudes and the competence of clinical investigators to enhance the recruitment and participation of minority populations in research. Their aim was to find strategies that are necessary to enhance the abilities of study investigators to relate and communicate effectively about health and clinical research within minority communities. They found that the majority of participants were reasonably culturally competent, however areas remained in which proficiency needs to be enhanced and recruitment of participants in clinical research could be improved. They found an acceptable level of respect and reasonable knowledge of the cultures of most patients for whom participants provide care and conduct research. They however reported that there is still a need for continued cultural sensitivity and competency training to enhance the understanding of certain aspects of minority cultures, group and international relationships, perceptions of disease and wellness.

The first arguments for cultural competence were made in light of an increasing diversity in the population of America. Following on from there it was about increasing access to high-quality care for the most vulnerable, this was possible because of the role of federal, state and local governments in both managing and financing health care access for vulnerable populations. The focus was on all patient populations rather than just minority groups. Corresponding research by Betancourt et al (2005) showed participants viewed cultural competence as being driven by both quality and business imperatives such as health insurers marketing the initiative to employers for the purpose of expanding their market share. Other informants of the Betancourt study felt that by embedding culturally competent strategies into quality improvement initiatives, managed care could advance cultural competence. None of the responses or research studies considered the merits of cultural competence in commissioning; it seems that the focus had simply been central to just increasing market share as opposed to investing in cultural competence at large. Further emerging perspectives from the study showed that cultural competence was highly dependent on organisational, systemic and clinical arenas for its advancement. Furthermore, links between cultural competence, improving quality, and eliminating racial and ethnic disparities in health care were described as being quite clear.

Additional arguments for culturally competent mental health services have been those made on ethical grounds.  Ridley (1985) contends that cultural competence is an ethical obligation. He further asserts that this means cultural competence is imperative, putting therapeutic and cross-cultural skills on an equal footing as other specialized therapeutic skills. That being the case, he recommends that an appropriate level of training to reach adequate levels of competence is necessary to ensure professionals are qualified to deliver care and therapy .

We say that cultural competent healthcare is about the ability to deliver care to service users that are of a different culture to that of the care giver, furthermore, that it is about tailoring services to the needs of those who have diverse backgrounds, values, beliefs and behaviours. This is a summary description which places the emphasis of cultural competence on delivery rather than commissioning, this is a crucial reason for this study as the delivery of CC has been about people rather than systems. Sue (1998) argues that a person is culturally competent when they possess the cultural knowledge and skills of a particular culture and are able to deliver effective interventions to members of that culture” (p. 441). Lopez (1997) considered the essence of cultural competence to be “the ability of the therapist to move between two cultural perspectives in understanding the culturally based meaning of clients from diverse cultural backgrounds” (p. 573). Once again we see that definitions relate to the capacity of the care giver to utilise cultural competent skills, there is no reference to the role commissioner or the development of the culturally competence in the service design. The wealth of cultural competence literature is evidence of how much it has been embraced however it is still a challenging concept and CC care though improved is not always delivered at its optimum.

Betancourt et al (2002) offered 3 barriers to culturally competent care. The barriers given were lack of diversity in the leadership of the workforce, poorly designed systems of care (commissioning responsibility) and poor communication between providers and patients of different backgrounds. Poorly designed services are scenarios that can be avoided if services are designed with adequate cultural competence intelligence. This can be accomplished within the needs of the assessment process; this is an important aspect of commissioning.

2.7 Dementia and Culture

There is paucity in the literature regarding dementia in relation to cultural competent commissioning however there are some studies that look at the influence of culture on dementia. Sun et al (2012), argue that there is an influence of ethnicity and culture on dementia caregiving. The evidence is reason to ensure that both commissioners and providers understand what these influences are and how they can used to improve both care and prevention of dementia. For this reason commissioners can be asked to consider the cultural demographics of their localities when preparing to commission dementia services. We know that culture shapes perceptions and behaviours and therefore shapes responses to cognitive impairment and dementia. Cox (2007) backs this claim up by asserting that the cultural beliefs of a patient are implicated in the ways that the symptoms of dementia or aging are perceived or displayed (wandering, confusion and forgetfulness). This is further evidence as to why we might need to commission services using cultural competent tools and practices. Success in this area might  enable us to describe culturally competent care as compassionate in its delivery as it considers the values of the care receiver and is discharged in a manner that delivers assistance, respite, dignity and personhood.

Factoring elements of culture in to the design and development of services demands a significant amount of cultural intelligence if services are required to ensure that in the delivery of care personhood is preserved (Kitwood, 1997). The researcher explored the concept of personhood and its relevance for a new culture of dementia care, explaining that the concept of care is linked to personhood both of which have ethics as a fundamental matrix.

The literature sheds some light on why the numbers of those accessing services or receiving a diagnosis does not match the numbers actually affected by dementia. Mahoney et al (2005) did a study of cross cultural similarities and differences studying African-American, Latino and Chinese people. Their assessment was concerned with impressions of onset and memory test diagnosis of dementia. They found that the major deterrent to having a relative assessed was a lack of knowledge about Alzheimer’s disease rather than culturally influenced beliefs. Furthermore, a failure on the part of the GP to recognise the disease was much blamed for low referrals for assessment and diagnosis than language or ethnic barriers. Motivating clinicians to adopt culturally sensitive communication patterns was a particular recommendation of studies. To this end, commissioners should play a significant role in ensuring this happens by including appropriate key performance indicators (KPI’s) where appropriate. KPI’s could include the level of cultural competence training and the development and implementation of cultural competent work force standards.

The literature asserts that cultural competence has the capacity to reduce discrimination, improve compliance to therapy and increase service accessibility (Betancourt et al 2002, Beach et al 2005, Kagawa-Singer and Kassim-Lakha, 2003, Saha et al, 2008, Bhui et al, 2012. With this in mind cultural competent care can be described as Evidence-Based Care (research to practice). Evidence based care has long been hailed by the NHS as the way forward and is the premise that value based commissioning relies on (Heginbotham, 2012). Nolan et al, 1998, questions this notion and contends that the alternative is a relationship-centred approach to care. Their study explored the development of research with family carers and people with dementia.

As younger people are also affected by dementia the search looked at a study by Beattie et al (2010) and found that concerning younger people in dementia care (under 65 years) there was a need for person-centred care that is tailor made to the needs of the individual.  Such care is expected to fulfil cultural competence criteria and this must be defined ahead of time and be capable of being measured. The study used a systematic review methodology to investigate studies which originated in the UK to highlight evidence that person-centred care, the advocated model of practice is not currently reflected in the majority of services provided in the UK. Findings argued for inter-agency collaboration, early assessment and an awareness of individual needs. All these elements are those which should be considered within the design of services in line with findings from the  cultural competent needs assessment process. Here we see that cultural competence and person-centred care are definitely linked hence it is discussed in some depth later on in this study.

A study by Mackenzie et al (2005) is one of the first to lead in the movement towards culturally competent dementia care however their focus was only on black and ethnic minorities affected by dementia. This is perhaps one of the most important studies considered in this study. The researchers were concerned with the question of evidence-based culturally appropriate care for BME populations affected by dementia. They highlighted the crucial issue of a lack of evidence base to guide professionals working with people affected by dementia. An equally important finding was the limited focus on beliefs about dementia and the type of treatment and support needed. These two issues are implicated in the problems faced by providers who have responsibility for supporting BME service users and families affected by dementia. As a researcher looking to justify the need for cultural competent dementia services these are findings that support the relevance of my research.

So much has been said about the capacity of cultural competence to yield good results and its importance as a core requirement for successfully working with diverse patient groups, however, the literature also presents dissenting views with regards to this notion. An important study led by Wong et al, 2003 expounds on the dissenting voices from Asian-Canadian practitioners who have embraced the concept of cultural competence. They assert that the conceptualisation of culture in most writings about the concept fail to recognise the fluid boundaries and the political character of culture. Their participants who work with ethnic minorities in a multi-ethnic project promoting mental health found that their knowledge and experience did not guarantee cultural competence. What these practitioners were able to evidence was the elusive, contextual and political character of culture amongst other things. In a recent study looking to define a conceptual model of organisational cultural competence for use in MH services (Hernandez et al, 2015) found that although the proposition that increased cultural competence in providing psychiatric services can reduce existing disparities is appealing, cultural competence lacks a clear means of operationalisation that can direct research and practice.

There is much to be said of the practice of cultural competence in terms of its efficacy, for this reason the training programmes used to skill practitioners should come under scrutiny. Beach et al, carried out a systemic review of health care provider educational interventions, to do this they identified studies that evaluated interventions to improve cultural competence from 1980 to 2003. They were searching for evidence of effectiveness and the costs and found evidence that there is an impact on patient satisfaction but poor evidence of an impact on adherence to therapy and poor evidence of the determination of costs.

In summary, the literature review has covered studies/findings of dementia and cultural competence/value-based commissioning, policy, models/frameworks, definitions and the evaluation of some training programmes. The purpose was to give an understanding of its relevance to the commissioning of dementia and other MH services for older people by highlighting how cultural competence has been used to impact health care delivery. It has become clear that a big gap in the literature is studies that look at cultural competence as it can be applied to commissioning.

The review discovered value based commissioning, however, though both concepts are similar it is decided that cultural competent commissioning is the appropriate counterpart  to cultural competent care delivery and cultural competent needs assessments. The review has comprehensively established the relevance of cultural competence to care delivery and understanding service users of all cultures. A wealth of theoretical theories was evident despite a lacking in consensus over its definitions. The review also leaves no doubt of the need to improve on its application to MH care delivery and the designs of training/teaching curricula.  This is related to the question of developing adequate key performance indicators for measurement especially within nurse training where evaluation of training content did not always report back conclusive outcomes in terms of its cost, effectiveness and patient satisfaction.

Although there is no doubt that much progress has been made (research, nursing, mental health care delivery, psychology, health care counselling etc) there are significant gaps in the evidence and research. To this end, effort is needed in the area of cultural competent commissioning with the aim of ensuring that cultural competence is operationalised within both health commissioning and delivery. It may be a better method for accomplishing the delivery of optimum person-centred care that service users find meaningful. Furthermore, it may ensure the concept and all that it embodies is  embedded at strategic level, this is because it is strategic policies that confer the status of cultural competence on organisations.

The review evidenced the concept of cultural competence as complex and multifaceted, lacking a common consensus amongst experts and

This study aims to produce as an additional outcome a set of guidelines and standards like those developed by Bean, Perry, and Bedell, 2001, 2002; Kim, Bean, & Harper, 2004. Their guidelines were developed for family therapists.

At a systemic level the NHS when embracing cultural competence, will need to make similar progress to the  American Psychological Association (APA, 1993, APA 2003) and the Association of Multicultural Counselling and Development (AMCD). Their framework will however need to focus on being outcome driven which is what is needed to ensure that performance can be measured optimally.

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