The dominant model (I don’t say the only model) of doctor-patient consultation privileges one viewpoint: the doctor’s. The relationship is a power relationship in which the doctor remains largely unquestioned and the patient is mostly powerless.
Whether benign or not, the balance of this relationship may be shifting, indeed has to change, if we are to deliver world-class health outcomes for users of health services in Wales, and to do so within the financial constraints the NHS is facing.
Last Tuesday’s Times (16 March 2010) published a letter (We must treat our minor ills ourselves) signed by a number of doctors and related professionals bewailing the fact that the ‘worried well’, half of them of working age, now represent approaching 20% of GP time. The ‘catastrophic impact of this dependency’ is detailed in the accompanying full-page (3) article (Workforce wimps cost NHS billions)which ‘demonstrates’ the huge costs of attending to the minor ills of half of those making 51.4 million visits for colds, headaches, back pain, indigestion etc: £2billion annually. (This is not to ignore the fact that, in a few cases, the presenting minor problem masks a deeper more serious disease or condition.) 90% of those visits for minor ailments resulted in a prescription.
In one way, the perception that patients, by and large, are powerless, might be challenged when we see them as having the capacity to drive the NHS this way. But GPs speaking about their own ‘victimhood’ behaviours, in an unreasonably demand-led culture of service use, does not change the central fact of the relationship that people have with their health professionals. If they have learned to be sick, to roll over and adopt the position of acquiescent or plaintive patient, so too have doctors learned to treat them in ways that remove most of their best opportunities for self-management. Launched in their letter to the Times, the Campaign for Self-Care has to be careful not to make the same mistakes.
If GPs feel compelled to (merely) manage ‘insatiable’ patient behaviours, then surely mitigating those very problems which affect the users of their services will bring them immediate benefits as practitioners? The way that people can be ‘empowered’ to better manage their health conditions, and not just minor ones, can lead directly to relieving the worst aspects of the ‘patient experience’, creating better health outcomes and contributing to the shift in behaviours that could, the Times suggests, lead to £10bn saving over five years. Unfortunately the emphasis in the article is mostly on (negative) patient behaviours: when the question of how doctors behave arises Dr Dixon, a GP from Devon, is quoted as saying: ‘…health awareness [on behalf of the patient]…needs to be balanced with more information on when you need to see someone [or not]. We have become merchants in investigations and referrals and our teaching role is one we need to invest in as well.’
The role of doctors as teachers of self-management skills is welcome. Self-managing health conditions is a very real solution to demand-led dependency. But users of services cannot become wise and responsible users without the tools to do so, and responsibility for their behaviour change cannot be simply expected of them without those tools. The opportunities to acquire them have to be grown rapidly and widely.
Empowering service users is not a question of defeating them in a war of attrition; enabling them to learn the skills to re-orientate their expectations, and to be well-informed about the decisions they do (need to) make, depends on giving them the power to engage in decision-making and act positively based on knowledge. The architect of the NHS, Aneurin Bevan once said ‘The purpose of getting power is to be able to give it away’. Practitioners need to recognise that their part in the dependency culture is not just better management of patient behaviours and expectations, but their own too. Genuine partnership is the key tool to achieve the win-win-win for patient, practitioner and organisation together.
Better outcomes, better use of scarce resources (practitioner time, money etc), depend critically on building a better focus for delivery of healthcare, and enabling all parties to behave differently when appropriate. If 90% of people who turn up in front of their GP with chest pain have no event or disease, then why on earth are we not enabling those people to make better decisions about their situations to everybody’s benefit? This does not preclude calling 999; far from it. But it means doing so when there is good reason, and knowing what a good reason looks like (thus, by contrast, knowing what is insufficient to warrant intervention). It means not heading to the GP with a sniffle, but knowing what to do if that cough begins to create breathing difficulties.
We have been conditioned to ‘play patient’; the NHS makes us ‘sick’. But being sick is not the same as having a disease or health condition. Disease is objective, medically diagnosed pathology; illness, the feelings that are associated with some disease/condition. Sickness however, is a social status granted to the person who is ill. It is a means to getting time off work, benefit support, a cup of tea in bed with some paracetemol, sympathy, help. We still incline people to play the sick role, and reinforce it by constantly refusing and indeed removing opportunities for patients to become informed, decision-making, service users, real partners in their healthcare and condition management.
The doctor’s armoury has relied in the past on their prestige as experts: we generally think of those who get the chance to study medicine as being amongst the brightest. This intelligence puts them in a class of decision-makers that others can feel uncomfortable to challenge. Added to this, their professional expertise, especially because of the inherent nature of healthcare giving, quickly creates a locus for unchallenged opinion based on that expertise. When a doctor says take this pill and you will feel better, have this operation and we can save your life, how can we be surprised that people jump immediately and uncritically to rely on that expertise?
Carry on Doctor, nowdays deeply culturally insensitive, caricatured this model of delivery, but Sir Lancelot Spratt would not have been remotely funny at that time if the parody did not strike at a truth. Some older (no disrespect) consultants will admit they were trained to act like ‘gods’. Sadly, a few, and not just older practitioners, still think they can act this way with impunity and resent any challenge to their power as doctors.
But challenge is not always for its own sake: joint-decision making is nothing to fear or resent.
There have been attempts to enable patients to become managers of their own conditions and sometimes these work well enough. They just don’t travel far enough, and perversely, some patients are reinforced in their roles as ‘sick’. Additionally, programmes to teach patients to become ‘experts’ are flawed. There is a false opposition between the patient’s ‘expertise’, living their condition, and medical training and experience.
Real partnership in healthcare does not dispense with medical expertise. On the contrary, such partnership continues to rely heavily on the professional’s gifts and training: it is the nature of that reliance, away from dependency to condition management, away from the medical model to medically supported decision-making, which is the step-change required now.
‘Incorporating the patient’s viewpoint’, i.e. bringing this into the doctor’s model, not giving it genuinely equal status, nor rearranging the entire relationship between ‘perspectives’, is not a solution. The Calgary-Cambridge guide to medical interviewing (all 71 points of it) still fails to address the key solution, as current condition-management programmes still fail to achieve the desired better health outcomes, better use of GP and other health practitioner time and better organisational returns in terms of the available cost-benefits. ‘Patient-centredness’ is not enough.
I was involved in a trial to support patients admitted with stroke/CVAs through the A&E; of one of the largest acute hospitals in Northern Ireland. A multi-disciplinary team (MDT), physios, OTs, nursing staff, social workers, speech therapists and any other relevant professional, all led by the consultant in charge, set out to improve services to emergency admissions and to create better outcomes for people with strokes. The person missing was the patient (and/or patient representative), but that was in 1978!
To this day, MDTs meet regularly in hospitals and still the person missing is the patient. We want people to stop adopting the sick role, to deal with their illness and disease or condition in a way that can defeat the pressure of insatiable demand for services. But we will not countenance the very thing that will bring this about.
The move to patient-centredness is certainly not new and may be already tired, especially when we have so demonstrably discouraged patients from building any skills that would allow them to self-manage appropriately. Imposing solutions from an organisational point of view won’t do either in a modern age: practitioner and organisational need cannot be served before service user outcomes if the world-class health outcomes are to become real. We cannot be satisfied with patient-centredness, especially in the absence of the person whose life it is.
The NHS has moved from its first days where doctors and opticians were directly engaged through the monies contributed by Tredegar miners and steelworkers, to serve the health needs of the community. In the 21st century we need (again?) a relationship in which the patient is the primary decision-maker, but their informed decision-making is in equal partnership with the expertise around them. We can reduce the dependency relationships patients have with the NHS, but we need do it in an intelligent and sustainable manner.
Written by Dr Kevin Fitzpatrick, WIHSC Associate
1. Waddell, G & Aylward M The scientific and conceptual basis of incapacity benefits TSO 2005 (p7)