Partnering with patients and person-centred care

Collaborative care must be built around the needs of individual patients and groups of patients.

Patient-physician relationship is at the heart of patient-centred care

The Canadian Medical Association stresses that at the heart of patient-centred care is the patient-physician relationship. The importance of this cannot be overstated. Built on values of trust, empathy, respect and honesty, it is the foundation on which our therapeutic alliance exists. The relationship must be beneficial to the patient, the physician and other providers.

The view of the profession is best summarised by the Canadian Medical Association, and I quote:
“Collaborative care entails physicians and other providers using complementary skills, knowledge and competencies and working together to provide care to a common group of patients based on trust, respect and an understanding of each other’s skills and knowledge.

This involves a mutually agreed upon division of roles and responsibilities that may vary according to the nature of the practice and skill sets of the individuals.”

Patient-centred care is very important for persons in vulnerable and disadvantaged populations

“Patient-centred care is particularly important among vulnerable and disadvantaged populations, such as the young, elderly, disabled or mentally ill and those from culturally diverse backgrounds or rural or remote areas” (Australian Commission on Safety and Quality in Healthcare).

The principles and approaches are considered to go some way towards addressing the inequity people can experience. It is seen as a way of supporting greater involvement of all people in healthcare processes and potentially achieving better healthcare outcomes.

Improving the quality of care with patient engagement

There is an emerging consensus in the healthcare policy community that informed and engaged consumers have a vital role to play in improving the quality of care that the healthcare system delivers to patients.

The expectation is that when consumers are armed with the right information, they will demand high-quality services from their providers, choose treatment options wisely and become active participants and self-managers of their own health and healthcare.

A meaningful experience is when the patient is fully informed and the provider has considered the patient’s preferences and goals.

Evidence is strong and indicates that when patients are fully informed and engaged in making decisions about their care, patient satisfaction goes up, results improve and the healthcare costs go down.

Partnering with the patient is about a fundamental shift in the power structure in healthcare and a renewed focus on the core mission of healthcare systems.

In 2001, the US Institute of Medicine (IOM) “Crossing the Quality Chasm: a New Healthcare System for the 21st Century” defined good quality care as safe; effective; patient-centred; timely; efficient and equitable. Patient-centred care is one of the six quality aims in this report.

Gribbs in 1999 identified three components of defining person-centred care:

• Patient-centeredness as recognition of individuality or specificity.
• As a recognition of personal, social and environmental factors that are constrictive of persons.
• Regulation of autonomy – work with the patient and not just on them.

Patients are healthcare’s richest, yet largely untapped, resource. Patients are smart, experienced, resourceful and determined. We need to capitalise on the growing momentum of improved patient engagement and help to realise their potential.

However, the word ‘patient’ is limited in its descriptiveness. By definition, a patient is a sufferer – one who patiently suffers or passively receives treatment. This reflects their relationship with their illness. It neglects those who do not access services. Hence we need to, in the long term, use the term ‘person-centred’ healthcare.

The science and art of medicine brought together

The two fundamental components of practice – the science and art of medicine – should be applied within our ethical and humanistic framework.

Current ‘evidence-based medicine’ overemphasises the value of science while ‘patient-centred medicine’ overemphasises the patient’s choice. Person-centred medicine with its biological, social and psychological emphasis brings the science and art together.

The WHO initiated the development of a prototype person-centred care index (PCI). In its current version, the PCI has 33 items organised into eight broad categories – as follows:

1. Ethical commitment
2. Cultural sensitivity
3. Holistic scope
4. Relationship focus
5. Individualised care
6. Common ground for diagnosis and care
7. People-centred organisation of services
8. Person-centred health education and research

Patient-centred medicine is defined in the Geneva Conference, as medicine:
“of the patient, for the patient, by the patient and with the patient”.

This all leads up to patient-centred integrated care for all.

Correcting the “corruption in the mission of healthcare”

A hundred years ago George Bernard Shaw lambasted the medical profession as a “conspiracy against laity”. Today the disease- and doctor-centric systems are too costly, wasteful, fragmental and often too uncaring. There is also marked variation in access to care, its quality and costs. Patients lack information on practice variation, the effectiveness of their care and the extent of medical uncertainty. “The corruption in the mission of healthcare requires urgent correction and how better to do it than enlist the help of those whom the system is supposed to serve – patients.” The physician and patients need to work in partnership if we are to improve healthcare and challenge deeply ingrained practice believes.

These four Cs are fundamental to the partnership between providers of care and patients:

1. Collaboration
2. Comparison
3. Coordination
4. Communication

A patient-centred approach can be achieved through:

• Empowerment
• Engagement
• Education
• Strong decision making

Elements of engagement

The term ‘engagement’ is used to mean anything from patient communication to information portals. It will lead to collaboration between patients and providers to design, manage and achieve healthcare outcomes.

By empowering patients to become partners in – rather than customers of – the healthcare system is a critical step on the road to achieving the best care at lower cost – McGinnis.

Education

Advocacy for patient education is driven by the belief, backed by some evidence, that engaging patients will reduce healthcare costs through avoidance of unnecessary investigations and treatment. It also will go a long way to decrease the asymmetry of information and promote informed decision making.

There is also a need for transferrable education of healthcare professionals, who have always adopted a reductionist and paternalistic attitude to healthcare delivery.

Shared decision making

Shared decision making is seen as the middle ground between informed choice and traditional paternalistic medical decision. It is developed in an attempt to reduce uncertainty.

Shared decision making and creating therapeutic concordance increase patient commitment in healthcare decisions and allow more open exchange between clinicians and patients.

In essence we are promoting consumer activism. We need to activate consumers to become agents of their own healthcare in a difficult process of change. We need to inform consumers to make choices.

The overarching themes and messages include:

• Culture shift
  • Making wise and informed choices and using limited resources wisely will require a significant culture shift.
• Listen fast, listen fully
• Patient engagement is a skill, not a trait
• Trust matters

Prepared, engaged patients are fundamental precursors to high-quality care, lower costs and better health.

Acknowledgement

• Putting patient first
  • Patient-centred collaborative care discussion paper - July 2007, Canadian Medical Association
• Patient-centred care
  • Improving quality and safety through partnerships with patients and consumers, Australian Commission on Safety and Quality in Healthcare.

- Prof Morgan Chetty, Chairman of the IPA Foundation