BMJ 1999;319:719-720 ( 18 September )

Editorials

Paternalism or partnership?

Patients have grown upand there's no going back

Paternalism is endemic in the NHS. Benign and well intentioned it may be, but it has the effect of creating and maintaining an unhealthy dependency which is out of step with other currents in society. Assumptions that doctor (or nurse) knows best, making decisions on behalf of patients without involving them and feeling threatened when patients have access to alternative sources of medical informationthese signs of paternalism should have no place in modern health care. The articles assembled in this issue of the BMJ consider the scope for creating meaningful partnerships between doctors and patients and between health policymakers and local communities.

Partners work together to achieve common goals. Their relationship is based on mutual respect for each other's skills and competencies and recognition of the advantages of combining these resources to achieve beneficial outcomes. Successful partnerships are non-hierarchical and the partners share decision making and responsibility. The key to successful doctor-patient partnerships is therefore to recognise that patients are experts too.^1-3 The doctor is, or should be, well informed about diagnostic techniques, the causes of disease, prognosis, treatment options, and preventive strategies, but only the patient knows about his or her experience of illness, social circumstances, habits and behaviour, attitudes to risk, values, and preferences. Both types of knowledge are needed to manage illness successfully, so both parties should be prepared to share information and take decisions jointly.

The concern to equalise relationships between health professionals and lay people is gathering momentum. Consumerism was strongly promoted in the 1980s as part of the market ideology which infused health policy in many countries. The problem with consumerism was that it encouraged people to make demands but failed to emphasise reciprocal responsibilities. Growing awareness of unexplained variations in patterns of medical practice and of the gap between public expectations and the supply of services has led governments to consider ways in which demand for health care can be managed.⁴ Partnership has therefore replaced consumerism as a key plank of public policy. Official statements in the United Kingdom are peppered with the term, which is popular with politicians both because it evinces a warm glow but also because it emphasises mutual self help. The new emphasis is on shared information, shared evaluation, shared decision making, and shared responsibilities.

Patient partnership is therefore firmly on the agenda in the NHS. This year we have been promised a revised Patient's Charter; a relaunch of the patient partnership strategy; the establishment of NHS Direct Online (an online version of the telephone information and triage system); the first results from the national patient and user survey; and now, in a little noticed section of the public health white paper, a new strategy for healthy citizens.⁵ The government wants us all to be better informed about risk. It wants us to know about treatment options, outcomes, and the limitations of medical care. It is promising advice via telephone helplines, website links, health skills training programmes, and a new handbook of common ailments. Self help and informed choice is to be encouraged in the hope that it will keep costs down and ensure that demands for health care are channelled appropriately.

Will it work? Several hurdles need to be overcome. Little is known about the readiness of patients to take on decision making responsibility. Evidence exists that many patients do have strong treatment preferences,⁶ that these are not always predictable,⁷ and that doctors often fail to understand them,⁸ but some patients may not want to have an active role thrust on them. Younger people tend to be more critical of professional paternalism and more likely to expect active participation in decisions about their care,⁶ but some older patients and some with serious illnesses prefer to defer decision making to the doctor, perhaps because it allows them to avoid responsibility for the consequences of "wrong" decisions.⁹ It will be important to find ways of offering involvement which do not place an unwanted burden on sick people.

For doctors the trick will be to determine which patients want to be offered choice and which prefer a more passive role. The requirements for informed consent require some level of patient engagement with decision making, and the General Medical Council has laid down stringent information requirements.¹⁰ Informed consent can no longer be seen as nothing more than getting a signature on a form. But in an eight minute consultation how feasible is it to determine patients' preferences and sensitivities and provide full and unbiased information (p 753)?¹¹ There will certainly be a need for more and better training in communication skills (p 766)¹² and for better access to good quality information to support decision making (p 764).¹³ Howie et al found an association between continuity of care and patient enablement (p 738),¹⁴ but is this compatible with the demand for easier and faster accessfor example, via the government's new walk-in clinics?

As O'Connor et al's systematic review of decision aids shows, patients do not necessarily make conservative choices when they are fully informed about the risks and benefits of treatment options (p 731).¹⁵ In the end the government may be disappointed if demand continues to rise despite its efforts to empower patientsbut they should not be. If it increases the chance of patients being treated like grown ups, it will have been worth it.

Angela Coulter, executive director, policy and development. 

King's Fund, London W1M 0AN (acoulter{at}kehf.org.uk )

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1.	Balint M. The doctor, his patient and the illness. London: Tavistock Publications, 1957.
2.	Tudor Hart J. A new kind of doctor. London: Merlin Press, 1988.
3.	Wennberg J E. Dealing with medical practice variations: a proposal for action. Health Affairs 1984; 3: 6-32[Medline].
4.	Pencheon D. Matching demand and supply fairly and efficiently. BMJ 1998; 316: 1665-1667[Free Full Text].
5.	Secretary of State for Health. Saving lives: our healthier nation. London: Stationery Office, 1999 (Cm 4386).
6.	Guadagnoli E, Ward P. Patient participation in decision-making. Soc Sci Med 1998; 47: 329-339.
7.	Richards M A, Ramirez A J, Degner L F, Fallowfield L J, Maher E J, Neuberger J. Offering choice of treatment to patients with cancers. Eur J Cancer 1995; 31A: 112-116.
8.	Coulter A, Peto V, Doll H. Patients' preferences and general practitioners' decisions in treatment of menstrual disorders. Fam Pract 1994; 11: 67-74[Abstract/Free Full Text].
9.	Charles C, Redko C, Whelan T, Gafni A, Reyno L. Doing nothing is no choice: lay constructions of treatment decision-making among women with early-stage breast cancer. Sociol Health and Illness 1998; 20: 71-95.
10.	General Medical Council. Seeking patients' consent: the ethical considerations. London: GMC, 1999.
11.	Elwyn G, Edwards A, Gwyn R, Grol R. Towards a feasible model for shared decision-making: perceptions and reactions of registrars in general practice. BMJ 1999; 319: 753-756[Abstract/Free Full Text].
12.	Towle A, Godolphin W. Framework for teaching and learning informed shared decision making. BMJ 1999; 319: 766-771[Free Full Text].
13.	Shepperd S, Charnock D, Gann B. Helping patients access high quality health information. BMJ 1999; 319: 764-766[Free Full Text].
14.	Howie J G R, Heaney D J, Maxwell M, Walker J J, Freeman G K, Rai H. Quality at general practice consultations: cross sectional survey. BMJ 1999; 319: 738-743[Abstract/Free Full Text].
15.	O'Connor A M, Rostom A, Fiset V, Tetroe J, Entwistle V, Llewellyn-Thomas H, et al. Decision aids for patients facing health treatment or screening decisions: systematic review. BMJ 1999; 319: 731-734[Abstract/Free Full Text].

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