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PRIMARY CARE: Angela Coulter and Nick Dunn After Bristol: putting patients at the centre • Commentary: Patient centred care: timely, but is it practical? BMJ 2002; 324: 648-651 [Full text]

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Time gentlemen time

peter r. williams   (19 March 2002)

Lack of time or of role?

Aureo Muzzi   (22 March 2002)

"It's attitude, stupid" to paraphrase Bill Clinton

Roger M. Goss   (29 March 2002)

None so blind

Mitzi MA Blennerhassett   (1 April 2002)

Patient-centred care: let’s start with those who most need it

Josip Car, George K Freeman, Aziz Sheikh   (8 April 2002)

Time gentlemen time 19 March 2002
peter r. williams, GP principal north oxford medical centre, 96 woodstock rd., oxford OX2 7NE Send response to journal: Re: Time gentlemen time	I would like to echo the sentiments expressed By Nick Dunn in his commentary on Angela Coulter's article , After Bristol: putting patients at the centre. General practitioners need time to deliver patient-centred care and eight minutes is simply not enough. After twenty-five years in practice, time spent teaching doctors-to-be and experience in defending doctors in the Courts, I am convinced too little time spent in encounters with patients is a recipe for dissatisfied patients and dissatisfied doctors. Yet intelligent discussion of this topic rarely creeps into government directives or reports on the NHS. More efficient use of time is a poor excuse for not providing more time. Most doctors are efficient. What they lack is sufficient face-to face contact with their patients. The proportion of time spent updating the computer, performing opportunistic health checks or simply recording encounters grows at the expense of useful communication, patient education and seeking shared decisions on common problems.Isn't it about time we declared a moratorium on patient- centred practice until the important subject of time is adequately addressed? And if this means fifteen minutes on average with each patient should this not be factored in to the number of GPs we require to make it all come true? I firmly believe in patient-centred care but I also believe it will never happen unless time is devoted to it. Peter Williams. No competing interests
Lack of time or of role? 22 March 2002
Aureo Muzzi Ospedale Santorio v Bonomea 265 34100 Trieste Italy Send response to journal: Re: Lack of time or of role?	I am convinced that we doctors in the Italian NHS lack the time to dedicate to the patient as well as the conviction that is necessary to modify our approach to the patient. In fact the conviction prevails in many that we are only the executors and not people who can take part in order to modify the errors and backwardness of the system. The right way to a system of verification of health expense and to participation in order to reduce waste has been copied from the private sector, but only in fact its negative aspects, relegating doctors to mere executors of other people's decisions, also mistaken, without making doctors feel like protagonists of the change. It is obvious that this system leads only to the burn out of doctors and therefore of their relationships with patients.
"It's attitude, stupid" to paraphrase Bill Clinton 29 March 2002
Roger M. Goss, Director Patient Concern Send response to journal: Re: "It's attitude, stupid" to paraphrase Bill Clinton	LETTERS TO THE EDITOR 29 March 2002 “It’s attitude, stupid” to paraphrase Bill Clinton Editor - Coulter is arguably too kind. (1) She attributes lack of significant progress in putting patients at the centre to shortage of resources. All the evidence coming Patient Concern’s way suggests it is a lack of will. Putting patients first, or at the centre, means putting healthcare providers second or at the periphery. But how do you then ‘manage’ your customers if you are sidelined? How do you keep control and stay ‘in charge’? Improving the miserable experience of illness and thus becoming a patient depends primarily on a change of attitude. The provision of material incentives is the easy part. The public mood favours paying more to drag our healthcare service into the twenty first century. Yet enforcing sanctions for failing to treat patients legally (vide Miss B) and as human beings rather than medical problems remains a major challenge. Prescription, other than for the issue of drugs, is a dirty word in the NHS. Perhaps the promotion of a patient-centred service requires a more ruthless response to bad behaviour by medical professionals. Roger M. Goss Director – Patient Concern (1)Coulter A. After Bristol: putting patients at the centre: BMJ 2002; 324: 648-651 (10 March)
None so blind 1 April 2002
Mitzi MA Blennerhassett, cancer concern self help group secretary, member royal colleges' patient liaison groups Slingsby, York YO62 4AQ Send response to journal: Re: None so blind	Sir Researchers, patients and doctors know fundamental requirements for improving the doctor/patient relationship to be increased quality time, communication skills training and more cash if the doctor/patient relationship is to improve. But none of these will have an impact unless attitudes change. For dedicated, but debilitated, campaigning patients like myself it can sometimes feel like being caught up in the Israeli/Palestinian conflict: goodwill gestures meet a blank wall, a thin veneer of user involvement hides tokenism and exclusion, paternalism is still rife, the hierarchal system still feeds egos and instils the concept of infallibility. Areas of patient-centred innovation and good practice well known to those of us interested in partnership, should be shared and copied (Royal College Patient Liaison Groups, the 'Nottingham Project' etc). But parochialism, and above all the need to control, keep blinkers firmly in place. I share the frustration of enlightened clinicians who have to work alongside such dinosaurs; such 'little' men. Trust and respect have to be earned; clinical expertise is no longer sufficient in patients' eyes. 'He is a great man, who does not cling to power' (M Blennerhassett, 2002)
Patient-centred care: let’s start with those who most need it 8 April 2002
Josip Car, PhD student Department of Primary Health Care and General Practice, Imperial College, London W6 8RP, George K Freeman, Aziz Sheikh Send response to journal: Re: Patient-centred care: let’s start with those who most need it	EDITOR- Reflecting on the implications of the Bristol Inquiry, Coulter rightly emphasises the importance of putting ‘patients at the centre’ of the medical decision making process.1 Such shift in the balance of power, moving towards a more egalitarian relationship that may truly be viewed as something akin to the partnership model of care recommended by the Bristol Inquiry,2 is likely to be an essential pre-requisite to improving the safety record of healthcare systems.3 Dunn, in his accompanying commentary to Coulter’s paper, echoes an oft-heard criticism of advocates of patient-centred models of care, namely the failure to appreciate the resource, and in particular, time implications of nurturing and encouraging greater patient involvement in the decision making process.1 How then are we to overcome this major practical impasse? It is worth drawing attention to the fact that those most in need of ‘partnership’ are least likely to enjoy such a relationship, another example of the inverse care law. Consider some of the patients we spend most time with in talking about their illness. It is, in general, much easier to involve a well-educated and ‘communicative’ patient in discussions regarding the relative pros and cons of a particular treatment choice than it is effectively to engage with someone from a more socio- economically deprived background or with those from whom we are separated by language and cultural differences.4 But it is precisely these sub- sections of our community, the socially excluded, who are most in need of being empowered and enabled in their own care.5 We suggest therefore that attention is initially focused on delivering patient-centred care to those who have most to gain from shared decision-making. Once meaningful progress has been achieved on this front, we will perhaps be in a position realistically to broaden the partnership agenda. Josip Car PhD student, general practitioner George K Freeman,br> professor of general practice Aziz Sheikh NHS R&D primary care fellow Department of Primary Health Care and General Practice Imperial College of Science, Technology and Medicine St Dunstan's Road, London W6 8RP competing interests: none 1.Coulter A, Dunn N. After Bristol: putting patients at the centre * Commentary: Patient centred care: timely, but is it practical? BMJ 2002; 324: 648-651. 2.Bristol Royal Infirmary Inquiry. Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995. London: Stationery Office, 2001. www.bristol- inquiry.org.uk/ (accessed 5 Apr 2002). 3.Wilson T, Sheikh A. Enhancing public safety in primary care. BMJ 2002; 324: 584-587. 4.Howie J, Heaney D, Maxwell M, Walker J, Freeman G, Rai H. Quality at general practice consultations: cross sectional survey. BMJ 1999; 319: 738 -743. 5.Griffiths C, Kaur G, Gantley M, Feder G, Hillier S, Goddard J et al. Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study. BMJ 2001; 323: 962-970.