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EDUCATION AND DEBATE: Michel Wensing and Glyn Elwyn Improving the quality of health care: Methods for incorporating patients' views in health care BMJ 2003; 326: 877-879 [Full text]

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Meanings not things

Michael van Beinum, G12 8RZZ   (25 April 2003)

Users' views reflect their expectations as well as their experiences

Heather M Gage, Rosemary Crow, Sarah Hampson, Alan Kimber, Jo Hart, Lesley Storey, Hilary Thomas   (13 May 2003)

Meanings not things 25 April 2003
Michael van Beinum, Consultant Child and adolescent psychiatrist MRC Social and Public Health Sciences Research Unit, Glasgow University, 3 Lilybank Gardens, Glasgow, G12 8RZZ Send response to journal: Re: Meanings not things	Dear BMJ RE: Wensing, M. and Elwyn, G. (2003) Improving the quality of health care: Methods for incorporating patients’ views in health care. BMJ, 326:877-9. Wensing and Elwyn (1) make a number of important points, but their article can be criticised from one important perspective. In essence, the quality of health care is not a thing but has to do with meaning. The meaning of an experience cannot be investigated using a positivistic philosophy of science, but requires the application of hermeneutical approaches (2). When considering the meaning of a health experience, the role of language and the meaning of words come to the fore, as participants struggle with what is, and is not, allowed to be thought and said. In any dialogue between participants every act of communication arises from a background of past ideological encounters and ideological struggles (3). Such dialogues are never finished but are always open to further possibilities, with every conversation a creative act exploring the world (4). It is therefore remarkable that virtually no mention is made of the exercise of power by Wensing and Elwyn, nor any analysis made of the way the views of patients can be caught up in ideological power struggles between politicians, managers and clinicians in health care systems (5). Their positivistic stance also leads them to propose some very silly things, including suggesting that double blind control trials would be the best way of showing the effectiveness of patient views in changing health care systems. Not, I think, in the real world, where health care systems are subjected to continual, politically-led, change. It is an ethical imperative that the views of patients play an important role in the health care provided for them, but the application of an inappropriate positivistic philosophy of science to "measure" this may result in their voices being obscured, rather than facilitating patients to engage with the political complexities of their health care provision. Wensing, M. and Elwyn, G. (2003) Improving the quality of health care: Methods for incorporating patients' views in health care. BMJ, 326:877-9. Robson, C. (2002). Real World Research (Second edition). Oxford: Blackwell. Sandywell B. (1998). The shock of the Old: Mikhail Bakhtin's Contribution to the Theory of Time and Alterity. In Bell, M.M. & Gardiner, M. (eds.) Bakhtin and the Social Sciences. London: Sage. Bakhtin M. M. (1986). Speech Genres and Other Late Essays. (V. W. McGee, Trans.) Austin, TX: University of Texas Press. Clarke, J. and Newman J. (1997) The Managerial State; Power, Politics and Ideology in the Remaking of Social Welfare. London: Sage. Competing interests:   None declared
Users' views reflect their expectations as well as their experiences 13 May 2003
Heather M Gage, Senior Lecturer Deaprtment of Economics, University of Surrey, Guildford, GU2 7XH, Rosemary Crow, Sarah Hampson, Alan Kimber, Jo Hart, Lesley Storey, Hilary Thomas Send response to journal: Re: Users' views reflect their expectations as well as their experiences	Users’ views reflect their expectations as well as their experiences. H Gage, L Storey, R Crow, S Hampson, J Hart, A Kimber, H Thomas Wensing and Elwyn [1] rightly argue that quality of care improvements need to reflect what patients want, and that rigorous data collection methods are required to ensure users’ views about health care are valid. Although the authors acknowledge that prior expectations are a consideration in the formation of patients’ preferences, it should be pointed out that they are equally relevant to their evaluations of care. Moreover, it needs to be emphasised that health service planners require a thorough understanding of the expectations underpinning users’ views if they are to meaningfully interpret the feedback they collect, and action it appropriately. The number of studies reporting the measurement of patient satisfaction increased substantially in the 1990s [2]. These investigations were conducted in two main contexts: for health technology assessments, and as a management tool for quality monitoring. Although attempts to provide a theoretical basis for the collection and analysis of users’ views have focused on the role of expectations, few attempts have been made to operationalise this. The simplest model presents users’ evaluations as the difference between their expectations about a service encounter, and what they perceive was delivered, this approach examines how people make their judgements, and can explain why different users hold different views about the same level of service delivery. In practice, however, little is known about the nature of users’ expectations, what influences them and how they are affected by socio-demographic characteristics and health status. There is a large research agenda to address that also needs to distinguish different types of expectations (ideas, desires, aspirations, standards, entitlements, and social norms), and to investigate interactions between experiences and expectations. The Dept of Health is launching Trust-level performance indicators based on users’ evaluations of their care, in order to identify areas where quality improvements are required, and to incentivize changes [3]. Local Trusts are also to undertake more detailed surveys of users’ views and report on the action taken as a result. As is the case with health- related quality of life [4], the other main patient-centred outcome indicator, caution is required in interpreting the results of users’ surveys. Even if patient-centred issues are the focus of the evaluation [5], and data is collected by robust methods [1], meaningful conclusions will only be drawn and relevant service improvements implemented, if responders expectations are fully understood. Otherwise favourable feedback could mask low or imprecise expectations and views of poor quality care could be confused with high expectations. Moreover, efforts to manipulate users’ expectations or their perception of what is delivered may be overlooked. [1] Wensing M, Elwyn G, Methods for incorporating patients’ views in health care. British Medical Journal 2003; 326: 877-879 [2] Crow R, Gage H, Hampson S, Hart J, Kimber A, Storey L, Thomas H. The Measurements of satisfaction with Healthcare: a systematic review of the evidence. Health Technology Assessment 2003; 6 (32) In press [3] Dept of Health. Involving Patients and the Public in Healthcare: Responses to the Listening Exercises London, 2002. [4] Carr AJ, Gibson B, Robinson G. Is quality of life determined by expectations or experience: British Medical Journal 2001; 322: 1240-1243 [5] Carr AJ, Higginson J. Are quality of life measures patient-centred? British Medical Journal 2001; 322: 1357-1360 Competing interests:   None declared