BMJ roundtable debate: How can we get better at providing patient centred care?

Change the medical culture and create new models of care with patients

Ideally, each contact with healthcare would be with the providers best suited to meet an individual’s needs. One example cited was people who have behavioural or mental health disorders and social problems. Whitaker, proposed, “you need to have a team which includes nurse, psychologists, clinical social worker so that those issues are addressed fully and competently because they’re key to helping a person get well and stay well and not need to come back.”

Amir Hannan, a general practitioner, said we should question why emergency departments seem to be the first choice for people seeking care. Jeremy Taylor, from National Voices, suggested that it was not just a question of being unable to access care elsewhere. It reflected people’s genuine concern about their health, and knowing more about their worries and their expectations would help shape the delivery of services. Several participants at the roundtable made the point that an underappreciated part of a clinician’s role is to reassure. Rosamund Snow, The BMJ’s patient editor, said, “If you’re seeing a worried but well person, you’re doing your job.”

Coproduction of healthcare was widely seen as a positive step, with patients and clinicians “sharing the work.” Some argued that “patients are on the team but just not recognised.” Seres spoke of the “real role and great responsibility” of patients. As a patient, he said, it is “easy to pass the buck onto the clinicians and the professionals,” but if you do “you don’t have a partnership, and you don’t have a relationship unless both parties work at it.”

Alex Silverstein, past president of the International Diabetes Federation’s young leaders in diabetes project, referred to the “enormous disconnect” between patients and clinicians and agreed with the need to determine “active shared goals.” Determining these goals, recording them, and measuring whether they have been reached is important. Hannan discussed an initiative used in his practice where patients pledge their own health related goal as part of NHS Change Day. This is recorded in the medical notes and revisited in future consultations. Doing this provides a sense of “ownership” and promotes a “partnership of trust,” he said. He also urged greater patient involvement in commissioning services.

Taylor spoke of the value of harnessing the collective patient voice to push for new and better designed services. Rigarre agreed. All patients, she underlined, stand to benefit from the advocacy of patient groups and the efforts of individual patient leaders.

An important warning note was sounded by some that any advances in patient empowerment must ensure the less vocal and more vulnerable are not excluded. Too many people, Coulter warned, still feel that they are on their own and they “don’t belong to patient support groups.” Participants agreed that clinicians should see it as a priority for “everyone to be empowered.” The default position should be to assume all patients have capacity to make decisions about their care.

New technologies, better relationships

The use of new technologies to engage and empower people was discussed. A show of hands around the table found many people were using wearable activity trackers and mobile technology to monitor their health. Paul Wicks, from PatientsLikeMe, drew attention to the fact that many people now use the internet as “pre-primary care.”

The academic community need to realise “that’s where the action is,” agreed Paul Hodgkin, a former general practitioner and founder of Patient Opinion. “Patients have a voice now, and it’s a public voice. They’ve got Twitter, they’ve got Facebook . . . PatientsLikeMe, support groups” and so “they’ve got solidarity.” If more clinicians were to see the benefit of these already available resources for patients, including peer to peer support, and direct people to them, it might give more time to focus on those who need immediate attention.

Amid talk of system change and mindset shifts, participants were encouraged to come up with practical things that could be done now to advance person centred care. The list was long and included letting patients email clinicians, get results of routine blood tests texted to them, and using teleconferencing more widely (box). However, participants agreed that we should guard against moving to a “consumer” focused system.

Knowing about ways that promote person centred care is important, and so is incentivising them. “We’ve got measures to determine if person centred care is delivered. We just need to use them.” emphasised Coulter. There was broad agreement that following the principle “what gets measured gets done,” doing this for person centred care would enable it to be prioritised by healthcare providers.

But ultimately, participants agreed, “healthcare is about relationships.” If we want to improve the quality of healthcare, and people’s experience of it, we need to manage expectations and bridge the divide between physicians and patients. As Silverstein said, “we’ll only get to a partnership model when we reach a common position that what patients want and what GPs [and other doctors] want are actually the same thing.”