Time to deliver patient centred careBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h530 (Published 10 February 2015) Cite this as: BMJ 2015;350:h530
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Re: From patient centred generalists to GPs with special interests: ‘You only live twice’ or…maybe once?
The thought-provoking editorial by Richards and colleagues1 urging us to deliver patient centred care provided the impetus for re-visiting the subject of medical specialization. Fifteen years ago, the UK government established general practitioners (GPs) with advanced training in specific health conditions such as respiratory diseases, headache, hypertension and minor surgery as GPs with special interests (GPwSIs) within the National Health System (NHS).2 Based on the premise that GPs would refer their patients to a local GPwSIs, instead of a secondary or tertiary care based specialist,3 the aim of this NHS policy was to improve management of chronic conditions and increase patients’ accessibility to specialist care 2, without tapping into more expensive and scarce secondary or tertiary resources. Other objectives included shortening long waiting-list times for consultant appointments and reducing referral costs.2 Despite justification, establishment of this new cadre of GPwSIs has been met with some skepticism in regards to individual patients and the population’s overall health improvement.4
Following implementation of this model, various studies have evaluated GPwSIs services for dermatology and neurology care.3,5 Although clinical outcomes when compared with routine outpatient care did not differ, patients with skin problems were slightly more satisfied with GpwSIs services and experienced shorter waiting times for their first consultation.3 Similarly, patients experiencing headache were more satisfied with GpwSIs service provision in terms of symptom relief.5 However, in regards to cost-effectiveness, GPwSIs were not found to be a less expensive alternative.6 Cost analysis of GPwSIs service for non-urgent dermatological problems found it to be 75% more expensive compared to care provided by a hospital clinic.7 Remarkably, GPwSIs service cost was a staggering £208 in contrast to the £118 calculated for outpatient hospital care.7 Taking into consideration the national baseline fee for dermatology outpatients, the mean cost of specialist care was calculated at £127 per patient compared with £182 for the GPwSIs.7 Differences in the provision of care as well as multiple follow-up appointments for patients attending GPwSIs could partially explain these cost variations. 3
Greece is one of the Eurozone countries that have been severely affected by the ongoing financial crisis. Since 2010, the Greek government has adopted a series of austerity measures which reduced significantly the total health and social welfare expenditures. As a result, accessibility of the general public to health care and preventive services appears to be seriously compromised.8 In this context, implementation of a fully integrated primary care system is more essential than ever to avoid further collapse of the country’s social and health service system. 9 Greece has a lot to learn from countries such as the UK that have operationalized a general practice driven system for decades.10 However, given that Greek GPs are still far out-numbered by specialists, a national GP service network is unattainable at present. Accounting for only 2.8% of the total physician workforce, there is an average rate of 0.2% primary healthcare physicians per 1000 inhabitants.11 Most often, quasi primary care services are provided by specialists such as internists, cardiologists pulmonologists, dermatologists, neurologists and others in their private practices. Thus, the viability of the GPwSIs option in the current environment is questionable.
A number of obstacles hinder implementation of the GPwSIs initiative in Greece. First, there is no nation-wide general practice population coverage. Patients in urban centers are more prone to visit emergency departments or private specialists than a GP, even for common problems. Hence, it would be unlikely to choose a GPwSIs for a more complex condition. Second, there is lack of established health system networking whereas health expenditure is severely curtailed. Third, general practice positions in academia are scarce, minimizing the potential for broad visibility and acknowledgment by the general public. Literature suggests that possession of non-specific ‘soft’ medical knowledge and generalist attitudes are elements that contribute to less prestige.12 GPs often feel the need to be recognized as experts and regain some prestige in their careers. However, given the circumstances, the Greek health system is unlikely to secure, much less certify, a systematic, comprehensive and uniformly structured educational framework for GPs desiring a special interest qualification. Fourth, funding limitations make the commissioning process of specialist services by GPs considerably less feasible and viable. All three forms of payment encountered in developed countries, namely capitation, salary and fee-of-service 4, require payment for a service that may not be the sole one in the chain of health seeking behavior and delivery care options. Last, outpatient clinics of hospitals operated by academics and specialists offer the choice of privately paid specialty care services at competitive rates. This option potentially increases access for those who can pay out-of-pocket fees and could explain Greece’s limited demand for GPwSIs services.
Establishing a fully operating primary care network is a high priority, requiring many more generalists than specialist doctors as well as doubling the number of practice nurses. Claiming one of the highest ratios of physicians per 100,000 inhabitants in the EU, combined with one of the lowest ratios of nurses, the emphasis on curative services comes as no surprise, whereas health promotion, disease prevention, rehabilitation and home care services are on the sideline.9 The rising number of patients with multi-morbidities and complex, deteriorating socio-economic circumstances makes the bio-psycho-social model of care a promising approach.13 Stepping forward to satisfy holistic health needs in conditions of limited funding capacity is a major challenge. Patient centred care has been shown to improve quality while promoting appropriate use of health care services.14 On the other hand, health care delivery by GPwSIs appears to address patient needs in a fragmented way, since this option shifts general practice’s focus from the person to the disease-stricken system, adopting a biological rather than a bio-psycho-social model of care.4,15 Under this perspective, although GPwSIs seem to have found their ‘place’ in countries with an evolved primary care system, it would be premature to invest into this model in countries undergoing extreme economic hardships with a general practice field still experiencing growing pains and no luxury of ‘living twice’.
No competing interests
“We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.”
1. Richards T, Coulter A, Wicks P. Time to deliver patient centred care. BMJ. 2015 Feb 10;350: h530. doi: 10.1136/bmj.h530.
2. Department of Health (2000) The NHS plan: a plan for investment, a plan for reform (HMSO, London).
3. Salisbury C, Noble A, Horrocks S et al. Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial. BMJ. 2005 Dec 17;331(7530):1441-6.
4. Gérvas J, Starfield B, Violán C, Minué S. GPs with special interests: unanswered questions. Br J Gen Pract. 2007 Nov;57(544):912-7.
5. Ridsdale L, Doherty J, McCrone P, Seed P; Headache Innovation and Evaluation Group. A new GP with special interest headache service: observational study. Br J Gen Pract. 2008 Jul;58(552):478-83.
6. Roland M. General practitioners with special interests--not a cheap option. BMJ. 2005 Dec 17;331(7530):1448-9.
7. Coast J, Noble S, Noble A, et al. Economic evaluation of a general practitioner with special interests led dermatology service in primary care. BMJ. 2005 Dec 17;331(7530):1444-9.
8. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet. 2011 Oct 22; 378(9801):1457-8.
9. Lionis C, Symvoulakis E, Markaki A, et al. Integrated primary health care in Greece, a missing issue in the current health policy agenda: a systematic review. International Journal of Integrated Care 2009, 9:1-14.
10. Kousoulis AA, Symvoulakis EK, Lionis C. What Greece can learn from UK primary care experience and empirical research. Br J Gen Pract. 2012 Oct; 62 (603): 543.
11. Greek National Statistical Service. Physicians by specialty and dentists, by geographic region and prefecture: 2009.
12. Stein HF. Family medicine’s identity: being generalists in a special culture? Ann Fam Med 2006; 4 (5):455-459.
13. Eaton S, Roberts S, Turner T. Delivering person centred care in long term conditions. BMJ 2015;350:h181.
14. Stacey D, Légaré F, Col NF, Bebbett CL, Eden KB, Holmes-Rovner M, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014 Jan 28;1:CD001431.
15. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977; 196(4286): 129–136
Competing interests: No competing interests
Health care professionals will need to trust their patients if we want to deliver patient centered care.
Repeat prescription services, multidisciplinary healthcare, education, empathy, engagement and integrated services are the 6 areas of care that Silverstein 1 says that patients need from health care professionals to manage their own care.
Repeat prescriptions are not needed for every patient, but the remaining 5 areas cover the gamut of healthcare. These themes can be easily linked to the touchpoints identified in Robert et al’s2 article on Co-design.
One of the hopes of focusing on patient centered care, particularly around the multiple co-morbid patient is that efficiencies within delivery systems can be identified and eliminated. At the same time, the change in the relationship between care receiver and provider will provide for better patient (and provider) engagement.
In the same edition of the BMJ, Bewley asks maternity care providers to give women the evidence cited in the new NICE guidelines on intrapartum care so that they can make a decision about place of birth.3 This reminds us that whilst trust in the medical profession remains high, in order to move towards a more patient centric model, professionals will need to trust the decisions that patients make, even if they are perceived by some as the “wrong” decision.
1. BMJ 2015; 350:h248
2. BMJ 2015; 350: g7714
3. BMJ 2015; 350: h621
Competing interests: No competing interests
It is a very good thing that person centred care seems to be gaining traction in the medical community.
However, it will need to work practically, reproducibly and consistently. To get it embedded in the healthcare culture I suggest that it needs to be underpinned by a simple and memorable concept that encompasses the core things that are needed in the one to one therapeutic relationship between a professional and a patient.
I suggest that "competent compassion" fulfills these criteria. When a patient sees a professional they want them to be competent and compassionate - that is what we would all want for ourselves and families and friends. It encapsulates what is needed for quality care. One without the other is either dangerous or ineffective.
Let's not over complicate patient centred care and make it too academic and driven by top down strategies. The beauty of the concept of competent compassion is that it puts the onus on the professional to increase their competence and compassion - and gives them simple tools to do that. This then becomes an ongoing, normal part of practice which is not about sticks but about carrots and personal development.
Have a look at the website - www.competentcompassion.org.uk where it is explored further - and let me know if you want to have a look at the competent compassion checkup tools available for the professional, the patient and an observer, as required.
I believe that the vast majority of professionals want this - something simple and effective to refocus on the quality of individual care - rather than organisational targets that can ignore what really matters to actual patients - and us.
Competing interests: I am the founder of Competent Compassion - a concept explored in www.competentcompassion.org.uk
Richards et al call for patient centred care. I hope all doctors and medical educators will support this call. The first lesson I learned in medical school was the sentence by Murphy (1857-1916, abdominal surgeon): “The patient is the center of the medical universe around which all our works revolve and towards which all our efforts tend”. The patient is the reason we started studying medicine. The patient is the reason we go to our surgery. The patient is the fundamental reason we doctors exist. That is what medicine is all about: “placing the best interests of patients at the centre of everything you do”.
I hope there comes a day when we see that patient centred care really is a pleonasm!
1. Richards T, Coulter A, Wicks P. Time to deliver patient centred care. BMJ (Clinical research ed) 2015;350:h530 doi: 10.1136/bmj.h530[published Online First: Epub Date]|.
2. Barnhoorn PC, Youngson CC. Defining professionalism: Simplex sigillum veri! Medical teacher 2014;36(6):545 doi: 10.3109/0142159x.2014.909016[published Online First: Epub Date]|.
Competing interests: No competing interests
Medical care primarily should focus on patients, secondarily on family, and the tertiary care must be targeted on the community. Lack of patient centred care will not achieve health care goals in a country.
Competing interests: No competing interests
Traditionally neither patients nor the public have the power to shape the services they use and pay for: but how should we respond to this challenge? As part of the spotlight on patient centred care, Professor Robert(1) and colleagues make a compelling case for experience based codesign and, more broadly, for giving patients an active role in continual improvement within health services.
There is also an important role for patients ‘being there at the table’ from the start. Stronger patient involvement in the commissioning of health services is needed, if patients are to shape health and social services as they are being designed. This is essential if we are to design health care that meets the needs of those who use it. (2)
There are at least three important ways that patients and the public can contribute to decisions about their care. Through shared decision-making in clinical consultations; in the evaluation and continual improvement of health care; and in the design and commissioning of health services.
We can see good evidence of interest in the first, and the second. In health policy, professional training, and research, much emphasis is now placed on shared decision-making. We have witnessed growing patient engagement in the evaluation of health services, evidenced by national level patient surveys such as the General Practice Patient Survey, and in continual quality improvement, for example, using experience based codesign(1) Whether there is a real appetite for public and patient involvement in the design and commissioning of health services is a timely question but, given the underwhelming track record of success to date, there is genuine uncertainty about the answer.
Why should the public be involved in strategic choices about the design of health services? Perhaps because they are the ultimate recipients of the desirable and undesirable impacts of public policies; and because public engagement in health care decision-making encourages participative democracy, and public accountability.
Patients should also be involved in the design of health services because they have something unique to contribute: the perspective of someone who is ill. People who are healthy are most often in charge of decisions about the design and commissioning of health services. But there may be differences in what people who are healthy might view as being important in health care, compared to those who are ill. The experience of serious illness is rarely an emotionally neutral event. People who are ill, or have been ill, recognise the value of compassion in care delivery –potentially valuing this in a way that those who are healthy may not. A previous BMJ roundtable discussion highlighted the important of compassion in health care, and called for greater focus on compassion in the way we design and deliver care. Many patients also have a strong appreciation of the potential burden of treatment(3), and a personal understanding of how the design of health services can contribute to this burden, or diminish it, depending on how care is organized and delivered.
Making sure that patients are actively involved in continual improvement strategies, for example, through experience based codesign, is an important goal. Just as important is making sure that patients have a voice around the decision-making table from the start, as services are shaped and commissioned.
Charlotte Paddison (email@example.com)
1. Robert, G., Cornwell, J., Locock, Ll, Purushotham, A., Sturmey, G., Gager, M. (2015) Patients and staff as codesigners of healthcare services. BMJ;350:g7714 doi: http://dx.doi.org/10.1136/bmj.g7714
2. Salisbury, C. (2012) Multimorbidity: redesigning health care for people who use it. The Lancet: Volume 380, No. 9836, p7–9, 7. DOI: http://dx.doi.org/10.1016/S0140-6736(12)60482-6
3. May, C., Montori, V.M., Mair, F.S. (2009) We need minimally disruptive medicine BMJ;339:b2803 doi: http://dx.doi.org/10.1136/bmj.b2803
Acknowledgement: A related blog ‘Why we need more patient involvement in the commissioning of health services’ appeared in the Cambridge Centre for Health Services Research 17 June, 2013 at http://www.cchsr.iph.cam.ac.uk/844
Competing interests: No competing interests