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Rapid response to:

Feature Quality Improvement

How to improve healthcare improvement—an essay by Mary Dixon-Woods

BMJ 2019; 367 doi: (Published 01 October 2019) Cite this as: BMJ 2019;367:l5514

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Rapid Response:

Patient engagement and responsibilities the missing link in improving healthcare improvement

Dear Editors

I thank Mary Dixon-Woods for her interesting opinion piece on how healthcare improvement can be better.

I am however perturbed by the lack of discussion of healthcare improvement outside the NHS and other healthcare organisational framework, particularly with respect to the other half of the equation: the patient.

Much of the attention so far is on quality improvement (QI) by healthcare providers, but the healthcare product by which the system “delivers” to the consumer is by no means the same and consistent experience and service. Perception moulded by individual and societal expectations and outlook modulate how these products are received.

Hence any idea that a single standard and minimum necessities that form the essential basis of a healthcare package to be delivered to each and every one of the patients with a set of diagnoses, is at best naive, and at worst ludicrous and dangerous.

Labels like “integration”, “positive deviance”, “product dominant and even “service dominant” (which assumes health is co-produced with patients) place excessive emphasis and expectation upon the healthcare system to come up with products and service to suit individual patients; while this ideal is laudable, it is neither sustainable nor practical if taken to extremes.

Patient advocates will rightly point to human rights for patients to be treated an individual and raise the NHS constitution as a NHS England document supporting the patient’s individual rights to healthcare. If this ever should occur, then we would expect to see 57 million version of what the NHS should be, this is not realistic expectations. It is interesting that the NHS (England) constitution had 5 full pages of patient’s rights but had only three quarter of one page of patient’s responsibilities; curiously the Scottish version has placed more expectations upon what patients should do to help their NHS than their English counterpart.

And it would be reasonable and acceptable to the majority of society that having rights comes with responsibilities. Patients are not to be seen as just passive consumer of healthcare products and service, but should be pro-active in self awareness, self care and determination to take charge of their own health. Patients as primary stakeholders of the healthcare equations should also do their bit to minimise waste, be it in prescription medicines, appointment allocation, treatment services and material.

When healthcare QI fails to take into account the participation and interaction of consumers (ie the patients) the healthcare system rarely works to the best possible efficiency and minimal waste. This will require an investment in patient engagement and education beyond passive advertorial content, as well as a change to how society works. Only when the healthcare relationship is viewed as a contract with a balanced two way interaction with both side fulfilling each other’s expectations, only then can we reasonably expect any QI implementation to be effective without reservations.

But we may have a long way to go yet. There is some irony that 58 years after Kennedy’s “ask not what your country can do for you—ask what you can do for your country“ speech, only a few countries achieved that level of civil mindedness and cohesion, most of them in the non-English speaking world.

Competing interests: No competing interests

01 October 2019
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia