International Journal for Quality in Health Care 16:3-5 (2004)
© International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved
Editorial |
Meeting the patient partnership agenda: the challenge for health care workers
Health care systems around the world are currently being challenged by rapid and radical change in the socio-political and demographic environment. Ageing populations in many industrialized countries combined with improved treatment for many diseases, such as cancer, are expected to lead to an increase in the demand for care. At the same time, the average age of health care professionals is rising and the clinical professions, which now exist in a highly competitive labour market, are experiencing great difficulty in recruiting and retaining staff to replace those close to retirement [1]. More subtly perhaps, there are changes in the nature of social relationships that could have profound and far-reaching impacts on the health care sector. Many social structures have become flatter, less hierarchical and more decentralized than in the past and the status gap that previously existed between professionals and patients has also been challenged by improvements to education and access to information through the media and the Internet [2]. There is also pressure toward a model of care that involves active involvement and participation [3].In the UK, the need for a radical shift in the focus of health care change was given powerful impetus by a number of high profile failures in the health care system and subsequent enquiries. First among these was an investigation into the management of children receiving complex cardiac surgical services at the Bristol Royal Infirmary, England, between 1984 and 1995. The Inquiry found that the many system failures were compounded by cultural norms that prevented poor practice from being openly identified and addressed [4]. Many of the recommendations from the Bristol Inquiry focused on changing the culture of the UK National Health Service to make it more open and accountable by ensuring that patients and the public were involved at every level.
‘Patients must be at the centre of the NHS, and thus the patient’s perspective must be included in the policies, planning and delivery of services at every level.’ [4]
Since the publication of the Bristol Inquiry the term ‘patient-centred care’ has become central to much of the thinking about the future of the NHS. Although there is some discussion about its precise meaning [5], a useful and concise definition focuses on patients’ perceived needs:
‘Patient-centred care is health care that is closely congruent with and responsive to patient’s wants, needs and preferences.’ [6]
Changes in the socio-political and demographic environment have provided the context for a range of Government policies designed to reorganize health services around the patient’s journey and to focus on developing patient partnership and patient-centred care in the United Kingdom [7–10]. The move toward partnership has been reflected in the emphasis placed on empowering patients to become managers of their own care, notably illustrated by the Department of Health’s Expert Patient Programme [11]. This programme aims to promote awareness and create an expectation that patient expertise is acentral component in the delivery of care to people with a chronic disease. It aims to establish a programme for developing user-led self-management courses to allow people with chronic diseases to have access to opportunities to develop the confidence, knowledge and skills to manage their conditions better, and thereby gain a greater measure of control and independence to enhance their quality of life.
In addition to self-management, patients and the public are increasingly seen as having a role in the planning, delivery and evaluation of services to ensure that services are designed for users [7]. This duty is now enshrined in legislation through the Health and Social Care Act [12], which places a statutory duty on health authorities, primary care trusts and NHS trusts to involve and consult patients.
Ultimately, the changes we have outlined have the potential to provide an important challenge for the health care professional. Richard Smith, editor of British Medical Journal, has already highlighted the importance of preparing for partnership with patients in a special BMJ editorial devoted to this topic. Smith states ‘Being patient centred involves much more than being dedicated and caring. It’s a different way of thinking and behaving, where doctors and patients work together as true partners.’ [13] Change is demanded at the level of the clinical encounter and at the level of service planning, delivery and evaluation. We wish to pose some key questions in relation to the workforce. For example, what are the implications for the healthcare workforce in the United Kingdom and in other countries who have similar themes evolving within their health care policies? How can health care workers be prepared for some of the changes we outline and supported in order to successfully meet the patient partnership agenda?
While it is always difficult to make predictions, extrapolations from some current trends can provide some insight into the range of future possibilities. The desired cultural change in health care is likely to lead to a fundamental shift in the waythat clinicians and patients think about their roles and responsibilities. For example, health care professionals may move from being the sole providers of health care knowledge towards a more facilitative role, helping patients find their way through complex information and decision-making processes, as well as a network of services [3,14].
It seems that there could be a number of expectations of the future patient, although not all patients will want to adopt these roles, or indeed, be in a position to do so. The future patient may be expected to be more aware of good health behaviours for their particular condition, endeavoring to improve or maintain their health, as an expert patient, facilitated in this role by the health care worker, or by other patient mentors. To underpin the management of their condition, the future patient may actively seek information and have the skills to ably synthesize a range of data, including studies of effectiveness, in some cases being better informed than the health care worker. This picture of a future patient means they will need good communication skills to convey their expectations and needs. They are also likely to expect good communication skills from health care workers. We can imagine future patients seeing themselves as being in overall charge of their health care, supported by a developing knowledge base, self-management skills and full access to their health records. Future patients may see themselves as the ‘pilot’ of their care, with the health care worker acting as a ‘navigator’, providing useful information, guidance and expertise. Finally, the future patient will expect their evaluations of the effectiveness, appropriateness and acceptability of their care to impact on the provision of care and ultimately improve the patient experience, at an individual, local and national level. Health care workers may need to demonstrate how patient evaluations have contributed to improvements in health care provision. Ultimately the public may even expect a role in developing the characteristics of future health care workers, and in the overall strategic direction of health care policy.
While these characteristics of the possible future patient are by no means exhaustive, they do suggest that future health care workers will need to develop or enhance their skills in a number of areas to keep pace with current trends. Key areas where health care worker skills will need to grow include elements of facilitation, communication, negotiation, information synthesis, and the ability to engage with the processes of shared decision making with the patient. They will also need to have strong perceptual skills, in order to judge where the patient has placed himself or herself on the partnership continuum. For example, some patients may prefer a more paternalistic model of care, while others may wish for an autonomous approach. In some cases, health care workers may need to relinquish some traditional elements of their role, such as giving direction, particularly if patients want to become autonomous in their decision-making. There is a fundamental need to respond to the challenge of true partnership working and to acknowledge its potential to change attitudes, power distribution and ultimately professional self-identity. These elements are at the heart of the cultural changes required by the Bristol Inquiry [4].
While this agenda firmly focuses on developing services that place the patient at the centre, it has to evolve in partnership with health care professionals. The agenda requires that health care professionals develop and expand their psychosocial skills, underpinned by a shift in attitudes and values. The importance and difficulty of developing or enhancing partnership skills should not be underestimated, and will require time, knowledge, motivation and support. The development of these partnership skills will be enhanced if their teaching occurs in a multi-disciplinary environment, which could include patients as partners. As the providers of hands-on care to patients, health care workers hold the key to the successful implementation of the patient partnership policy agenda. The crucial questions are, faced with significant workforce issues, such as a shortage of nurses, an ageing workforce, and difficulties with recruitment and retention, how will health care workers meet the challenges of patient partnership and how can they be supported, so that they can contribute to the cultural change that is so clearly needed in health care?
Royal College of Nursing Institute, Oxford, UK
* Editorial Committee Member, The International Journal for Quality in Health Care
This editorial has been informed by work funded by MacMillan Cancer Relief. This editorial does not necessarily reflect the view of either MacMillan Cancer Relief, or the Royal College of Nursing.
References
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- Hardy M. Doctor in the house: The internet as a source of lay knowledge and the challenge to expertise. Soc Health Illness 1999; 21: 820–835.[CrossRef]
- Coulter A. The Autonomous Patient—Ending Paternalism in Medical Care. London: The Nuffield Trust, 2002.
- 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, Summary and Recommendations. London: HMSO, 2001.
- Kendall L, Lissauer R. The Future Health Worker. London: Institute for Public Policy Research, 2003.
- Laine C, Davidoff C. Patient-centred medicine: a professional evolution. Journal of American Med Assn, 1996; 275: 152–156.
- Department of Health. The NHS Plan—A plan for investment, a plan for reform. London: Department of Health, 2000.
- NHS Cymru Wales and The National Assembly for Wales. Improving Health in Wales—A Plan for the NHS with its partners. Cardiff: National Assembly for Wales, 2001.
- Scottish Executive. Our National Plan. A Plan for Action, a Plan for Change. Edinburgh: Stationary Office, 2000.
- Northern Ireland Act (1988). Section 75—Statutory Equality Obligations. Belfast: Department of Health, Social Policy and Public Safety.
- Department of Health. The Expert Patient, A New Approach to Chronic Disease Management for the 21st century. London: DoH, 2001.
- Department of Health. Strengthening Accountability—Involving Patients and the Public (Policy Guidance for Section 11 of the Health and Social Care Act 2001). London: HMSO.
- Smith R. Preparing for partnership. British Medical Journal, 2003; 326: 14 June.
- Wyatt JC. Four barriers to realizing the information revolution in health care. In Lenagaghan J (ed) Rethinking IT and Health. London: Institute for Public Policy and Research, 1998.
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