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Patient centred care
Patient centred care: essential but probably not sufficient
  1. K W Kizer
  1. Correspondence to:
 K W Kizer, President and Chief Executive Officer, The National Quality Forum, Washington, DC, USA;
 KWKizer{at}cs.com

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One of the many lessons to emerge from the analysis of the care of children in the cardiac unit at the Bristol Royal Infirmary is the importance of engaging patients in decisions about their health and health care. This is a message that has relevance to all healthcare professionals in all clinical settings. Patient centredness is crucial for good quality care, but achieving genuine patient centred care throughout health services will require transformation of systems as well as attitudes. In this issue (pp 186–8) we have reproduced Angela Coulter's paper “After Bristol: putting patients at the centre”, first published in the BMJ in March 2002.

The determinants of health and illness are not just biological, nor is a person's response to injury or illness. Patients live in families and communities of various types. They often work in less than healthy or even in hazardous occupations, and they relax in activities that may be health promoting or not. Patients live within a larger political, cultural, and environmental context that further affects both them and their families or communities. All of these “less biological” aspects of a patient's life influence his or her state of health or condition of illness. Indeed, health and illness are integrated phenomena—that is, they integrate biological, social and cultural, economic, political, occupational and environmental, recreational and other aspects of an individual's life. The specific health effect of these disparate influences is complex and often is much more important than traditional health care has factored into customary approaches to diagnosis and treatment. As Coulter so clearly espouses in her prescription for patient centred care,1 cognizance of these patient related factors is crucial for effective treatment.

Coulter's prescription for redesigning health services is sound and timely, as far as it goes. The need for putting patients at the centre of the healthcare universe may have been especially highlighted by the unfortunate events at the Bristol Royal Infirmary,2 but the need to redesign the healthcare delivery system to be more responsive to the perspectives and needs of patients is evident every day in clinics, hospitals, nursing homes, and other care facilities throughout the delivery system. Restructuring healthcare delivery to be patient centred will require a fundamental transformation of healthcare operations, which will necessitate a sustained and concerted effort and which will be accompanied by a certain amount of pain. If successfully executed, however, the end result will be more effective use of time and resources, reduced costs, improved coordination and continuity of care, and better outcomes. If done correctly, the transformation to a patient centred healthcare delivery system will substantially improve the quality of care, as viewed by both patients and caregivers, and it will almost certainly decrease the per patient cost of care.

A key element in redesigning the healthcare system to be more patient centred will be preserving and, in many cases, enhancing the caregiver-patient relationship. This intimate relationship is the medium by which information, feelings, fears, concerns, and hopes are exchanged between caregiver and patient. The integrity of this relationship is foundational for successful diagnosis and treatment. It is also a key determinant of how satisfying is the care experience for both patient and caregiver. Indeed, the process of interaction between caregiver and patient is often the most therapeutic aspect of the healthcare encounter.

While recognising the essentiality of transforming health care to be more patient centred for all the reasons that were articulated by Coulter, we also must be mindful that, just as health is an integrative phenomenon, so is health care. Indeed, health care involves complex relationships between and among caregivers and with the ambient environment that significantly impacts on therapeutic outcomes.

Modern health care is the most complex activity ever undertaken by human beings. It involves highly complicated technology that can seriously harm as well as miraculously heal. It is a team activity with more than 80% of the hands-on care being provided by non-physicians. The myriad of specialised caregivers are often focused on only one aspect of the patient's care, so there are many care “hand offs” among them. Information about the technical aspects of care must be communicated and acted upon by the various caregivers in a coordinated manner. These complex and multifaceted interactions need to be orchestrated in consistent and predictable ways that are mutually satisfying to both patient and caregiver. This is a social process that is subject to the cultural, economic, and political dimensions inherent to the care processes.

Just as the determinants of health and illness are not just biological, the determinants of health care are neither just biological nor just technical. Health care is an integrated phenomenon that has its own social, cultural, economic, and political dimensions that are often as important, or more so, than the technical dimensions on which we more often focus. Effective health care must integrate the biological, technical, social, cultural, economic, political, and other aspects of both patients and caregivers. These dimensions of care have to be integrated into the systems of care. We need to view health care as being provided by “treatment families”, “treatment teams”, or “therapeutic communities”, as opposed to something done by individual caregivers. Just as with patient's families and communities, health care families and communities may operate with varying degrees of functionality and be more or less effective.

Unfortunately, the dynamics of the relationships that caregivers have with each other and with the larger therapeutic communities in which they practice have not yet been well studied and are only rarely addressed in healthcare teaching. To improve the likelihood that the various therapeutic entities will promote health care, caregivers need to be trained in techniques of team based problem solving and team based care management. These are areas that have only recently begun to be addressed in health care, with nursing and anesthesia being the most progressive so far.3–5 Models of such include aviation style crew resource management, MedTeams, and anesthesia crisis management. Health care must also address the cultural and political contexts of care itself and how these interface with the larger societal, cultural and political contexts, each of which may facilitate or impede optimal therapeutic outcomes. Again, only recently have we begun to rigorously analyse and experiment with these dimensions of the care process.6,7

The patient centred model of care is essential because it promotes a “whole person” approach to care that recognizes the larger context in which patients live and function. However, it alone is not likely to be sufficient because it does not explicitly embrace the interdisciplinary and sociocultural nature of health care itself. The integrative nature of health care will have to be addressed if health care is truly to operationalize the patient centred model of care and if we are to achieve the improvement in healthcare quality that is so much needed.

One of the many lessons to emerge from the analysis of the care of children in the cardiac unit at the Bristol Royal Infirmary is the importance of engaging patients in decisions about their health and health care. This is a message that has relevance to all healthcare professionals in all clinical settings. Patient centredness is crucial for good quality care, but achieving genuine patient centred care throughout health services will require transformation of systems as well as attitudes. In this issue (pp 186–8) we have reproduced Angela Coulter's paper “After Bristol: putting patients at the centre”, first published in the BMJ in March 2002.

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