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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 …