Q: Can we really achieve patient centred care?

The inquiry into the failures of heart surgery at the Bristol Royal Infirmary in England made 198 recommendations. Many of them concerned the need to improve the way patients are informed and involved—in other words, achieving patient centred care. In this article, Angela Coulter, Chief Executive of the Picker Institute in Oxford, summarises some of the main things that need to be done. These include:

• encouraging doctors and patients to share information and make joint decisions;

• encouraging patients to review their notes;

• improving procedures for informed consent;

• giving patients access to unbiased evidence-based information;

• gathering feedback from patients in a systematic way and acting on the results;

• making healthcare providers more accountable.

Angela Coulter concludes: “What is needed now is clear leadership from the clinical professions, investment in information and training, and a willingness to change established modes of working”.

See page 186

“Coulter's prescription for redesigning health services is sound and timely, as far as it goes” (commentary, Kizer, page 117)

▸ ACTION POINT

We can achieve patient centred care, but we will need—among other things—clear leadership.

Q: Does publishing a set of national guidelines have any impact on practice?

Several reviews have concluded that national guidelines have little effect on clinical practice. In 1992 a set of guidelines was issued in the UK cautioning against excessive use of surgery for glue ear for children under 10. Researchers from the London School of Hygiene and Tropical Medicine looked at the figures from 1975 until 1998. They discovered that the rates halved between 1992 and 1998, and that after the guidelines were published the rate of decline increased from 1.6% to 7.9% per year. They call this a “dramatic alteration in the speed of change” and identify five factors:

• The surgeons were already worried about overuse of this operation.

• The rate of surgery had already peaked and was starting to fall.

• GPs were sceptical about its value.

• Recent organisational changes meant GPs had a financial interest in trying to avoid surgery.

• Parents were apprehensive, following media scepticism.

The authors conclude that the guidelines accelerated an existing change.

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▸ ACTION POINT

National clinical guidelines may help to change behaviour—though make sure first that the “climate” is favourable.

Q: Do GPs prescribe rationally or out of habit?

Rational prescribing involves setting a therapeutic goal and choosing the best possible treatment for achieving it. Dutch researchers asked 61 GPs to “think aloud” while making prescribing decisions in two therapeutic areas, giving them 305 transcripts to analyse. They found:

• 40% of decisions could be described as “habitual” (defined as taking treatment decisions without any specific contemplation).

• More than one drug was considered in less than half of the transcripts.

• The doctors did not necessarily compare treatments explicitly with each other.

The authors suggest that offering information on the expected benefits and costs of drugs would be useful, particularly for those willing to change their habits.

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▸ ACTION POINT

We need to make better information available to GPs if we want better prescribing.

Q: How good are the quality measures drawn up by expert panels?

A number of “expert panels” in the UK have been using a “systematic process” to develop review criteria to assess the appropriateness of health care. The authors had been involved in developing review criteria for angina, asthma and type 2 diabetes. In this study of 60 general practices they used audit, a postal questionnaire and interviews to test reliability, validity and acceptability. They found that the proportions meeting these requirements were 54%, 59% and 70%, respectively. “This study shows that some of the criteria developed previously by expert panels were unoperationalisable, unreliable, too rare to be useful, or too hard to extract reliably,” they write. “This finding emphasises the fact that quality measures need field testing before they can be used in quality assessment.”

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▸ ACTION POINT

Measures of quality devised by experts should always be “field tested” before being applied.