Requiring patients to be active decision makers is casting a very reluctant hero, comments Professor Bastian Seidel
When patients are required to be proactive decision makers, the health system is often casting a very reluctant hero into the role.
Looking at the most recent federally funded health programs, it struck me that it’s become commonplace to talk about “consumer-centric” mental health care packages and “client-based” aged care services. Of course, we have long accepted that when discussing Medicare it is all about the “service users”.
Nowadays, listening tentatively to the loud whispers about the brave new role of Australia’s Primary Health Networks as commissioning bodies for some forms of health services, I wonder whether these services will be chosen by a computer algorithm and then delivered by a remote controlled drone. Surely what works for consumers of Google and service users of Amazon would also work for Australian healthcare clients in any setting? There may even be an app for all of this?
What ever happened to our patients?
As a medical doctor, I naively assumed that it was all about treating our patients. A patient, of course, is a person receiving or registered to receive medical treatment or a health program.
But reading Dr Iona Heath’s book The Mystery of General Practice1, I was intrigued by the concept that a GP may offer much, much more that just health programs or medical treatment. As Dr Heath, Immediate Past President of the Royal College of General Practitioners in the UK, describes it, the GP serves as a witness to a patient, being an interpreter and guardian at the interface between illness and disease. The role of the GP as it was taught to me was that of a friend, comforter, confidant, counsellor and a resource of context-specific knowledge. Therefore, my professional goal as a GP has always been to specialise in my patients. Not more – and not less.
Never did I think that I could be perceived by either policy-makers or my patients as a “client manager” who may be paid based on some key performance indicators and consumer feedback.
Calling patients consumers, clients or service users is not the same as empowering them. In his book, A Better NHS2, Jonathon Tomlinson suggests that doing so is very unlikely to change the prejudices associated with illness and disease because these prejudices are too deeply historically and socially embedded. The relationships between patients and medical professionals have, however, evolved throughout history as traditional hierarchies have changed: patients have become better educated and medical doctors have been taught to be more patient-centred.
Treating patients as consumers, clients or service users can of course create significant problems, as even an article in the Harvard Business Review3 points out:
1. Patients don’t want to be there: People don’t seek out healthcare without reason (may I add here that the number of recreational colonoscopies performed is actually very low). Something is wrong and patients want to have it solved.
2. Patients aren’t equipped to be there: Even when patients are willing to be decision makers, they may not have the tools. At a time of unusual stress, the system asks them to absorb technical information and make difficult decisions that require specialised expertise. When patients are required to be proactive decision makers, the health system is often casting a very reluctant hero into the role.
3. Patients aren’t in it alone: To design for patients alone is to forget that they are part of a complex system and are often not independent decision makers. Decisions are shaped by other stakeholders: friends and family who support the patient, in this day and age, Facebook friends,the insurance company who foots the bill, practitioners who provide care and expert advice, the hospital administrators who inform system-level protocol and so on.
Are doctors just providers selling services to healthcare consumers? Is it a scenario from a brave new world where consumers visit a provider for another transaction in a commoditised society?
The idea that this all can be reduced to money is sickening when we are caring for patients as in Iona Heath’s model. New York Times columnist, Paul Krugman4 even argues that the prevalence of this kind of language pervading policy and programs is a sign that something has gone very wrong with the discussion about our society’s values in general.
Policy makers and program architects need to take a step back and assure us that, in their eagerness to ‘consumerise’ the medical experience, they don’t undermine the quality of care by demanding more of patients then they should be expected to deliver.
As medical doctors and GPs it is time for us to speak out.
Bastian Seidel is a Clinical Professor at the University of Tasmania and a rural GP. He is the current Chair of RACGP Tasmania.
References
1: http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/The_Mystery_of_General_Practice.pdf
2. https://abetternhs.wordpress.com/
3. https://hbr.org/2012/01/the-trouble-with-treating-pati/
4. http://www.nytimes.com/2011/04/22/opinion/22krugman.html?_r=0
