By Stephanie M Topp
With the upcoming Cape Town symposium generating increasing buzz, the associated 2014 class of Emerging Voices has just started their distance-learning modules. As always, in the lead up to the ‘main event’ those participating in this forum engage in a series of online discussions about relevant themes, generally chosen for their relevance to the conference. In the opening discussion held over the past fortnight, this year’s Emerging Voices discussed ‘patient centred care’ and ‘people centred health systems’ including where the differences lay between the two and what some of the common barriers and facilitators are to achieving them. In this blog we summarize some of those thoughts and invite other HSG members to consider the relevance and applicability of these ideas to their own setting.
By and large the EVs agreed with the 5 principles of patient centred care originally outlined by Mead and Bower (2000) and echoed in various places, including this report from the International Alliance of Patient Organizations.
- A bio-psychosocial perspective – providers viewing an illness / condition not only as a ‘clinical’ or ‘medical’ condition, but the result of interacting biological, pyschological and social factors.
- The ‘patient as person’ – providers understanding that the patient is someone experiencing illness (and much bigger than just the illness), rather than as just a vehicle (subject) of that illness.
- Sharing power and responsibility – an equal patient-provider relationship.
- The therapeutic alliance – a patient and provider relationship in which decision making is shared, ensuring the relationship itself has therapeutic value since it encourages more thoughtful and appropriate decisions and treatment choices.
- The doctor as person – the doctor is not just a ‘tool’ through which diagnoses / treatments are made. Rather the doctor is one half of a very important relationship and that the doctor’s own approach, his/her assumptions, work patterns will influence and reflect in the outcomes.
With a few exceptions most participants felt that patient centred care has not been achieved in their own countries to date. Among the reasons listed were chronically overcrowded clinics in which providers had little time for patients; cadres of health care workers (particularly doctors) whose training emphasized medical diagnosis but not communication or empathy; and patients whose capacity to interact with the system was undermined by a lack of information and/or confidence to be equal partners in decision making. Several participants also pointed to the way assessment of health service performance in LMIC and elsewhere remains geared towards more easily measurable indicators that may not do justice to the relational components (e.g. trust) of ‘patient centred care’.
Through a discussion of many a varied factors that currently impede patient centred care participants gradually built a more comprehensive picture of the complex interactions between certain factors that are required to achieve it. For example, EVs drew particular attention to the inter-dependence of providers, patients and the broader community in achieving people centred care, suggesting in the process that perhaps ‘patient centred’ is a misnomer, since what is most desirable is in fact closer to a partnership.
On the provider side, however, much discussion revolved around the complementary themes of capacity and the role of pre-and in-service education in providing health workers with skills beyond those of just medical diagnoses on the one hand; and patient orientation shaped by workplace and organizational culture on the other hand. Several participants drew attention to their own personal experience of how medical training may not be sufficient to enable the degree of communication and empathy necessary for patient centred care and highlighted the fact that real attitudinal change amongst professional cadres is frequently slow and difficult to change. Strong leadership (not to be confused with management which focuses more on coordination and planning) was pointed out as necessary to help promote a common vision of patient centred care (in a clinic setting, for example by mentoring juniors and modeling certain behaviours) as well as to help prevent a slide backwards in attitudes and behaviours where gains had been made.
On the patient and community side, much emphasis was placed on the need for better informed and motivated patients and family members, and the need for a community willing and capable of participating in promoting their own health. This discussion provided a neat segue for those involved in thinking about social accountability and empowerment, as a question was posed as to whether patient centred care can be achieved in the absence of an empowered client? And related, whether social accountability still needs initial stimulus and support from above?
There was some back and forth over what is understood by patient satisfaction and how this related (or not) to patient empowerment? A number of EVs pointed out that patients need a minimum level of information about the system in order to be able to engage with it meaningfully – to which we should perhaps add capabilities (as explained Amartya Sen for example) – or the skills, confidence and experience necessary to act on that information. But several participants made the valid point that patient satisfaction can also be understood as more than whether a patient’s (often low) expectations of services are met; satisfaction may in fact go to the heart of the need for respect and human treatment – a critical precondition for establishing what Mead and Bower term the ‘therapeutic alliance’.
Of relevance to the upcoming symposium, most participants agreed that a people centred health system is one that acknowledges the central role of human relationships, needs and decisions to system functionality. They suggested that a people centred health system will help and may even be a necessary prerequisite to achieving and sustaining patient centred care, for example through the way the system moulds providers’ competency (through training) and orientation (through norms established in the work culture). While acknowledging the role that resource shortages and associated incentives inevitably have on these issues, several participants also pointed to the way embedded power dynamics shape health systems at all levels. They noted that a people centred health system must be engineered in such a way as to prevent power being consolidated in the hands of just a few. It was thus suggested that a possible definition of a people centred health system could be: a system that is conscious of power dynamics and alert to the need for corrective action where power relations become skewed.
Given all this, a final question arising was whether people centred health systems that promote patient centred care are feasible in LMIC? Interestingly, the recent struggle of Western health systems to embed a patient centred approach clearly demonstrates that this issue is not exclusively linked to problems of resource availability (acknowledging that this nonetheless forms a critical backdrop). Rather – openness to reform and re-invention seem like key criteria in both developing and developed settings. While the challenges for LMIC remain substantial, therefore, localized examples of success in promoting patient-centred care and the current energy and momentum related to better understanding and strengthening people centred approaches do provide the basis for optimism.
Steph Topp (@globalstopp) is Health Systems Advisor at the Centre for Infectious Disease Research in Zambia (CIDRZ) and Research Associate with the University of Alabama at Birmingham. She was a 2013 Emerging Voice and is lead facilitator for the 2014 Emerging Voices online discussion relating to people centred care. She is also a co-facilitator for the SHaPeS thematic discussion group on Power and Health Systems.