Patient centred primary health care

Below you will find the abstract for the talk on this topic as part of the International Seminar on Innovation in Primary Care.

Health extends well beyond the absence of disease or infirmity, which focuses solely on the negative range of the health spectrum. Disease based thinking, however, is a paradigm that has helped enormously in advancing medicine. It easily accommodated infectious health problems that had a clearly identified and simple etiology: there was a single cause for each problem and dealing with (curing!) the disease was basically an issue of dealing with responsible etiological agent. This continues today in the form of claims for the discovery of gens that are responsible for health conditions, for personality traits and even complex psychological functions. Progressively and unopposed, the idea crept in that health was just about ensuring that the heart worked, the lungs worked, the kidneys worked. And progressively the patients disappeared behind their conditions when not simply their organs.

Surely a straw man in our days? Unfortunately not. A prime example is at hand: the Quality and Outcomes Framework, the biggest initiative for pay for performance in the world, has provided General Practitioners in the UK with financial incentives for managing their patients. All clinical incentives in this framework are condition specific. The implicit assumption is that patients can be reduced safely and effectively to their blood pressure, their renal function, their cholesterol levels. And yet we know this is not the case.

We need to put the patient at the centre of the provision of health care. If philosophy, ethics or humanism are not good enough reasons for reversing this situation, perhaps we should be reminded that patients are responsible for their own care 24/7, that they know more about themselves (attitudes, behaviors, symptoms, compliance, incentives, preferences) that clinicians and health professionals will ever do, and, in the current economic climate, that if given the opportunity of making an informed decision, many patients will choose more conservative approaches than clinicians (and even forgo any treatment or diagnosis procedure) thereby simultaneously making substantive savings.