Will the patient care?

I'ut~l. Illth, I,ond. (1973) 117, 195 log

Will The Patient C a r e ? * DAVID !t. H. MFI('AI.Ft: ~,I,A

, ~'1 I t . 11 { ' h ~ , ~,1 R ( ' ( i

P

Ot'prlt'lmFlll t~l~( ' o n l m l t t t i t y .~I¢'¢fi¢'itt¢', Vtti~ t'r,sity of ,N'oltitt,~hont .~fi'dtcul .S~ h,.,I

Introduction LO()KIN(; at what has been writlen .'tbout the change.,, in the Natumal Health Ser~ ice after 1 April t974, it is dilficult to see whether from the patient',~- e)e ~le,~ an3thlng ~itl be different. Most patients, if they are aware of an3' change,. ',,.ill echo the great dictum "plus qa change plus c'est la m,~me chose". Mo.,,t health centres ~ill c(mtJnuc t.~ rcprc,,ent ,ml) a co-habitation betv,'een public health doctors and G.P.s rather than a true marrmge ~lfll variable ;JTllOU/ItS o f co-operation and communicalhm° variable arnount', of attachment of staff and disappointingly few innovative, co-opcrati~e programmes t~ take tile inlt~.~tt~e ~n health care, This being so, the patient v, ill not e~en notice, lcl alo~'m care! Nevertheless, if in fact the administrative changes in tile Nata,,nal tteahh Scr',ice are going to achieve their aim, then tile primary and col'nmunity care nlU,,t ira fact lmpro~e its perlk-wmance to tile poinl at v, lfich it can take the strain (~11 tile h~,,,pital service ~hlch is under severe sirloin. It is time also lhat the underlying philo,oph.~ of a Na!lonal Heallh Service as oullil~ed bolh by Dawson and Be~eridge (that ,,u,.'h a S e r v i c e ~, o m cerned with the Nation's health, not the Nation"~ disea~,e) shc~uld at ke, t be implemented. If hi fact tt~ese two objectives ate to be met. then the crucial poirll of change i,, ihe primary care facility, that is the heahh centre. If the cm~lmunity care ,,cene doe, change, then the patient ',,,ill notice things and the patient xvil} react according to ilis or her altilude,,. that is according io how much and ill w h a t \v;,l.v he or she cares. For too long. the itlrl:.tlC conservatism, stoicism, and inertia of the British public have made the medical profession leave the palients ° altitudes to medical care oul of considcraticm. Medical care has been proffered on a "take it or leave it" basis by medical services. ~laich ha~e had other thing,, to bother aboul than whether the patient cares.

Why Does I t r01atter W h e t h e r the Patient Cares ? Patient attitudes are primarily of importance because altitudes shape bch:p, iour and patients" attitude and behaviour to heallh care has very considerable implication,. In many cases, failures to implement knowledge to improve the heahh of tile Nation are due Io our inability to induce behavioural changes, which would improve healih. Sensible diet. abandonmertt o f smoking and wearing seat bells are three obvious examples. If we could achieve real behavioural changes in these areas, the expectation of life. particularly f'or males, would change radically and large sums of money would be sa~ed [\)r deployment in other areas o f health. Cl'he American Medical Association uses this fact as an excuse when opposing changes in the medical care delivery system in the United States.. on the basis that il would not make any difference to the expectation o f life, since that is ill the hands of the patients, not the doctors[ It is hoped that heahh care providers in Britain would not shirk their responsibilities in this way.) But even short of these Iofly goals, altitudinally determined behaviour changes could improve tile elficicncy and effectiveness of thc National t4ealth Service very considerably. *Presented at a sym['~osiunl, Commltttil)' C t t r e - . 1 9 7 4 ~,tttd A ftvr. a jOinl mec~ing of the Research G r o u p of the Society of Medical Officers of Health and the Royal College o f General Practitioners.

PUBLIC i l l ! A t _ T I t

t96

VOL. 87 N O . 5

If the patient cares, then the patient will m~tke use of proffered screening and outreach programmes. If the patient cares, they will tend to seek care earlier I\)r appropriate con•clitions. If the patient cares, then they will identi~' and accept care I'rom the appropriate heahh worker and not ahvays insist on getting it fi'om one source, but become more discriminating in their use of the service. All these thirigs ~ould improve the performance o f the National Health Service. H o w Do W e Find O u t W h e t h e r t h e Patient Cares? Patients" and consumers" attitudes have been investigated on and oil" for quite a long time. Most people are Familiar with Ann Cartwright's book Patients am~ their Doctors, a more recent paper {Varlan, Dragounis & Jefferys) in lhe Journal of the Royal Co//c,ee o[ General Practitio~wrs and a Harris Poll in 1972, have all queslioned people on their attitudes toward their General Practitioners. Such studies, however, are oF limited value and are acknowledged to contain many pitfalls. The lwo major ones are the well known and documented attitude among patients: "All doctors are fools and rogues except my doctor", and the experimental difficulty that very often they rely on putting hypothetical questions to the subject such as, "'What would you do i f . . . ? ' " which has been shown to bear very liHle relationship to what the patient actually does.

[ .........

Community Health , Council

G Local Authority oer,ooo, Sac,el

!

I !

Dehned

populmqon

F~ABCD

I

"

i

I

A

_ ,.= Centre

Hospital

-

I

]

T Area

Areo

Health Aut h o t i ty

Local Authority F

joint Consultative

Committee $ FIG. I

, ,? l

District Health

Authority

w,

WILl. -[itl( I'A'III:N1 { ' A R I "

I't"

Since, however, the importance of the patients attitude,, ix that ii alte~.ts their hcha'~t,~ur. theft it seems to be IogJc~il to make mea.~urements of lhe patients" bchaxJ~)ur und part|cuktrly in change.,, in that beha',iour, ~e, a ','.'at>of finding out v, hether the,, t_'g,re and in ~ha! way they care. A series oF lheorelica} meas~remenl', ~.~Jll no~ be sugge,,ted. }tgure I ~ a diagranmlalic represent;ilion of the tr~ms~mtiona] /i¢]d o f primmer} and v',~rnnlun~.,, c;~rc with the aicas of mea.-,urement sh.o,.,.i]. The measurements could ~nclude the f, qh;v, ing: A t t i l t q d i n o l : ( la,ehtl~, i(~ural} [A) Acccst, ibilit>' Me~tsurement for utilization ot' ItC uli)i/att,,n and ca,,uahy utllliati o1' tho,,e "'al ri,,k"). Utilization of nearly pr~itered service.,, ~a~ "., of" pro. coted u~ers, e.g. t:amily Planning b.v \%.i,Ol111el'lI(*l 46 .',e;tr~, old) t!tilization of special purpose clinic~ (,is drop in that diagno,i~, at ordinary surgeries). Reduclkm in house calt~ (t~ther than doct{~r originated I, (E) Conlldence Number o( p:ltiellt r'eque~,ts f\~r rel'erral. Nunlber of patient ret'usab, l\>r referral. Number oI patient requc.,,ts i\~r te,,ts, Nuri-tbm of patient refusals for test>. (!-') Recogrlition Reque~,t for deployment of" Personal Social Set\ ices f PSS) bel\~re health lea l'l't ellels, Refu.,,als t\~r deploymenl of PSS after health team olt'er~,. l#reakdown of PSS laid on by health team. l:all in direct requests to e S s for health related .,,upport (recognition o1" health centre as appropriate resource). (G) Responsibility Constructive criticism from C o m m u n i t y Heahh Council to Area Health Authority. W h a t Do W e N e e d to M o n i t o r Patients' A t t i t u d e s / B e h a v i o u r ? The strengtl~ of tile eommuniiy physiciarl/gener~tl practitioner team .should be a combination ot" the detined population, the G.P.s clinical and personal kno,,~ledge about tile patients in his deiined population: and the community physician's administrative and measurement skills. This combination of features is important, not mereh' as a basis for measurement and experiment, but for planned operalions to improve the community's health. The experimental capability would in fact be the basis for planning for such initiatives. They need to be underwritten by an ongoing data system thai. is data need to be collected continuously and analyzed continuously, rather than on a sporadic basis t\~r intermittent research projects. This will require built.in manpower systems now, and later computer capability down to the level o1" individuai 'ffe:'dlh centres. At this level, stall" should be augnlenled by data clerks with direct inpu,* capability, ei~.her by' on-line tele-type terminals,

198

PUBLIC t l E A L T t t VOL. 87 NO. 5

key punches, or visual scanning methods. At A . H . A . level would be the computer and the necessary team to process the data produced and to produce feedback for the team at the health centre. Tl~is presupposes in~.ensive education of doctors who are about to go into health centres so that they can see ~'hat they can get out o f such a system, which could be put crudely as "'being on lop o f their practice--not underneath it !" It would require very close liaison between the community physician and the G.P.s in the planning stages, so that they could and would not accept this sort of data retrieval not as a threat or a monitoring or an audit system, but as a positive tool for them in the running o f their practice. It would require intensive education of the c o m m u n i t y physician to make him an expert in data handling because it is just as important that he should be able to measure the impact o f a health centre and the activities of his team on the population they serve as it is that he should have expertise in the more traditional concerns of the M . O . H . The fundamental importance of such a system would lie in its ability to feed back meaningful data to the Area Health Authority, as a basis for constructive demands l'or change.

Summary Administrative changes in the National Health Service must be mirrored by operational changes. Such operational changes should be aimed at enhancing the health o f the community and therefore at changing the basic work altitudes of the primary care team. Their success will depend largely on patients" modification of their behaviour, which in turn will depend largely on their attitudes to their health and to their health service. A series of behavioural measurements is suggested that would allow a community care team to monitor changes in its patient population attitudes and behaviour. This information would provide feedback not only for the community physician/general practitioner team, but also for the Area Health Authority.