Living up to expectations - has patient-centred care gone too far?
Alex Warren
Guest Writer
Does anyone ever really pay attention to the adverts above the seats on the Tube? Just the other day I found myself on the Victoria line, heading for my mid-sessional exam, looking up at an advert for a private healthcare company. The advert featured a mock Underground line with stops including ‘the treatment you need, when you need it’ and ‘getting seen by a specialist of your choice’. The implication of these bullet-points was that these were things that one could not expect from the NHS, voids that only the private sector could fill. This made me think: do healthcare professionals have a reasonable idea of how much choice their patients expect regarding their treatment – and is our system capable of living up to these standards?
Over the last half of the previous century, the concept of patient-centred care has grown to rest at the very centre of the public healthcare paradigm. In the last few years alone, patients have gained the right to choose which hospital they are admitted to and the right to access their medical notes on request. Whilst there are notable exceptions, it’s interesting to note that the professional medical bodies – the GMC, BMA, and the various royal colleges – are often reported in the media as opposing these expansions of patient choice. There exists an argument that this may just be as a result of a ‘generation gap’, but nevertheless, this antagonism brings up the idea that autonomy may be moving away from a healthcare ideal into the realm of a political tool.
At the end of November, NICE published their new guidelines for NHS maternity services. The most controversial change to these rules, which apply to all NHS trusts in the UK, is the new requirement that patients who have no clinical indication for a caesarean section cannot now be refused one. In other words, patients can now deliver their children through a C-section for no reason other than that they request it. Doctors’ judgement no longer plays a part – obstetricians who object to performing C-sections on their patients on these grounds must now refer them to a doctor who will.
Taking time to analyse NICE’s decision, however, one has to wonder whether any other factor supports these guidelines other than patients’ autonomy. It costs the NHS about £1,000 more to deliver a baby via elective C-section as opposed to a planned vaginal birth, and also takes up valuable hospital resources: operating theatres, anaesthetists, neonatal ICU beds for the 13.1% of babies delivered by elective C-section who require critical care. And finally, in a hair-pulling-inducing catch-22, some NHS trusts receive bonuses averaging at £250,000 in part for reducing the number of elective caesareans they perform, as a result of the Department of Health’s Care Quality Improvement Network financial incentives initiative.
Yet the government is willing to ignore this – a preponderance of logic, it seems, is ceding to the demands of patients to have increased choice. These are the symptoms of a major shift in our medical culture. Strong financial and medical arguments are being thrown out of the window to pay respect to our patients’ right to autonomy. We’ve seen this evolution over a long period of time, the consumerist nature of our interaction with the healthcare system growing with the general liberalisation of our medical culture since the 1960s. Whilst this progress has certainly allowed us to deliver healthcare in a manner both ethically better and more satisfying to the patient, surely there has to be a limit to what the NHS can provide.
There is no practical possibility of a publicly-funded healthcare system providing bespoke care for every one of its adherents. That said, it is a socially and ethically accepted fact that everyone has a right to self-determination, including the right to refuse treatment or to ask for reasonable alternatives. The real crux of this issue is deciding which of the mock Tube stops on the advert that Victoria line commuters see every morning should be considered the basic requirements of a healthcare system, and which are ‘luxuries’ that patients can access only through the private sector. Common sense applies here: patients do not walk into hospital expecting a private room, one-on-one nursing care and cordon bleu cuisine, but they do expect to have single-sex wards, excellent sanitation and edible, regular meals. The NHS cannot afford to be a la carte – the difficulty arises in choosing what to put on the set menu.
Consider the idea of patients being given the right to choose the specialist they see when referred to a hospital. Political trends don’t rule this out as a possibility – patients can already choose which hospital they wish to be treated at, for instance. Administrative costs aside, this measure would probably not adversely affect the NHS; I suspect most patients don’t really care which specialist they see, providing they are qualified and competent. Similarly, under the current system, patients very rarely have requests of this nature turned down. A woman who asks to be referred to a female gynaecologist would be sure to have this request honoured, even though there is no legal stipulation for this to be so. That said, it would not at all be surprising if, should patients be granted the right to choose a specialist, this would be politicised as another great gain for patients’ autonomy. X
An example of another non-issue touted as patient choice which we can all relate to is when, on visits to hospitals and GP surgeries, medical students are required to gain consent for their presence, even if they are doing nothing more than sitting in the corner observing. Does a patient’s right to autonomy allow them to dismiss students whose clinical exposure and experience are vital to their studies, and thus to their future medical practice? F1s don’t gain patients’ permission when shadowing consultants on ward rounds, and in reality the only difference between a first-year doctor and a final year medic is four letters.
The laughable aspect of this dilemma is that, if medical students were introduced with a statement, rather than a question, indicating that their role is within the medical team rather than implying that it’s outside it, very few patients would object at all. All the arguments fall in favour of allowing healthcare students to sit in on consultations or examinations, in much a similar fashion to the aforementioned Caesarean debate, yet we still insist on gaining consent. It’s at this point that we really have to wonder whether our medical culture of patient-centred care has become bogged down in the mundane. And perhaps the even more dangerous prospect is that in doing so, patients are being denied the choices that matter most to their health. X
How else could we have arrived at a situation where not only do a significant minority of patients wish to be subjected to major surgery when there are less traumatic options available which are safer for both mother and baby, but the party line is now that the NHS must honour these decisions? Despite at first glance seeming like an insult to doctors’ judgement, the C-section guidelines could well be a subtle incentive, designed to persuade doctors to work out what their patients actually want, rather than throwing them pointless ‘choices’ which just function as gimmicks. If doctors can’t refuse women a dangerous procedure, then it is even more vital that they communicate the facts to their patients.
The concept of patients making bad choices about their own healthcare is nothing new. As testament to this we only have to look at the rates of non-compliance with treatment (reported as anything up to 40%) to see how often patients act against medical advice. As stated earlier, patients have the right to refuse, or not to start, any treatment they like. The medical profession should respect this right, but it is a whole world away from the right to demand a treatment for which there is no medical need and receive it on the NHS. The difference with the Caesarean section debate is that patients having unnecessary surgeries impacts negatively on the NHS, and thus on the wider population.
It’s very easy for the medical community to put this down to ignorance on the part of the public, to blame the media for mis-educating the masses with block headlines of cancer cures and the latest superfood. But the issues of noncompliance won’t be solved by giving patients more of these ‘gimmicks’. Another recent example is the proposal that all patients will be able to access their medical records online, which is a real-life counterpart to the specialist-choosing thought experiment discussed earlier. It’s highly doubtful that swathes of people felt that the system was standing between them and details of their thirty-year-old appendecectomy.
On the most basic level, acute patients want to get better quickly and with minimal disruption to their lives. Chronic patients want optimum quality of life and a psychosocial support network that allows them to cope with their illnesses. It’s hard to see how allowing patients to access their medical records or demand unnecessary operations meets these objectives. Without wanting to move into a debate that looks like it will dominate the coming year, it’s certainly an absurd situation where patients have more choice than ever, but large numbers of the terminally ill still can’t legally access the deaths they want.
As with most issues in modern medicine, there’s no quick fix. But perhaps this is one of those cases where conservative management of the patient is the better option. The massive grassroots movement against the recent NHS reforms, evidenced by the success of pressure groups such as 38 Degrees, shows us that when patients really want something to change, they’ll make their voices heard. It’s a shame on our system that one in three patients doesn’t comply with treatment, and that mothers feel compelled to undergo traumatic surgery. Unless we take action to stop patient choice being used as a political playing card, there’s a real danger that public confidence in the healthcare system could fall even lower – the consequences of which could be disastrous.
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