In a BMJ article about personal health budgets, the chair of the Royal College of General Practitioners in the UK, Clare Gerada, says
“Should we be spending taxpayers’ money in cash strapped systems on gardening or aromatherapy that may make people feel better, but for which there is no evidence that it actually makes them better?”
This statement is a great example of the power issue at work in the practice of Medicine. The issue of personal health budgets is about the extent to which patients should be given the power to decide about what health care they want to receive. Dr Gerada uses this term “actually makes them better” – what does that mean? If someone who is suffering from a chronic incurable disease (and which chronic diseases are “curable”?) presents with terrible pain, or incapacitating fatigue, or paralysing anxiety, then what exactly is the definition of “better” – is there a “real” better and a “pretend” better? Surely, only the person themselves can tell whether or not their suffering is less, and only the person and their friends and family can tell if that person is now living a “better” life?
This use of “actually” is typical of doctors who reduce illness to lesions. They are thinking about someone who has less pain, but has no change in their underlying pathology – their MS plaques for example. Is that a sensible way to think about illness and health care?
There is a struggle going on, and it’s a power struggle. There are “experts” who think they are the only people who know what is best for patients. I don’t agree with them. If you ignore what the patient is telling you, if you ignore the “evidence” of the person’s life, then you’ve lost the plot!
Patient centred care means putting the patient at the heart of the care – not ignoring them or dismissing their reports of what is helping because “the evidence” doesn’t agree with this patient’s experience.
Heroes Not Zombies 
Dr Gerada made this speech at the Primary Care Conference held in Liverpool last Thursday. Though many of her points are laudable I get the impression that it’s only doctors who must be heroes. It’s doctors who must rush in ‘save’ patients etc and inspire their 15 year old sons to want to study medicine. Patients own subjective measure of their own health seem never to enter into the equation.
http://www.guardian.co.uk/commentisfree/2011/oct/20/nhs-doctors-pressure-caring-market.
As Chair of the Royal College of GPs, this does not bode well for those doctors who wish to empower and strengthen the patients’ own role in their health and well being.
A senior midwife I know observed a younger midwife check on the progress of a woman in labour. She saw the midwife check the machine showing the foetal heart rate; the machine reading out the woman’s contractions and never asked the expectant mother how she herself was feeling. She left the hospital based midwifery service and went back into community midwifery. Dr Gerada could learn much from my midwife friend.
My more cynical side is honour-bound to suggest that a large part of the resistance by the medical establishment to the changes proposed in the Health & Social Care Bill is that the shift towards personal health budgets/a more commercial approach to buying healthcare from any willing provider will inevitably shift the balance of purchasing power away from that medical establishment and towards individual patients (and/or their chosen professional intermediaries)…
.., in my opinion, the profession often say it sets great store in enabling patients (with sufficient capacity) the autonomy to decide their own care, but simultaneously places a large number of bureaucratic obstacles to prevent them doing so. They feel that as health care professionals they can still make the best judgement at the end of the day; I look forward to seeing some of this paternalism brushed aside by individualised purchasing.
As professionals, we should inform, educate and enable people to make choices. People can’t choose if they don’t have information. But then we should let them make their choice, even if we think it’s unwise or “unevidenced”.
Of course, when taxpayers money is at stake, there is an argument that the State needs to intervene to ensure money is spent in a way that is productive to the taxpayer. But the State’s definiton of productive can differ to a patient’s, which in my opinion makes encouraging people to take financial responsibility for their own healthcare (where possible) even more important to reduce the opportunities for such potential motivational cross-purposes to occur.
aye, there’s the nub of the issue, isn’t it? Who decides what’s “productive” when it comes to personal health?
I do agree with your views about personal responsibility….including the financial kind!