Defining and disambiguating patient-centredness
This paper elucidates what 'patient-centredness' is, first by identifying its boundaries and distinguishing it from ideas and practices it is sometimes confused or conflated with. It goes on to set out the key elements of patient-centred services and briefly explores approaches services can take to becoming patient-centred.
It argues that patient-centred care uses the biopsychosocial model, which means that 'illness' is not reduced to biological markers, but is understood in the wider context of what constitutes health and of a person's life. It also argues that patient-centred services are not designed around doctors' specialties, and that 'treatment' is not defined in terms of doctor-controlled services or products such as pharmaceuticals, where other interventions are seen as merely ‘supportive’ of patients or physicians’ treatments regardless of their relative efficacy in creating good health-outcomes.
The paper makes the case that patient-centredness defines ‘health’ or ‘wellness’ according to the World Health Organization’s definition: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1946). This entails a biopsychosocial approach.
The paper states that patient-centred services are:
- health effective - since patients use health-services to get well and stay well, patient-centredness is about ‘health-effectiveness’ first and foremost.
- health efficient, where efficiency requires that only those components that help to deliver health-effective services are included in the service. In patient-centredness, ‘costs’ are construed in terms of personal costs and social costs, the latter including but not limited to the financial costs to the service, the payor, and society. In patient-centredness, efficiency also means integration. Patients’ needs are already integrated within the patient and patient-centred solutions to those needs are therefore also integrated.
- ethical in the sense that health professionals are appropriately qualified to for the care they provide, and services address the determinants of health, not just the presenting problem.
- collaborative, involving multi-disciplinary team working, with the patient as part of the team.
- meaningful in the sense that they must be personally relevant and meaningful to the individual patient and his/her health-narrative, which enables the services to be tailored to the individual.
- empowering, where empowerment is developed through the patient’s development of knowledge, through facilitated participation (e.g., in mutual education with clinicians and through negotiated, clinical decision-making, for example), as well as through enabled but autonomous health-behaviours.
- trustworthy - Trust entails reliability and integrity, shown by consistency, responsiveness, openness, accountability, honesty or ‘transparency’, and demonstrated values such as respect, fairness, humility, and scrupulousness. These characteristics are communicated through a level of emotional intelligence and a set of interpersonal skills that demonstrate active listening, empathy, compassion, and caring, leading to a resilient and health-effective rapport. Trust entails holding individual clinicians responsible for their actions and their influence on patient’s health-outcomes.
The paper argues that to create patient-centred services patient-centred standards are needed, which should also specify how these principles can be operationalised and measured, and how they relate to patient-centred service-designs. It makes the case that an essential clinical step in creating patient-centredness is to measure a person’s health as defined by the WHO. The paper further argues that it is also necessary to assess the variety of methods of patient-participation to ensure that health-effectiveness is kept as the primary goal of any health-service.
The paper concludes that patient-centredness does not happen if individual aspects of it are extracted and applied as a veneer over the current system. This raises the question of what is necessary and what is sufficient to create a patient-centred system of health-services. The authors argue that the paper identifies the characteristics that are necessary, given the overarching purpose of creating the optimal health-outcomes for the patient, and that these necessary characteristics, well operationalised, are also likely to be sufficient to create patient-centred health-services and therefore services that are demonstrably health-effective, health-efficient, and sustainable.