Lay Co-opted Member, Academy Medical Royal Colleges and President, National Association of Patient Participation Groups
Received date:13 May 2009; Accepted date: 24 June 2009
Choice and personalisation of patient care are both embodied in Lord Ara Darzi’s review of the future of the NHS, designed to promote patient independence. Personalisation of the care that patients receive is increasingly recognised as the key to patient-centred health care. Self-care is about people taking respon-sibility for their own health and well-being. But the widespread adoption of self-care programmes and personalisation of care will surely depend on the ability of the health services and healthcare professionals to assist in the personalisation of services and care to enable individuals to live with, to manage and to monitor their own condition. Personalisation in self-care is important, as not all patients can self-care to the same extent. Furthermore, there will be points in the life of individual patients when they are less able to self-care.
The Picker Institute has argued that:
... full patient centred practice by definition demands a positive, two way relationship between doctor and patient and its adoption should recognise the need to tailor practices according to the individual patient their prefer-ences abilities and expectations.
However, in order to tailor practices according to the needs of individual patients, it is necessary to win the hearts and minds of all healthcare professionals and not only doctors, and that would include managers, so that the established system of health can be changed where necessary. Two examples are given in order to illustrate where such changes could help patients. While the examples have been taken from patients with coronary heart disease, the principles described may well apply to many other situations.
Consider patients who have had a heart attack, who have been successfully treated in hospital and are dis-charged to the care of their general practitioner (GP). For these patients this means taking their medication every day, having regular cholesterol tests, as well as ensuring that any lifestyle changes such as exercising and dietary control are followed. Now self-care means taking responsibility for this process. This includes not only lifestyle changes but also organising the medi-cation and the cholesterol blood test.
Acquiring medication: repeat prescriptions
Many patients who have had a heart attack are pre-scribed drugs that may include a combination of beta-blocker, aspirin, statin and angiotensin-converting enzyme (ACE) inhibitor. Most patients receive a pre-scription for each drug for two months. Many GPs have introduced systems to streamline the organis-ation of repeat prescriptions. A common system is that three working days are normally required for repeat prescriptions delivered to the surgery, and seven work-ing days for those sent by post with a stamp addressed envelope enclosed.
The first system requires the patient to pay two visits to the surgery followed by at least one visit to the pharmacy. The second system requires the patient to post the prescription approximately every eight weeks. That of course assumes that the packet size for all the drugs is the same. If not, then there may be an add-itional requirement for a repeat prescription.
One explanation for the two-monthly prescription is that should the patient die or the drug not be needed, the unused drugs may be wasted with a con-sequent unnecessary cost to the NHS. But has the cost for the NHS of the practice time in processing the prescription and the pharmacist’s time in dispensing the drugs been considered? As the patient does not normally see a healthcare professional every two months, why are the drugs not prescribed for three, four or even six months at a time? This would reduce the cost of the time of both the practice and the pharmacist but would increase the drug cost in the short term.
Nowhere in this equation has the cost of the patient’s time been included, or the convenience of the patient. Modern information technology (IT) systems could allow even more efficient communication by the practice emailing the prescription either directly to the patient or to a selected pharmacist.
It is recommended that the same group of patients have their cholesterol tested every six months. A typical scenario is that a self-care patient requests a form from the practice perhaps at the same time as a prescription is renewed. As blood tests are not carried out in all GP practices, the patient then has to make an appoint-ment with the local hospital. It would be helpful for patients who take responsibility for this aspect of their own care to be able to make an appointment for a cholesterol blood test without having first to acquire a form from the practice. One solution would be for such patients to be ‘registered’ with the local hospital. Alternatively, the appropriate form could be issued automatically by the practice with a repeat prescrip-tion, thus ensuring that the patient is being monitored.
Patients with coronary heart disease who self-care find it helpful to know their cholesterol levels. The normal procedure is for the pathology laboratory to send the results directly to the GP. Often there will be no need to inform the patient of the results as these are considered to be within normal limits. But that is not satisfactory for the patient who has not seen the results and who wishes to be able to monitor their own health. It is appreciated that patients may be able to receive the results from the practice over the phone. However, this is not the situation in all practices, where an appointment with a GP is required to receive test results. A solution is for the results to be sent directly to both the GP and the patient at the same time. This challenges conventional thinking, as path-ology services do not normally deal directly with patients in terms of results. Even if pathologists accept this suggestion, they may be concerned about the confidentiality of the results (personal communication from Dr Helen Williams, consultant histopathologist). This is understandable but surely not insurmountable.
These examples illustrate the challenges for doctors and for the healthcare system in embracing personal-isation of care. They demonstrate that the time and the cost to patients is not always considered in the plan-ning and delivery of services. They also demonstrate how quite small changes in practice can make a great difference to patients who have had to learn to live with long-term conditions.
Commissioned; not externally Peer Reviewed.