Person-centred care in primary care: the key to sustainable quality in the NHS?

The theory and evidence base behind person-centred care is not new. It started in the 1990s with Ed Wagner’s chronic care model. And in the last three months there have been excellent papers detailing the evidence base and measurement tools from National Voices and the Health Foundation.

Also, with a new person-centred approach in diabetes, the Year of Care pilots have shown this can improve patient and population level outcomes and reduce resource use. It appears this can be one way to hit the magic 'triple aim' of the Institute for Healthcare Improvement.

But boy is it hard to implement this approach in primary care. Anything that requires a paradigm shift in care is always going to be tricky. As a full time GP partner in Sheffield, I understand the difficulties.

Workload is rising rapidly – a combination of care being moved into the community without associated resources, an ever increasing range of medications and treatment options, and a politically fuelled rise in patient expectation. None of these things are, in theory, bad. The glass-half-full spirit in me sees this as a challenging and opportunistic time, requiring a different way of thinking and doing.

But if we need a cross-the-board paradigm shift, then starting with a workforce that is drained of energy and spare capacity to think is never good. I know the Royal College of General Practitioners are fighting hard to reverse this situation with their 'Put Patients First' campaign, and buy back some capacity in primary care.

Fortunately, person-centred care may be one of the solutions to this ballooning workload. The solution to increasing demand in the previous decade was to provide more resources as we saw unprecedented investment in the NHS under New Labour. But we don't have that option now, and in a way, I'm glad.

Most people intuitively know that chucking money at a problem is not a sustainable option. But crucially it runs the risk of disempowering people from thinking and acting for themselves. Have ideas for better access like NHS Direct or Darzi Centres improved health, or just fuelled the public need for a medical opinion for the range of normal experiences of life? 'Better pick up the phone than think for yourself – just to be sure'.

I would say it's far better to systematically embed a person-centred approach, where patient activation is central. The recent King's Fund paper, by Judith Hibbard, advocates matching behaviour change techniques according to people’s starting level of confidence and skill, to nurture their own resourcefulness.

In the field of education, teachers have been doing this for years, and are surprised that we in the medical profession don't recognise that people of different abilities require different educational approaches.

Person-centred care, particularly for long-term conditions, values activities that work on supporting self management, shared decision making, and proactive patient-led care planning. These 'enabling' techniques all work towards nurturing and supporting patients to tap into, and grow, their own resource. All this is in the context of what matters most to the patient involved. To adapt Armatya Sen's Capability Approach, you could call it 'helping people to achieve the health they have reason to value'.

Thinking of the prime medical mantra of 'first do no harm', I would suggest we start to see any process that takes power away from patients as actually doing them harm, however well intentioned.

Of course we need to check this approach is what patients want, but judging by the evidence base for person-centred care proposed by National Voices, and the political call to arms from the Arthritis and Musculoskeletal Alliance, this is how patients see the future of high quality health care. But do these organisations truly represent the views of the most needy and often most disempowered patients we see? My experience suggests that years of paternalistic-style care (health and social) has corralled many patients into a very passive role in their health care.

So we have some work to do. Taking a lead from the Health Foundation's Co-creating health programme we need a sustained effort to build systems, and support practitioners and patients, that value and prioritise person-centred care.

We'll need to 'meet' people at which ever point they are starting this journey of system and behaviour change. It will be a big effort requiring vision and sustained energy, with coordinated support from all the political, professional and patient representative teams (not to mention the media and business sectors). If we can get there the prize is huge – sustainable quality in our NHS.

Ollie is a GP and clinical commissioning lead in Sheffield, www.twitter.com/olliehart7

Further reading

For more resources and information on person-centred care, visit our person-centred care resource centre.