Final Report > Chapter 23: Respect and Honesty > Partnership: involving patients and parents in decision-making

Partnership: involving patients and parents in decision-making

10 Many patients now wish to have a greater level of involvement in decisions about their care. One clear message from Bristol is that this is certainly true for parents who, almost always, want to be closely involved in their child's care. Even those who say that they would prefer not to know too much are entitled to be given the opportunity to be involved, to the extent that they would feel comfortable. An editorial in the `BMJ' captured the point well: `For doctors the trick will be to determine which patients want to be offered choice and which prefer a passive role.' [7] That patients should be more active partners in decisions about their care is already acknowledged as public policy. The NHS Executive's Patient-Partnership strategy, relaunched in 1999, states clearly:

`Achieving [patient partnership] will require that patients are given the information that they want about themselves and their care and ensuring they are treated with respect and as partners in their care.' [8]

11 Partnership is also reflected in professional guidance. The GMC's guidance, `Seeking patients' consent: the ethical considerations', for example, states: `It is for the patient, not the doctor, to determine what is in the patient's own best interests. ... you may wish to recommend a treatment or a course of action, but you must not put pressure on patients to accept your advice.' [9]

12 It was suggested to us in Phase Two that involvement in decisions about care can also significantly improve a patient's prospects for recovery. Angela Coulter, a contributor to one of our seminars, wrote:

`Patients with hypertension benefit if they are allowed to adopt an active rather than a passive role in treatment, patients with breast cancer suffer less depression and anxiety if they are treated by doctors who adopt a participative consultation style, and patients who are more actively involved in discussions about the management of their diabetes achieve better blood sugar control. Patients whose doctors are ignorant of their values and preferences may receive treatment that is inappropriate to their needs.' [10]

13 This notion of `partnership' between doctor and patient featured in a number of submissions to Phase Two, including one from the Royal College of General Practitioners (RCGP). The RCGP acknowledged that many doctors in practice today have been trained along the lines of a traditional model of consultation, in which the patient's only active contribution to the conversation is the presentation of symptoms. For many years now, however, the approach used in the training of GPs has differed from this traditional model. Instead, a model of partnership is advocated, in which: `... the patient and doctor meet as equals with different expertise. The doctor has the medical knowledge and skill, but the patient has personal knowledge and skill. ...' [11] In this model of partnership, the whole structure of the consultation changes and the power in the relationship becomes more evenly shared. The RCGP also stated that partnership: `... is not to deny ... that the professional has expertise. ... for this partnership to work patients need information about the problem presented to them in a language that they understand. They may need time to consider. Patients may prefer a particular treatment. ... The professional needs to respect the patient's perspective and the patient needs to respect the professional and the service.' [12] The `BMJ', in its editorial, argued similarly:

`Partners work together to achieve common goals. Their relationship is based on mutual respect for each other's skills and competencies and recognition of the advantage of combining these resources to achieve beneficial outcomes. Successful partnerships are non-hierarchical and the partners share decision making and responsibility. The key to successful doctor-patient partnerships is therefore to recognise that patients are experts too. The doctor is, or should be, well informed about diagnostic techniques, the cause of disease, prognosis, treatment options, and preventive strategies, but only the patient knows about his or her experience of illness, social circumstances, habits and behaviour, attitudes to risk, values, and preferences. Both types of knowledge are needed to manage illness successfully, so both parties should be prepared to share information and take decisions jointly.' [13]

14 The importance of partnership was also emphasised by a submission to Phase Two from the Royal College of Nursing. [14] In it, the College argued that the development of skills to enhance partnership is vital for the professions, for example, in aiding patients to participate in making informed decisions about their care. The Royal College of Surgeons also recognise the trend towards partnership. It argued, as in fact did the RCGP, that patients will differ in their preferences and that this should be acknowledged.That said, in a patient-centred health service, a consistent approach to involving patients is needed. It can no longer be acceptable for patients, having been treated, as they are now for the most part, as equal partners by their GP, then to go into hospital and be confronted with old-style paternalistic attitudes from some consultants.

15 Many parents who gave evidence to the Inquiry commented in their statements, or through their representative groups, on the improvements which they felt were needed in the attitudes shown by healthcare professionals towards patients and particularly parents. Overwhelmingly, they emphasised the need for parents with a child in hospital to be involved in their child's care and for parents' expertise, as the people who know the child best and who care for the child, to be fully acknowledged and appropriately engaged. This approach is now regarded as good practice when children are in hospital. We believe that it should be standard, routine practice. We have no doubt that this approach, whereby parents and patients are alongside and in partnership with the professional, rather than following and doing what they are told, is the way forward for modern care in hospital.

Footnotes

[7] Editorial; `Paternalism or Partnership?', `BMJ' 18 September 1999; 319: 719 - 720. www.bmj.com

[8] Department of Health. `Patient and Public Involvement in the New NHS', London: Department of Health, 1999. (Health Service Circular: HSC (99) 210) available from www.doh.gov.uk

[9] General Medical Council. `Seeking patients'consent: the ethical considerations', November 1998. www.gmc-uk.org

[10] Coulter A et al. `Sharing decisions with patients: is the information good enough?', `BMJ' 30 January 1999; 318: 318-322. www.bmj.com

[11] Seminar 7. The Royal College of General Practitioners. Position Paper

[12] Seminar 7. The Royal College of General Practitioners. Position Paper

[13] Editorial; `Paternalism or Partnership?', `BMJ' 18 September 1999; 319: 719 - 720. www.bmj.com

[14] Seminar 7. The Royal College of Nursing. Position Paper