It takes more than a buzzword to reform culture.
The Federal Government has released its Strengthening Medicare Taskforce Report, outlining a vision for Medicare. In the 12-page report, the term “person-centred” was used 15 times to describe the kind of primary care system the taskforce envisages.
But what does it really mean to be “person-centred” in the healthcare context? How can a complex system with multiple, and sometimes competing, stakeholders achieve a person-centredness that this report evokes? Further, what kind of values does this draw on to guide our approach to assessing decisions and practice in healthcare; what is good or bad, right or wrong, or just?
What matters to whom?
The healthcare system, from a federal and state point of view, needs to provide structures, processes and outcomes for every Australian, regardless of needs. This means that the decisions made in relation to resourcing and allocation are not always going to reflect the needs or desires of the individual in the system.
Take, for example, a person who wants to receive ongoing, subsidised access to mental health care. While that individual may want to see a psychologist every second week, the system will only provide access to up to 20 sessions in a Mental Health Plan, with not all 20 guaranteed.
From a policy maker’s point of view, it may be preferable that 1000 people are engaged in some form of mental health care, rather than some having access to many more sessions. A psychologist may be motivated to see as many patients as they can because they want to have as wide an impact as possible, or because their employer mandates it.
In other realms of healthcare; a cancer patient may have goals and preferences in relation to the quality of their life and functionality over the quantity of life left, whereas a clinician or policy maker may be motivated to “cure” the disease, to extend number of years, or to meet performance measures (e.g., number of successful surgeries, courses of treatment) that may tie into future resourcing and allocation decisions, as well as professional and peer esteem.
Clearly, there is not always a match between what a person in the healthcare system wants or needs and what the system, clinicians and health professionals, administrators and policy makers think matters.
In this way, healthcare can be seen as utilitarian – where we strive to do the most good, for the greatest amount of people. We aim to use what resources and funding is available to improve the most lives possible.
Person-centred care can sit in contrast to this. What is important, rather, are individual goals and preferences for our health.
But there may be other ways to think about how the term “person-centred” is being used in proposals such as the Strengthening Medicare Taskforce Report. Person-centredness can be understood as a shift in thinking, away from the traditional delivery of care which focused on illness or disease-specific responses, to an approach which contextualises care decisions with the patient as a unique being, understanding their functional, spiritual and value-based needs.
For example, a 2012 German study into prostate cancer care found that, post-surgery, approximately three-quarters of patients suffered erectile dysfunction3. The impact of something like this on one’s quality of life can be incredibly burdensome.
But one clinic was found to have less than half of the national rate in their patient outcomes. Similar research into the rates of urine incontinence found that the same clinic had 11 times lower rates than the national average.
So, what was this clinic doing so differently? Several factors likely contributed to their success, however two critical ones for the context of this discussion are that a) data on the outcomes and experiences of these patients are collected and routinely fed back to surgeons and clinical staff, and b) time is allocated to regular, deep reflection on performance, in teams.
Through this open process, everyone comes together to review these data in a discussion group – an environment that is cultivated not as a punitive space for intense performance management, but one for learning and development. As such, centering the person’s experiences and outcomes can directly lead to improved quality of care in a broader way, by supporting the learning and development of practitioners so that they can do their jobs better.
Cases such as this one exist throughout the world. What underpins these successes is a robust system for collecting information about people’s experiences of disease and illness, and factoring in time and resources to learn and reflect on this valuable information.
Perhaps with this lens, “patient-centred” means centering patient experiences and outcomes in aggregate, where the consequences and impacts of treatment and techniques are reviewed regularly, guided and prompted by the reports that persons give the healthcare system.
But can this be achieved at a national or state level, outside of a specialist care context such as the prostate cancer clinic in Germany? It may be difficult, given the various needs of communities.
What will work in Dubbo won’t be the same as Alice Springs, Cairns, Melbourne, or Launceston. And not every patient will be willing or able to provide such insights about their experiences or outcomes, whether this be because of language, digital literacy, technology or other barriers.
Likewise, not all healthcare settings will have the appropriate tools or culture necessary to regularly review and learn from patient experience and outcome data.
While the Strengthening Medicare Taskforce Report touches on the needs for organisational and cultural change to improve access, coordination, and digitalisation, it falls short of answering the deeper issues, including how to promote a culture across healthcare that will give increasing weight to the patient perspective, not just clinical technical knowledge and skills.
Professor Christobel Saunders AO is the James Stewart Chair of Surgery at Royal Melbourne Hospital and a board member of Oncology Republic.
Nina Roxburgh is a PhD Candidate at the Monash Bioethics Centre, Monash University.
