Moss Grove Surgery
Kingswinford, West Midlands
Practice manager within a 12,700, progressive, six-partner GP practice involved in GP registrar training, undergraduate teaching and multidisciplinary training
GPs wanting to make the most of NHS reforms and modernisation need to understand the needs of their patients and, in many cases, need to modernise the way they view them. In 1990, I carried out some research portraying a definite unequal power balance between patients and their GPs, which was totally encouraged and accepted by patients at that time.
At the time, patients' passivity and compliance was seen by the patients themselves as the appropriate balance to the respect and admiration patients felt towards GPs. In fact, patients preferred an unequal power base, leaving the power and leadership of their total medical care to the GPs' indepth knowledge and experience.
Having researched patients' views some 12 years later, my research proved that while patients still provide huge evidence of respect and admiration for GPs' knowledge and experience, it also demonstrates evidence of a consumerism and acknowledgement of patients' rights to be allowed a more indepth understanding and knowledge of general practice and local healthcare commissioning.
This definite demonstration of a culture change to that of "patient/ consumer" may well have been politically generated. The Declaration on the Promotion of Patient's Rights in Europe came into place in 1994, and was followed by the Patient's Charter in 1996 and the present government's drive towards patient involvement as the means for improving quality and effectiveness of NHS services.
The government's previous initiative to involve directors of the Virgin organisation to make recommendations on how to make the NHS more "customer-focused" confirmed its thinking of patients as consumers of healthcare, which was supported by my research amongst local patients within the West Midlands, likening the NHS to other consumer-driven successful organisations, such as the Virgin group of companies.
The present culture within the NHS is more than 50 years old, and my own research confirms present government thinking that patient culture has changed dramatically over the last 10 years, patients now wishing to be classed as "consumers of healthcare" rather than "patients". This demonstrates that the pressure of change portrayed by the government for GPs to listen to their patients and deliver a "patient-focused" service appropriate to local needs should be heard and acted on within primary care.
The role of practice managers
If GPs allow, patients (or consumers) are now ready to become involved; however, they lack insight into the unique workings of general practice and the wider NHS.
As practice managers, it is part of our extended role to deliver training to our patients (consumers) on the workings of the NHS system, to enable them to move forward, both increasing their autonomy and supporting GPs at the same time, allowing them credibility to to take part in the decision-making processes underpinning projects such as practice-based commissioning (PbC).
The GPs' views
GPs' current opinion that patients do not have sufficient knowledge to make informative decisions may well be due to the lead for patient involvement not being initiated by GPs themselves but imposed by government pressures. Indeed, my informal interviews and discussions not only confirmed GPs' fear of inadequate patient knowledge, but also revealed fears that patients' ideas and expectations for improving quality may far exceed the realms of possibility, and that patients would expect far more from them than they could deliver locally.
GPs' evident lack of enthusiasm for patient involvement appears to be based on their view that seeking patients' opinions will require response and change at local and national levels, which they believe will be extremely difficult to achieve ethically and financially, thereby making such patient participation difficult to maintain.
Our present government has already given a commitment to patients nationally regarding their involvement (as consumers of healthcare services) to improve the NHS. Initially, this commitment may well have increased votes within the political arena, but, from now on, patients' views that are not listened and responded to will inevitably lead to a distrust in the present government and the NHS as a whole, giving rise to the belief that the government will want to demonstrate a clearly receptive response to patient-driven initiatives.
The "patient experience" section of the Quality and Outcomes Framework (QOF) is, I believe, the beginning of its demonstration of the need for practices to demonstrate clear user involvement. I think that this section will be enhanced and carry more points when the framework is updated from April 2006.
Towards a partnership approach
There is a national need for a partnership approach linking patients, GPs, practice managers and community staff together to improve local standards, making change not only more effective but at the same time sharing the responsibility of change and provision of service across the whole team. Until there is a "whole team" approach between practice and community teams, and a practical approach towards a "two teams become one" arrangement locally within general practice, it will be difficult to provide flexibility of services across practices to meet the demands of individual practices.
Research confirms that patients still have a healthy respect and admiration for the autonomy of GPs, not tarnished in any way by their being asked to participate. On the contrary, providing a complementary process allows them to feel part of the organisation. There is evidence that patients' expectations may be adrift from reality, which may well be due to their lack of understanding and knowledge not only of how the NHS runs but also to activity restrictions locally imposed by central government.
Therefore, it would appear that encouraging patient involvement could well provide the leverage GPs require to support their own ideas not previously acted upon by local NHS providers and government bodies. GPs, within their unique status of self-employed contractors to the NHS, could well use patient involvement as a tool to help them maintain their independence, contrary to political thinking, without feeling any guilt or disloyalty to the overall NHS organisation. More than 10 years on, it is evident that patients still demonstrate a trust in their GPs' nonpolitical, independent view of the NHS and its local implementation, and that they fully support the work of their GPs.
Although patient culture and their wish to be viewed as consumers of healthcare rather than patients has changed dramatically, it would appear that GP culture has not changed at the same pace. GPs need to overcome their fear of involving patients and now look at the positive ways in which a patient panel or a patient group can give them the support they need to be successful, not only within the realms of the new GP contract but also within the new PbC arena.
Within PbC, patient involvement is crucial, not only in order to implement the change, but also primarily in delivering their vision of what that change should be. Moving a service from a local hospital may provide a better service elsewhere, but are patients willing to travel outside of the area – even for a better service, especially if it is a routine procedure?
Do patients (consumers) want more minor surgery to be delivered within their GP practice? What would be their priority/wish list, and how do we know if we don't ask them? A patient panel is crucial to the success of PbC: who can argue with the moving or transfer of service from secondary to primary care if your patients are requesting it? How can the PCT turn down a business case that is totally reflective of patients' needs? The current thinking within the NHS and its need to view patients as consumers fully supports GP practices who support their patients ... or should we say their consumers!