Getting patients to take responsibility for their own health

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Patients will only progress when they take responsibility, writes David Haslam.

It started with a phone call from a patient who was staying in my area for a couple of days and had forgotten his blood pressure tablets. “The doc said I must never be without them,” he said. As he couldn’t get out, and since the flat where he was staying was just round the corner from where I lived, I said I would drop a few in on my way home.

I’m glad I did. I’ll never forget the sight of this chain-smoking, 23-stone man, sitting in an armchair surrounded by cans of lager, overflowing ashtrays and a huge portion of fish and chips. But the only health issue that was worrying him were the tablets he had left at home.

What was it the government adviser Sir Derek Wanless, who died last week, said about the population having to be fully engaged in their own health? This scenario begged so many questions about attitudes to health and illness. While this particular patient might have been depressed and paralysed by a sense there was nothing he could do, nevertheless the issue that struck me most is just how he had compartmentalised his health as being a matter to be dealt with by his doctor. He wasn’t alone.

Another scenario. This time a man in his late thirties who had been suffering with chronic back pain. For the first time in what seemed like years, he came into my consulting room smiling and upright, rather than hunched and despondent. “What made the difference?” I asked. His answer fascinated me. “I suddenly realised that this was my back, my problem – not yours,” he said. “You’d been doing your best, but to be honest I hadn’t been bothering with the exercises or any of the other advice. I just wanted you to sort it out. But then I realised that the only person who could really help was me.” And so he started the exercises, and lost weight, and got fit – and the results were remarkable.

Two stories, but the common factor to both was that they had seen their health as being someone else’s problem.

We can’t go on like this. No one is more committed to the NHS than me, and I understand the complexities of the issues. Entire generations have learnt to turn to the NHS at the earliest opportunity, the very first symptom. And we have frequently encouraged this – albeit unconsciously – by failing to treat our patients as sentient adults, rather as passive recipients of our advice and therapy.

For centuries, professions were defined by the body of knowledge they held. The professionals knew stuff, the patients or clients knew their place. Now, all the knowledge in the world is open to anyone with a laptop or smartphone, the relationship has to be very different – and clinicians have to change their approach. And it’s gradually happening.

For years, I was an examiner for the Royal College of GPs membership test and I often asked candidates about the acceptability of patients having their own blood pressure machines. Fifteen years ago it was a very rare candidate who thought this appropriate. Now the situation is very different.

Patients should expect to have access to their records. Patients should understand what their pills are for and how they work. There is increasingly strong evidence that patients who understand and are involved in managing their conditions – and in decisions about their care – have better outcomes. It feels almost embarrassing to write a sentence like that, as it seems so blindingly self-evident, but for years many of us failed to explain, educate, share and support. We’ve just treated. And on top of all this, there is also good evidence that if you increase self-care, satisfaction rises and costs fall.

Despite this, self-care hardly seems to be a priority for the NHS. The whole system needs to embrace it, but rarely prioritises it. Medical and nursing staff, both in primary and secondary care, are inconsistent in the messages they give. But it is critical that the whole system takes the messages on board, and it is hardly surprising that many patients feel that they aren’t “allowed” to self-care if the NHS does not repeatedly tell them that it is their body and that it’s more than fine to do so.

Clinical commissioning groups may have an opportunity to create a world where self-care, from managing minor ailments to taking greater control of long-term conditions, is the norm and not the exception.

For many years, there was a US Airforce base near my general practice, and I and my colleagues looked after many of the families of the aircrew. There are precious few ways in which I consider the US attitude to healthcare as being better than ours, but even 25 years ago I was struck by the fact that if I told a British patient I was giving them a prescription they would say: “Thank you doctor.” Whereas an American patient would say, “Why?” It took more time, but – my goodness – it was refreshing.