Angela Coulter: Person centred care—what works?

angela_coulter_2“There’s no evidence that it works.” In these days of evidence based medicine, that’s a real clincher—a good reason to avoid a treatment or procedure that offers no proven value. But can we take it on trust that those making this assertion have a good grasp of the evidence, or could this be simply an excuse for resisting change? Those of us who have been calling on clinicians to make greater efforts to inform, involve, and empower patients have heard this excuse many times.

In 2006, my colleagues and I embarked on an ambitious quest: to track down evidence on the effects of patient focused interventions and make it easier to find. We confined our search to relevant systematic reviews, and found far more than we had expected. Eight years have passed since we began this endeavour, and now the latest version—a web tool—has been updated by the Evidence Centre, and published by National Voices, the UK’s leading coalition of health and social care charities.

This collection of evidence describes key findings from 779 systematic reviews—a much larger number than when we first started looking. The evidence is far from perfect, but several important points stand out:

1. Information is effective therapy. Access to good quality health information—written or electronic—can increase people’s knowledge, understanding, and ability to cope. The impact is greater when written information is targeted, personalised, and reinforced by verbal information from clinicians.

2. Patient involvement leads to better clinical decisions, especially when these are supported by evidence based decision aids for patients, and effective decision support by specially trained staff. This leads to better communication, more accurate risk perceptions, and more appropriate treatment choices.

3. Integrated self management support works best. Collaborative self management support—underpinned by personalised care plans and provided as part of routine healthcare—has the potential to reach more people with better results than externally provided, lay-led, self management courses. Although the latter can have beneficial effects too.

None of these findings are new. We’ve known for some time that these things work, and now we can be even more confident. Why then is it taking so long to implement what is known? It’s hard for lay people to distinguish reliable health information from unreliable, yet only a tiny minority of NHS trusts have achieved certification against the Information Standard, the kitemark for quality information. Half of hospital inpatients say they would have liked more involvement in decisions about their care, but very few are given access to decision aids and encouraged to express their concerns and preferences. Only 3% of general practice patients with long term conditions have a written care plan that is shared with them, and systematic, self management support is still a rarity.

Why don’t NHS trusts and clinical commissioning groups take these things more seriously? We must stop blaming this inaction on the lack of evidence for effectiveness. Lack of will is a more likely explanation. Is it too much to hope that the new emphasis on redesigning and integrating care will galvanise action at last?

Angela Coulter works in the Health Services Research Unit at the University of Oxford and for the Informed Medical Decisions Foundation. She is a trustee of National Voices and a member of The BMJ’s Patient Panel.

Competing interests: Angela Coulter is a trustee of National Voices, and advised on the web tool “Prioritising person-centred care—the evidence” which is the subject of this blog. This author’s full declaration of competing interests can be found here.