Full engagement in health

In his review of future funding needs for the British NHS, Derek Wanless called for a new focus on moderating demand by investing in effective health promotion and disease management with the active involvement of individual patients and local communities.¹ The fully engaged scenario, which entailed a radical change in professional and public roles, was the most ambitious of the three alternatives modelled by his team, but they concluded that it offered the best and most cost effective means of matching demand to supply of health care in the longer term. Achieving this involves promoting self care—for example, by encouraging patients to adopt healthy behaviours and to diagnose and treat minor ailments, involving them in treatment decisions, and supporting them in active self management of chronic conditions. This strategy is now enshrined in official policy for the NHS in England,² but to what extent is it being implemented in primary care?

A new international study published last week by the Commonwealth Fund of New York shows that British patients are a long way from being fully engaged.³ Drawing on a survey of 8672 adults selected at random in Australia, Canada, New Zealand, the United Kingdom, and the United States and interviewed between March and May 2004, the study focused on patients' experience in primary care. It found that British patients were generally more positive about the organisation and funding of health care than those in the other countries, but patient centred care is not yet the norm. Although patients in Britain experience greater continuity in primary care and much lower out of pocket costs than those in the other countries, there are indications that health care is delivered in a more paternalistic fashion in the NHS. The United Kingdom performed worse than the other countries in relation to information about medicines, shared decision making, patients' access to records, preventive advice, and self management of chronic disease.

More than a third (37%) of those in the United Kingdom taking regular prescription medicines said their doctor had not reviewed their medication in the past two years and 39% said they had not been given an explanation of likely side effects of their medicines, a notably worse result than the other countries. British patients also reported the worst results in relation to involvement in decision making: only 27% reported that their doctor always tells them about treatment choices and asks for their ideas and opinions, compared with 41% in New Zealand and 43% in Australia. Only 28% said they had access to their medical record, again the lowest proportion of all the countries. Advice on weight, nutrition, and exercise was also not forthcoming from British general practitioners. Only 28% of British patients reported receiving this advice, compared with 52% in the United States. Similarly only 28% reported receiving counselling about emotional issues that might be affecting their health, compared with 38% in Canada.

Among British patients diagnosed with a chronic disease, only 45% had been given a plan for managing their care at home, compared with 63% in New Zealand and 64% in the United States.

A growing body of evidence shows that patient engagement in treatment decisions and in managing their own health care can improve patients' experience and often results in more appropriate and cost effective utilisation of health services and better health outcomes.⁴ The key to greater patient engagement lies in building health literacy and ensuring that clinicians help patients to help themselves. In addition to the potential for achieving greater efficiencies in resource use, encouraging patients to take more control when they are ill may also prove to be an effective tool for improving public health, as well as personal health. Paternalistic styles of practice tend to create dependency and undermine self reliance. Promoting involvement, empowerment, and a sense of ownership of their health care could be the best way to ensure that people adopt healthier lifestyles. For public health policy to be realised, paternalism must be replaced by active encouragement of patients to participate in their own care.

The place to start is primary care. Although the general practitioner contract includes incentives to improve performance in relation to dietary advice, smoking prevention, and blood pressure checks, it does little to encourage patient engagement.⁵ On the contrary, it promotes an essentially doctor led model, with few incentives for clinicians to empower patients to take control of their own health. Once again there seems to have been a failure to join up the separate strands of health policy. The NHS should be supporting the public health push towards full engagement not working against it.