COMMENTARY

European Journal of General Practice, 2010; 16 : 67–69

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Commentary on Series: The research agenda for general practice/family medicine and primary health care in Europe. Part 3. Results: Person-centred care, comprehensive and holistic approach.

Ideology and partnership in research and clinical practice

NICKY BRITTEN

Institute of Health Service Research, Peninsula Medical School, University of Exeter, UK

Introduction

The review of these three different research domains makes fascinating reading (1). These familiar yet poorly defi ned concepts refl ect the aspirations and values of general practice as much as actual clinical practice; none of them has been comprehensively investigated.

Patient-centred care

The term patient-centred care, more recently person-centred care, has a long track record and strong rhe-torical value. It has found its way into many health policy documents as well as educational programmes. The fact that it is not well supported by a body of high quality evidence shows that it has strong ideo-logical and pedagogical value. For general practitio-ners the term person-centred care signals that, unlike doctors in secondary care, they are as much focused on the person as on the disease. The term ‘ relation-ship-centred medicine ’ has been used by Roter, who claims it is the optimal form of patient-physician relationship (2). She characterizes this relationship as medically functional, informative, facilitative, responsive and participatory. Her review sets out the evidence in support of specifi c aspects of relationship-centred care. The importance of medical functionality is highlighted by Graffy et al., who ask whether adopting a patient-centred approach

Correspondence: N. Britten, Veysey Building, Salmon Pool Lane, Exeter EX2 4

ISSN 1381-4788 print/ISSN 1751-1402 online © 2010 Informa UK Ltd. (InfoDOI: 10.3109/13814788.2010.481710

might distract professionals from addressing clinical problems (3).

Comprehensive approach

The comprehensive approach is also a broad term that does not easily lend itself to research. Again there is an ideological element to this term which signals that general practitioners engage with the ‘ messy reality ’ of patients with multiple needs, mul-tiple morbidities, and in multiple different contexts from disease prevention to palliative care. Much of the evidence underpinning evidence based medicine is carried out on comparatively young patients with single diagnoses, carefully selected to take part in randomized controlled trials. This is not the popula-tion who constitute the workload of many general practitioners. My own plea would be for GPs to research these real world multiply morbid patients, to fi nd ways of supporting their complex self-man-agement regimens, as well as determining how to adapt simplistic clinical guidelines for treating them. Boyd et al. ’ s paper gives the hypothetical example of a patient with fi ve diagnoses, whose recommended treatments (as set out in fi ve disease specifi c clinical practice guidelines) confl ict with one another (4). This patient would take 12 separate medications, requiring 19 doses taken at fi ve separate times during a typical day. The guidelines also recommend 14 non pharma-cological activities if all nutritional recommendations

SG, UK. E-mail: nicky.britten@pms.ac.uk

rma Healthcare, Taylor & Francis AS)

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are pooled as one. The authors identifi ed drug inter-actions that could result from concurrent adherence to all fi ve guidelines, and noted that recommenda-tions could contradict one another. They noted that most clinical guidelines do not modify or discuss the applicability of their recommendations for older patients with multiple comorbidities, although this is the daily task of the GP.

Holistic approach

The holistic approach is even less well supported by any primary care based evidence, although the term has been investigated rather more in the context of complementary medicine. Complementary practi-tioners often claim the term holistic to distinguish themselves from biomedical practitioners, including GPs, and their claims are supported by patients (5). In the US, the term ‘ integrative medicine ’ has more infl uence. The model of integrative medicine includes a personal medical home (which in Europe is pro-vided by the general practitioner), patient-centred care, a team approach, elimination of barriers to access, advanced information systems, redesigned offi ces, whole-person orientation, care provided with a community context, emphasis on quality and safety, enhanced practice fi nance, and commitment to provide a full scope of services (6). The model explicitly includes complementary and alternative medicine alongside biomedicine. American authors advocate the model of integrative medicine on the grounds that it avoids fragmentation (when comple-mentary therapies are provided separately) and emphasizes the need to change current models of health care delivery. While this model has its roots in the particular setting of US health care, it provides a tangible and clearly specifi ed model of holistic care as well as integrative medicine clinics as research sites.

Ideology

The fact that all these concepts are poorly defi ned and poorly researched suggests that the point is not about research evidence. Much of the discussion is in opinion papers. A different focus would be to ask how these concepts refl ect the values of general practice, why they matter, and what function they perform. All of them seem to have ideological value in differentiat-ing general practice from hospital medicine. As all these broad and inclusive terms are too broad to be researched, precise defi nitions of their component parts would facilitate focused research. To do this, we need to identify the salient aspects of the ideological claims. For example, the argument that GPs are

responsible for all their patients ’ needs (if Starfi eld ’ s defi nition is accepted) requires comprehensive measures of these various needs, and research meth-ods, which can capture the complexity of managing multiple problems.

The role of patients in research

All these concepts are concerned with the patient journey as well as the disease journey; if we want to know the relationship between these two sets of journeys, we need to be able to measure the patient journey as well as we can measure the disease jour-ney. To meet this research challenge, we need to engage patients as research partners as well as part-ners in clinical practice. The review does not mention patient and public involvement in research, but such involvement could make a big contribution both to the defi nitions of these concepts and how to measure them. A recent review published by the UK organiza-tion INVOLVE, which supports greater public involvement in research, provides many examples of the impact of public involvement (7). This includes impact on the research agenda, research design and delivery, and research ethics. Patient involvement would contribute to the identifi cation of key aspects of health care most relevant to patients, as well as creative ideas about how to measure them. It seems quite illogical to conduct research into patient-centred care without involving patients in setting the research agenda and designing the research (8).

Conclusion

These three terms all serve ideological rather than practical purposes, and the ideological elements may have distracted researchers from making clear defi ni-tions and developing appropriate research instru-ments. The review summarizes the need for both of these elements very well. There is a continuing clin-ical challenge of attending to the patient ’ s journey as well as the biomedical task. There is an urgent need to engage patients as partners in research as well as partners in clinical practice.

Declaration of interest: The authors report no confl icts of interest. The authors alone are respon-sible for the content and writing of the paper.

References

Van Royen P, Beyer M, Chevallier P, Eilat-Tsanani S, 1. Lionis C, Peremans L, et al. Series: The research agenda for general practice/family medicine and primary health care in

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