Provider‐centric models of care in which most consumers of healthcare are passive

Patient-centred care has been the holy grail of healthcare systems for at least 30 years. The vision was of motivated and informed patients involved and consulted on their healthcare, actively participating in choosing from the services offered and interventions available. However, progress towards this vision has been slow and erratic, and health systems and professionals have not only struggled to articulate how such a vision could be made to work, but also how it could be sustainably implemented. Despite these difficulties, many advances have been made and today patients are better informed and more involved in their care, and the clinical decision-making processes of their healthcare providers. There are many examples of good holistic patient centred-care systems. However, Nirvana remains elusive, and most western healthcare systems still deliver care largely from a provider-centric perspective. For much of their journey through the healthcare system, patients are still passive consumers/recipients of interventions. In previous decades, health professionals were often perceived as, and accused of, being egocentric, paternalistic and even patronising towards their patients. It was felt that the health professional was the expert in a very complex area of science that was beyond the comprehension or capability of most patients to understand. The natural corollary of this position was that one would not expect that patients would either want to know, need to know or have any pressing desire to be involved in complex clinical decision-making. As we have made progress towards improving patient-centric care, it has become clear that many patients are well informed and do want to be actively involved and consulted on clinical decision-making; however, this is not true for all patients, nor has it proven to be easy for all health professionals. Medicine is a complex and rapidly changing science, and to the layperson often very confusing. Making sense of the myriad of rapid advancements in clinical options, technological devices and diagnostic treatments can be a daunting task for a layperson. Patients also have access to a plethora of ‘expert opinions’ offered through the popular media which often leave them confused, uncertain and sometimes downright misinformed. Medicine and healthcare are not perfect sciences. Is it reasonable to expect that every patient will be able to navigate competently and successfully the complexities of this system? Is it even ethically appropriate to place the burden of responsibility for making potentially crucial clinical decisions on to every patient (or their family)? Many patients just want to be ‘made better’, they do not wish to have the pressure or responsibility of defining the ‘what’ or deciding the ‘how’. This dilemma will not be easily addressed and not for every patient at every course of their life. Clearly, there is no instant recipe that can be used to transform rapidly our practitioner-centred system from what it is today to what we have aspired it to be, but in recent years there is an additional emerging imperative to do so. The imperative is the rapidly growing need for different clinical options or interventions in order to reduce or control the dramatic increase in lifestyle-related/generated diseases. Action to halt these diseases requires interventions that are beyond the capability of the current health system in its current provider-centric, facility-based form. The system has little direct ability to intervene to prevent the development of lifestyle-related diseases. Moreover as, more often, the patient presents late and in an advanced stage of disease, the system is increasingly limited to only providing symptomatic care. In order to respond to this imperative does the health system of the future need to be profoundly and drastically different than the system of today? There is much talk of ‘new-models-of-care’ required to respond to ageing populations, limited or declining budgets, new technologies and rising expectations of a burgeoning global middle class. But just how new and profound do these really need to be? The traditional health teaching and training programmes, and silos within which health professionals learn and practise, have encouraged and reinforced provider-centric behaviours that result in a narrowness of intervention with patients. Such interventions have been very effective for acute and communicable diseases, but are proving to be much less successful in dealing with diseases of lifestyle. Most patient contact with professional healthcare providers is still usually within health-centric practices, hospitals and outpatient clinics that best suit the efficient utilisation of the health professional. However, the mechanism to respond to this imperative is already all around us. An extensive range of social and health sector workers already work in the community and healthcare continuum. These resources are not currently the traditional general practitioners (GP) and hospital-based clinicians. By using these resources in different and coordinated ways and by linking them through technology, these almost universally passionate, committed and highly expert individuals could significantly enhance the efficacy of the overall healthcare system. There are already many innovative ideas and approaches, new technologies and novel applications of health interventions being tried, tested and proven in hospitals, clinics and communities. Thus, in fact the change needed may not be as profound, far reaching or massive as many may think, because many of the ideas and ways in which the system needs to change already exist. At its simplest level, the future model of care may just need to be a broader base of utilisation of an existing workforce. It may simply be a case of actively seeking out and utilising the skills of all members of a much wider healthcare community and aligning them in connected ways to enable holistic care for the patient (and their families). Homes and communities are often visited by education and social sector support workers and educators, but in guises other than health, health support or lifestyle management. Leveraging workforces that already have existing relationships with communities through cross-training and enhancing their profiles is likely to be one of the few viable options for extending the reach of the healthcare system, particularly given the continuing fiscal limitations and international shortages of health professionals. Upskilling these workers as part of the health intervention framework that reaches from the hospital through the GP into the home has real potential to be able to reach and respond to the epidemic of lifestyle diseases. Topol1 has neatly encapsulated the questions and opportunities that we need to consider and act on in his book The patient will see you now. Technology and the Internet provide the active consumer with information that enables greater levels of knowledge and clinical understanding than has heretofore been possible. Health professionals are regularly confronted by patients armed with in-depth information on their condition, or perceived condition, possible treatments and likely outcomes. The role of the health professional inevitably will change from that of being the holder of the knowledge, options and potentially decisions, to more one of wise counsel. In short, ‘control/power’ in the relationship is largely shifted from the health professional to the patient. Mate and Salinas2 have described an approach involving the concept of ‘flipping’ the interactions with the patient. They have highlighted how many interventions of health professionals come from the health professional-centric context. While in fact, many of these actions or interventions could actually be supported and/or performed remotely, often by the patients themselves (or by family members), via technology that already exists. The Royal College of General Practitioners published a recent inquiry into Patient Centred Care in the 21st Century (RCGP (2014)).3 This report not only highlights that generally current care practices are mostly certainly not yet truly patient centric, but also that multiple new elements and interventions will be necessary in order to truly achieve this nirvana. In short, while an empowered supported patient served by a flexible and responsive health workforce is still an important goal, it is one that remains to be achieved. Life in the 21st century is busy and people access complex services as and when they need them, and often in a cursory and inconsistent or poorly informed way. Most of the time, people rely on the wisdom of service experts or agents (e.g. mortgage brokers, service managers for our vehicles, real estate agents, personnel consultants, career consultants, project managers). It appears increasingly likely that the role of the medical professional will also move in this direction. There is no single solution for ensuring that our future health care system is fit for purpose or sustainable. The current model of our healthcare system is likely to require some sort of change. Profound change is difficult, but possibly not necessary. A relatively simple route to achieve this change could be to utilise the services of the wider health/social/education workforce and how we train and leverage the skills and increase the span of patient interaction to include much more community and in-the-home contact. It must also ensure we find ways to maximise the benefit of the growing number of consumers who are accessing the health system already well informed and with clear expectations for their healthcare.