Why we need more patient involvement in the commissioning of health services

According to the declaration of Alma Ata, “people have the right and duty to participate individually and collectively in the planning and implementation of their health care.” Charlotte Paddison reflects on how well we involve patients in commissioning of health services, and why we might want to try harder.

There are at least three important ways that the public can contribute to decisions about their care. Through shared decision-making in clinical consultations; in design and commissioning of health services; and in the evaluation of health care.

We can see good evidence of interest in the first, and the last. In health policy, professional training, and research, much emphasis is now placed on shared decision-making. We have witnessed growing patient engagement in the evaluation of health services, evidenced by national level patient surveys such as the General Practice Patient Survey, and by the use of patient reported outcome measures to determine the impact of health care on health from the patients’ point of view. Whether there is a real appetite for public and patient involvement in the design and commissioning of health services is a timely question but, given the underwhelming track record of success to date, there is genuine uncertainty about the answer.

Why should the public be involved in strategic choices about the design and improvement of health services? Perhaps because they are the ultimate recipients of the desirable and undesirable impacts of public policies; and because public engagement in health care decision-making encourages participative democracy, and public accountability.

Patients should also be involved in the design of health services because they have something unique to contribute: the perspective of someone who is ill. People who are healthy are most often in charge of decisions about the design and commissioning of health services. But there may be differences in what people who are healthy might view as being important in health care, compared to those who are ill. The experience of serious illness is rarely an emotionally neutral event. People who are ill, or have been ill, recognise the value of compassion in care delivery –potentially valuing this in a way that those who are healthy may not. A recent BMJ roundtable discussion highlighted the important of compassion in health care, and called for greater focus on compassion in the way we design and deliver care.

Historically, public input into decisions about health services has tended to be a reactive, anecdote driven process often mediated by the media who function as a proxy for public opinion. Organisations such as LINks have struggled to involve a wide range of people of all ages and different sections of their local population. With the creation of Healthwatch and Clinical Commissioning Groups, we may see new opportunities to improve the quality of patient and public involvement in health services decision-making. Perhaps a timely change is afoot. This is needed, both to breathe life into promises embodied in the declaration of Alma Ata, and to address the call by the Francis Report to better value the patients’ voice within health care.

What to learn more?

The patient patient’s blog #PatientLeaders

Whose shoes? A catalyst for change in health & social care through co-production together to improve lives

Experience-based co-design tool kit, King’s Fund


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