Patients as co-producers of heath

One of Julian Tudor Hart's own illustrations in A New Kind of Doctor

Essays in honour of Julian Tudor Hart

This is the third of three essays we are publishing looking at the lessons of legendary Welsh GP Julian Tudor Hart, who died aged 91 on 1 July 2018.

Progress in health care depends on developing professionals as sceptical co-producers of health gain rather than salesmen of process, and developing patients as sceptical co-producers rather than consumers searching for bargains and shorter queues.((This and all following quotations, except where noted, are from Julian Tudor Hart, The political economy of health care (Second edition), The Policy Press 2010))

Julian Tudor Hart was a passionate advocate for partnerships with patients, shared understanding and shared decision making, long before it was the subject of editorials in the British Medical Journal and international conferences were dedicated to it. His commitment developed from the practical experience of providing continuous care to the same population in a Welsh mining valley for decades.

Mutual trust and a shared understanding of illness and healthcare requires continuity of care and a detailed knowledge of patients and the place they live. In recent years, digital technology has made medical knowledge and clinical guidelines available to anyone with a smartphone, and with this has arisen the ideas that any doctor, anywhere, will do; that shared-decision making can be done by protocol and that biometric data is more important than the social data.

One consequence of this is that the kinds of patients that Babylon (and their NHS partner GP At Hand) are recruiting, do not, on the whole have,

Complex, continuing problems, including both biological and social factors, [that] present the most difficult challenges to clinical medicine, and account for a high proportion of overall workload and costs.

Many problems that patients present with can be solved with a quick word of advice or a simple prescription. But patients cannot usually be divided into those whose problems are straightforward, and those whose problems are complex. Many consultations contain a mix of simple and complex problems; biological, social, psychological, moral and practical knowledge comes into play.

Without knowledge of the social and biographical contexts that affect how patients present, doctors run the risk of treating every symptom as if it represents disease, rushing to make a diagnosis before they have fully appreciated the problem. This problem is made worse when the doctor does not have the ability to see the patient again.

Chronic problems require continuity – patients’ stories need to be already known, not endlessly repeated to successive strangers. Episodic interventions fragment care, tending to keep patients passive and to promote inappropriately heroic roles for professionals, because salvage, whether or not it is successful, always trumps prevention.

Many problems that GPs help patients cope with, like chronic pain, severe obesity, and diseases caused and complicated by unhealthy lifestyles are inseparable from social and material deprivation and past experiences, especially childhood trauma. New research is shedding light on the mechanisms by which past trauma can lead to adult diseases, but Tudor Hart was well aware of the need to explore the past in order to make sense of the present,

If doctors or patients can find any reason, however implausible, for a mechanistic explanation of symptoms or a somatic label, most will seize this with relief, rather than enter the bog of their innermost fears and anxieties, which they may share as much as the patient. If any trace of even the most doubtful evidence of somatic disease can be found, preferably with some apparently simple surgical solution, both doctor and patient can return to short consultations about body engineering and repairs and keep away from the dangerous ground where causes so often lie. On the other hand, to have any hope of rational care with measurable health outcomes, we must pay the price in more staff, longer consultation times and wider, more sceptical and more compassionate imagination: a black box designed from experience of handling human problems, not from managing assembly belts.

As one of his many admirers, past president of the Royal College of General Practitioners, Iona Heath wrote,

Doing nothing is preferable to leaping to conclusions; applying inappropriate or premature labels; medicalising ordinary human distress; and instigating futile or ineffective treatments.((Heath I, The art of doing nothing, European Journal of General Practice, Vol. 18 2012, Issue 4))

Doing ‘nothing’ is impossible in a consultation where doctor and patient are strangers to one-another and will never meet again, where medicine is a trade and where patients are consumers. Patients with chronic, complex problems need a doctor who can commit to working with them over time.

For Tudor Hart, working with patients over time, in the same place, taught him from direct experience how social conditions determined health.

Distinguishing distress from disease requires a knowledge of place as well as people. Tudor Hart called himself a ‘Glencorrygologist’:

I knew more, did more, and certainly wrote and spoke more about the health problems of Glyncorrwg, than any other doctor. So I became the world expert, a specialist in at least the initial recognition, and often the terminal management, of the entire potential range of health problems in that unique community. … What higher ambition could any doctor have?

His legacy lives on in initiatives like GPs at the Deep End, networks of GP practices serving the most deprived populations in Glasgow and a number of other cities around the world, sharing research, education, advocacy and support. Fair Health in Yorkshire have developed a curriculum about health inequalities for GPs and Medical Students. The curriculum combines epidemiology with patient stories, mixing public health with personal narratives just as Tudor Hart did in his research and in practice.

At the heart of Julian Tudor Hart’s philosophy of practice was relationship-based care, guided by science and directed towards health-gain, community empowerment and social justice. This remains as important for us and our patients now as it was for him and his patients.