Not a day goes by without media reference to healthcare delivery. And whether rhetoric is emerging from a political, administrative or provider arena it’s always the same: ‘…healthcare is about the health of all patients not just those who can afford it…’; ‘…value and quality should drive patient services not fee-for-services rendered or bed occupancy’. But in these debates it is hard to see the patient front and centre of the care.
In a recent systematic review of patient centred care and recognition of the concerns of patients in health care decision-making, more than half the studies looked at cancer, end-of-life care or incurable diseases; and patients and researchers alike (largely in Western countries) appeared only to pay attention to care in the face of life’s great certainty: death.
At the other end of the disease spectrum (far away from Western medicine) and focused on communicable rather than non-communicable diseases, patient centred care was found to be less impactful – unless it saved resources. A South African study of multidrug-resistant tuberculosis treatment revealed that a hospitalised model was 42% more costly than a devolved model. Apparently, decentralised or community-based therapy “puts less strain on patients”, though the authors concede it doesn’t fully address the critical non-adherence problem, which showed more than 20% of South African patients default on treatment.
So, if not the patient what then is the centre of healthcare?
The cold, hard truth is that despite our best altruistic attempts we have created a simplistic healthcare model where patients and providers are on the periphery of a system – not dissimilar to Copernicus’ struggle to place the sun, not the earth, at the centre of our orbital system. At worst we are a plentiful commodity circling around our organisational suns. At best, undiscerning consumers who individually and collectively wield little bargaining power.
The real core of healthcare is now the combined, and sometimes competing, gravitational forces of financial, workforce and service resources where cost effectiveness, balanced budgets and medical and nursing shortages are the central concerns.
If we genuinely want to put the patient first we must begin the process of understanding that we (patients and doctors) are in their orbit not the other way round. Once we are comfortable not being at the centre we will be better placed to work out ways to live as the planets do and reap the benefits of our larger powers, rather than manage the lives of dying patients.
The Thinker 
Working in Southern Africa, I find the health services much less patient-centred than UK. At the community clinic where I work, we pay special attention to treating drug resistant tuberculosis, but it is disease-centred, not patient-centred. This is a complicated, difficult disease to treat, using multiple drugs with grim side effects for long periods. It is a source of frustration that the patient isn’t always compliant or adherent. My patients with non-communicable diseases have access to fewer resources in comparison, but they get more patient-centred care because that’s how I was trained.
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Health care is an industry and private providers are in the game for the profit not to altruistically and benevolently improve the health of the community at large. Health promotion, on the other hand, is usually community driven and aimed at reducing the admissions to costly secondary and tertiary government facilities. The patient, or the individual is more often reactionary, rather than proactive and many will view healthcare as remedial, non-discretionary and a consumption of products where their choice is limited by the options presented by their treating practitioner. The patient lacks control and choice in illness treatment and wellness is not sufficiently sexy to make news.
I also consider that there are major failings in the training of a treating practitioners with most being taken into secondary and tertiary environments for their internships rather than primary care. So, as a beginning practitioner, you learn how to rely on sophisticated (and expensive) investigation and treatment modalities before you learn how to engage in primary care and health promotion….turn our training system upside down and we might have a chance of reducing cost and promoting wellness.
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