PATIENT PARTICIPATION IN GENERAL PRACTICE
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239 psychiatry in a coherent whole. As such it deserves attention and respect. Most of all it requires testing further. RACHMAN and PHILLIPS22 have boldly predicted that "the medical students of the future can be expected to spend less time studying HENRY GRAY on anatomy and more time reading JEFFREY GRAY on fear." " PATIENT PARTICIPATION IN GENERAL PRACTICE ALTHOUGH general practitioners have a reputation for stubborn conservatism, and resisting new ideas as threats to their independence, there is evidence of a change in their outlook. New ideas are appearing more rapidly than ever before in general practice. One of the most recent and most radical is the patient participation group-an idea that has blossomed into a national association and has received the blessing of the Royal College of General Practitioners, which has published a series of essays on the subject.’ The essence of the idea is that a group of patients, representative of the practice as a whole, holds regular meetings with the staff in order to break down the barriers between doctor and patient or, to quote one of the authors, to "improve the closeness offit at the socio-medical interface". To many practitioners, few innovations can ever have seemed so threatening. At worst it summons up the picture of the practice being taken over by an unholy mixture of the most frequent practice attenders, the unhappily married escaping from home, and a task force from the Militant Tendency. Fortunately, it seems it is seldom like that, but awareness of the fear has led many of the contributors to write in the firmly reassuring tones ofa parent coaxing a nervous child into the sea for the first time: be brave, try it and see, you won’t drown. In fact, there may be a greater danger of patient- participation groups degenerating into mutual-esteem meetings, in which practice representation is merely symbolic; for one of the problems is how a group of twenty to thirty in a practice of ten or twelve thousand patients, whether elected or selected, can genuinely represent those in the practice who are least articulate and possibly most in need. This is a familiar problem of democracy, but it has a special significance when the purpose of the groups is-to communicate in both directions. Patients are able to influence practice organisation and voice their complaints, but the groups are also seen as a means towards health education, a stimulus to voluntary care in the community, and a powerful pressure group when the practice petitions authority. No-one could quarrel with any attempt to improve communication between doctor and patient; but some see deeper philosophical and political purposes in patient- participation groups. At one practice (where a notice in the waiting area invites patients to inspect their own notes) there are "weekly workers’ meetings [and] policy is decided at the monthly management collective which is open to all patients, participating as equals with the staff. One author sees the group not only as a means of improved communications but also as having "a role of even deeper significance: it will actually blur the margins between consumers andproviders". Fine as that sounds, it could be argued that relationships are improved by clarifying rather than blurring the margins. 22 Rachman S, Phillips C Psychology and medicine. London: Temple Smith, 1975: 158. 1 Peter Pritchard, ed. Patient participation in general practice. London- Royal College of General Practitioners (occasional paper no. 17), 1981. £2.50 Patient participation has aroused the enthusiasm of those who have instituted such groups; and some of the enthusiasm is about changed attitudes not easily susceptible to measurement. But there is an obvious need for evaluation. One wants to know, for instance, whether these groups have led to real improvements in practice administration and organisation; more important, it should be possible to measure whether they have led to tangible benefits in health education and preventive medicine-whether, for example they reduce the number of consultations for minor self- limiting conditions but increase the number of requests for cervical smears, screening for hypertension, and routine immunisation in those socioeconomic groups in which such requests are traditionally lowest. This would be a stern test, but if patient-participation groups passed it with flying colours they would rid themselves of any suspicion of being no more than a gimmick or passing fashion; instead they might become an established part of primary care. AIDS TO VISION IN Britain nearly three-quarters of the visually disabled people are over the age of 65 years, and most of them have missed out on the technological advances of recent years.’ i Almost all physiological and psychological research into vision is done on young people, often with normal sight, and many of the low-vision aids are of little use to the elderly, for whom poor vision is often not the only handicap. A new W.H.O. booklet, from the Regional Office for Europe,l discusses strategies for the visual rehabilitation of poorly sighted people. Inevitably, in seeking to make research and development recommendations suitable to the many different patterns of health care in Europe, it suffers from too many generalisations-to say nothing of that stiff and forbidding prose that often characterises W.H.O. publications. But it touches interestingly on techniques for enhancing visual stimuli, and on the use of other senses in the retraining of the visual process. It also makes a welcome plea for more perceptive and sensitive measurement of visual acuity and ability than the customary Snellen and reading cards which depend on static high-contrast black-and-white alphanumerics. Such conditions rarely exist in everyday life, especially for the ageing eye, and it is time that acuity under conditions of varying contrast was used more often in assessment, and in the prescription of low-vision aids. More research is also needed into the phase relationships among the spatial-frequency components of visual targets and how these are related to different optical and cerebral conditions. In fact, there is a wealth of new knowledge of the physiology and psychology of vision3 but very little of it has yet been applied to diseased eyes; the booklet cites some new work from West Germany on the use of visual information from apparently totally "blind" fields after cerebrovascular accidents. As regards changes in services, the main recommendation is that each visually disabled person should have early access to a multidisciplinary centre where accurate ophthalmo- logical, optical and psychological assessment may be made and visual retraining and rehabilitation organised. In this respect, as so often before, Scandinavia (especially Norway) seems to have taken a lead. In Britain no-one has even 1. Cullinan TR. Epidemiology of visual disability. Health Service Research Unit report no 28. University of Kent at Canterbury, 1977. 2. Regional Office For Europe. The use of residual vision by visually disabled persons. Report of a W.H.O meeting. Copenhagen: W.H.O , 1981. 3. The psychology of vision. London: The Royal Society, 1980.
Transcript of PATIENT PARTICIPATION IN GENERAL PRACTICE
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psychiatry in a coherent whole. As such it deservesattention and respect. Most of all it requires testingfurther. RACHMAN and PHILLIPS22 have boldlypredicted that "the medical students of the future canbe expected to spend less time studying HENRY GRAYon anatomy and more time reading JEFFREY GRAY onfear." "
PATIENT PARTICIPATION IN GENERAL PRACTICE
ALTHOUGH general practitioners have a reputation forstubborn conservatism, and resisting new ideas as threats totheir independence, there is evidence of a change in theiroutlook. New ideas are appearing more rapidly than everbefore in general practice. One of the most recent and mostradical is the patient participation group-an idea that hasblossomed into a national association and has received the
blessing of the Royal College of General Practitioners, whichhas published a series of essays on the subject.’ The essence ofthe idea is that a group of patients, representative of thepractice as a whole, holds regular meetings with the staff inorder to break down the barriers between doctor and patientor, to quote one of the authors, to "improve the closeness offitat the socio-medical interface". To many practitioners, fewinnovations can ever have seemed so threatening. At worst itsummons up the picture of the practice being taken over by anunholy mixture of the most frequent practice attenders, theunhappily married escaping from home, and a task force fromthe Militant Tendency. Fortunately, it seems it is seldom likethat, but awareness of the fear has led many of thecontributors to write in the firmly reassuring tones ofa parentcoaxing a nervous child into the sea for the first time: bebrave, try it and see, you won’t drown.In fact, there may be a greater danger of patient-
participation groups degenerating into mutual-esteem
meetings, in which practice representation is merelysymbolic; for one of the problems is how a group of twenty tothirty in a practice of ten or twelve thousand patients,whether elected or selected, can genuinely represent those inthe practice who are least articulate and possibly most inneed. This is a familiar problem of democracy, but it has aspecial significance when the purpose of the groups is-tocommunicate in both directions. Patients are able to
influence practice organisation and voice their complaints,but the groups are also seen as a means towards health
education, a stimulus to voluntary care in the community,and a powerful pressure group when the practice petitionsauthority.No-one could quarrel with any attempt to improve
communication between doctor and patient; but some seedeeper philosophical and political purposes in patient-participation groups. At one practice (where a notice in thewaiting area invites patients to inspect their own notes) thereare "weekly workers’ meetings [and] policy is decided at themonthly management collective which is open to all patients,participating as equals with the staff. One author sees thegroup not only as a means of improved communications butalso as having "a role of even deeper significance: it will
actually blur the margins between consumers andproviders".Fine as that sounds, it could be argued that relationships areimproved by clarifying rather than blurring the margins.
22 Rachman S, Phillips C Psychology and medicine. London: Temple Smith, 1975: 158.1 Peter Pritchard, ed. Patient participation in general practice. London- Royal College of
General Practitioners (occasional paper no. 17), 1981. £2.50
Patient participation has aroused the enthusiasm of thosewho have instituted such groups; and some of the enthusiasmis about changed attitudes not easily susceptible to
measurement. But there is an obvious need for evaluation.One wants to know, for instance, whether these groups haveled to real improvements in practice administration andorganisation; more important, it should be possible to
measure whether they have led to tangible benefits in healtheducation and preventive medicine-whether, for examplethey reduce the number of consultations for minor self-limiting conditions but increase the number of requests forcervical smears, screening for hypertension, and routineimmunisation in those socioeconomic groups in which such
requests are traditionally lowest. This would be a stern test,but if patient-participation groups passed it with flyingcolours they would rid themselves of any suspicion of beingno more than a gimmick or passing fashion; instead theymight become an established part of primary care.
AIDS TO VISION
IN Britain nearly three-quarters of the visually disabledpeople are over the age of 65 years, and most of them havemissed out on the technological advances of recent years.’ iAlmost all physiological and psychological research intovision is done on young people, often with normal sight, andmany of the low-vision aids are of little use to the elderly, forwhom poor vision is often not the only handicap. A newW.H.O. booklet, from the Regional Office for Europe,ldiscusses strategies for the visual rehabilitation of poorlysighted people. Inevitably, in seeking to make research anddevelopment recommendations suitable to the manydifferent patterns of health care in Europe, it suffers from toomany generalisations-to say nothing of that stiff and
forbidding prose that often characterises W.H.O.
publications. But it touches interestingly on techniques forenhancing visual stimuli, and on the use of other senses in theretraining of the visual process. It also makes a welcome pleafor more perceptive and sensitive measurement of visualacuity and ability than the customary Snellen and readingcards which depend on static high-contrast black-and-whitealphanumerics. Such conditions rarely exist in everyday life,especially for the ageing eye, and it is time that acuity underconditions of varying contrast was used more often in
assessment, and in the prescription of low-vision aids. Moreresearch is also needed into the phase relationships among thespatial-frequency components of visual targets and how theseare related to different optical and cerebral conditions. In fact,there is a wealth of new knowledge of the physiology andpsychology of vision3 but very little of it has yet been appliedto diseased eyes; the booklet cites some new work from West
Germany on the use of visual information from apparentlytotally "blind" fields after cerebrovascular accidents.As regards changes in services, the main recommendation
is that each visually disabled person should have early accessto a multidisciplinary centre where accurate ophthalmo-logical, optical and psychological assessment may be madeand visual retraining and rehabilitation organised. In thisrespect, as so often before, Scandinavia (especially Norway)seems to have taken a lead. In Britain no-one has even
1. Cullinan TR. Epidemiology of visual disability. Health Service Research Unit reportno 28. University of Kent at Canterbury, 1977.
2. Regional Office For Europe. The use of residual vision by visually disabled persons.Report of a W.H.O meeting. Copenhagen: W.H.O , 1981.
3. The psychology of vision. London: The Royal Society, 1980.
