Clare's patient policies

Medical Matters:Following his untimely death, much has been said about the enormous contribution Anthony Clare made as a writer and broadcaster. In particular, his role in bringing psychiatry out from behind the hospital wall and into mainstream society cannot be overstated.

But Prof Clare was also a practising clinician. When he made the decision to withdraw from media work and public life, part of the next phase of his life, as he saw it, was to devote more energy to clinical work.

Moving from St Patrick's Hospital to the geographically separate unit at St Edmundsbury, Lucan, gave him the opportunity to develop a different form of psychiatry - one that emphasised a broad multidisciplinary approach with a reduced reliance on medication. Whereas psychiatry had traditionally adopted a symptom-based diagnostic method leading to a specific (often pharmacological) treatment, Clare decided to work towards a system based on "treating the problem rather than the diagnosis".

Those he looked after in recent years recall someone who always treated them as equal. Patients were struck by his kindness and genuine empathy, delivered in a refreshing no-nonsense style. Crucially, he did not induce dependence in his patients; rather, his method was to facilitate and enable people to plot a path to recovery, appropriate to each individual.

As you might expect from someone who was superbly tuned to the zeitgeist, he was responding to a societal mood change that clearly wanted more patient involvement in decision-making. Anthony Clare was sensitive to the need to move forward to a more equal partnership.

While there is a clear ethical, political and scientific basis for moving in this direction, it remains a challenge in practice. And there are critics who dismiss talk of patient-centred care as an over-emphasis on the "touchy-feely" aspect of healthcare, while questioning its relevance to the search for excellence in clinical medicine.

There is substantial evidence that encouraging self-care and engaging patients in treatment decisions can lead to better health outcomes. Angela Coulter, the chief executive of Picker Institute Europe, an independent organisation specialising in measuring patients' experience of healthcare, is an enthusiastic advocate of involving patients in the clinical process.

In recent contributions to medical literature, she has argued that strengthening patients' engagement works. When we as patients are active participants in a shared decision-making process, we have a better knowledge of treatment options and more realistic perceptions of likely treatment effects. The choices we make are also more likely to reflect our preferences and attitudes to risk, which in turn increase the likelihood that we will stick to the treatment we have agreed to. Of course, not everyone wants to participate in decision making to the same degree; one of the challenges for doctors is how to predict what role patients want to play.

A study published in the October issue of the British Journal of General Practice found that GPs' perceptions of their patients' desire to be involved in decisions about medicines are inaccurate in most cases. Doctors are more likely to underestimate patients' preferred level of involvement when seeing new patients. A separate study found that 60 per cent of patients were happy with their level of involvement. However, 25 per cent of patients had a less active role, while 15 per cent had a more active role than they preferred.

Clearly, this is a tricky area and one that needs further research and, most importantly, public debate. It is unlikely that a "one size fits all" solution will be found.

But the provision of sufficient and appropriate information is a first step. And health literacy is fundamental to patient engagement.

I certainly learned this lesson during my early years in independent practice. Providing healthcare to poorer patients living in deprived circumstances is a challenge at the best of times, but when people cannot process and understand health information, it makes it very difficult for them to look after themselves.

After a year or so in the practice, I became concerned at the number of young women who, despite taking the contraceptive pill, still became pregnant. While theoretically 99 per cent effective, the various brands I prescribed at the time seemed to fall well below this level of effectiveness.

Eventually, the penny dropped. Despite my exhortations to read the patient information leaflet inside the pill packet, very few responded with questions. Why? Because most had quite low levels of literacy which prevented them absorbing the information put at their disposal by the manufacturers.

No matter how much they wanted to, these women could not fully participate in shared decision-making. It was a salutary lesson in the need for a well-resourced and multidisciplinary approach in order to facilitate people's involvement in their health.

As much as Anthony Clare made psychiatry more accessible during his lifetime, there is still much to be done if medicine is to offer a true partnership to patients.

Dr Houston is happy to hear from readers at mhouston@irish-times.ie but regrets he is unable to respond to individual medical queries.