Person Centred care: an untapped resource to increase patient capacity to manage multimorbidity in the context of poverty?

Problem

Despite significant investment over 20 years, health inequalities have persisted and, sometimes worsened. This is pertinent for multimorbidity (MM), which is more prevalent, and begins earlier, in areas of high socioeconomic deprivation (SED).Person Centred Care (PCC) is a cornerstone of modern healthcare, yet a recent literature review demonstrated the patient voice is (ironically) missing. This is particularly so for socially vulnerable populations. Previous work has suggested PCC is especially important in the context of both MM and SED.We aimed to explore the experience of PCC and its impact, as part of a wider study exploring individual/community factors that influence capacity to manage MM in the context of SED.

Approach

Ethnography conducted within a community experiencing high SED in the West of Scotland over 18 months (142 hours participant observation in four community groups and 25 in-depth interviews with patients with MM). Two participatory workshops and one focus group were conducted towards the end to explore emerging themes, including PCC which emerged strongly as a capacity enabler. Thematic analysis conducted combining all data sources.

Findings

Participants experienced both good and poor care from their GPs, and the wider health service; negative experiences were detrimental to engagement and capacity to manage MM. Effective PCC for the participants required a therapeutic relationship and power sharing. Key to a therapeutic relationship was connection and trust, continuity of care and challenge combined with support. True power sharing was exceptionally beneficial to participants’ wellbeing and capacity to manage MM, but it rarely happened. Power sharing only ever occurred in the context of a strong therapeutic patient-practitioner relationship. Lack of agency in the practitioner relationship, or within the health system, or misunderstandings about illness (of which patient may be unaware) were key barriers to power sharing. In addition, the desire to be a “good patient”, particularly post-pandemic, was a significant barrier.In addition, there was a shared community experience of stigma, and of none of the systems working, which fundamentally altered how people approached all statutory services including health. People responded by getting angry or disengaging - neither of which helped. Good PCC was able to, at least partially, negate these experiences. Where it worked well, primary care shifted to a system that was “for them”.

Consequences

Good PCC in the context of SED and MM is important but often not experienced. It could be critical in enabling patients, improving wellbeing and, if well-resourced, may narrow health inequalities. Further work to understand how true power sharing can occur in this context, and what resource that may require of practitioners is crucial. Research to understand the pressure of “being a good patient”, and its impact on access, particularly in socially vulnerable groups post pandemic, is also required.