Patient empowerment, an additional characteristic of the European definitions of general practice/family medicine

Abstract

Growing evidence supports the inclusion of patient empowerment as a key ingredient of care for patients with chronic conditions. In recent years, several studies based on patient empowerment, have been carried out in different European countries in the context of general practice and primary care to improve management of chronic diseases. These studies have shown good results of the care model, increasing patient and health professionals’ satisfaction, adherence to guidelines and to treatment, and improving clinical outcomes. In 2011, the Wonca European Council included as the twelfth characteristic of the European definitions of general practice/family medicine: ‘promote patient empowerment’. The aim of this paper is to clarify the meaning of 'patient empowerment’ and to explain why family medicine should be considered the most suitable setting to promote it. The inclusion of patient empowerment as one of the essential characteristics of general practice fills a conceptual gap and clearly suggests to the European health care systems a tested model to face chronic diseases: involving and empowering patients in managing their own conditions to improve health and well-being.

Keywords::

• patient empowerment
• general practice
• chronic diseases
• self-management

KEY MESSAGE:

• Patient empowerment is essential in managing chronic conditions

• Family medicine is the most suitable setting to promote patient empowerment

• Patient empowerment is an essential characteristic of general practice/family medicine

INTRODUCTION

At the annual meeting held in Warsaw in September 2011, the European Council of Wonca approved the decision to include in the definitions of general practice/ family medicine a twelfth characteristic concerning patient empowerment. The Italian delegation had proposed to amend the definition in 2006, based on literature and experiences carried out mainly in the United States. The suggestion of ‘integrating patient empowerment as an essential characteristic of the discipline of general practice/family medicine’ was explained in a paper published in 2008 in the European Journal of General Practice, illustrating the concept of empowerment, revising scientific literature, and comparing it with the characteristics of family medicine (1).

In recent years, several projects based on patient empowerment, have been carried out in different European countries to improve management of chronic conditions. A few examples are Project Leonardo (2) and Project Raffaello in Italy (3), Diabetes Project Leuven in Belgium (4), Ready to Act in Denmark (5), Birmingham Ownhealth (6) in the UK, and TERVA Project (7) in Finland.

All cited studies, carried out in the setting of general practice, demonstrated good results of the care model, increasing patient and health professionals’ satisfaction, better adherence to guidelines and to treatment, and improving clinical outcomes. Recently, in the Apulia Region, in Italy, a care model for chronic diseases has been implemented in primary care, based on health professionals’ integration and patient empowerment (the Nardino Program) (8).

THE DEFINITION OF THE TERM EMPOWERMENT

The term ‘empowerment’ has been defined by the community psychologist Julien Rappaport as ‘a process by which people gain mastery over their lives’ (9). Feste and Anderson, referring specifically to health, affirm that empowerment is ‘an educational process designed to help patients develop the knowledge, skills, attitudes, and degree of self-awareness necessary to assume effectively responsibility for their health-related decision (10).’

The idea of empowerment was first introduced in the 1960s by the Brazilian pedagogue Paulo Freire. He distinguished two basic methodologies of education: the ‘banking approach’ and the ‘problem posing approach’ (11). In the ‘banking approach,’ teachers deposit a body of information into basic learners, who have a passive role in the educational process. In the ‘problem-posing approach’, teachers relate to learners as equals. They act as facilitators helping them analyse their own situation and experience and create their own plans of action. When people identify a situation, they react in accordance to what they understand. The reaction corresponds to their level of comprehension: if the comprehension is critical, or predominantly critical, the action will also be critical and aware (Table 1) (12).

Table 1. Freire's types of consciousness: A three stage empowerment model (1).

Types of consciousness	Natural consciousness	Magical consciousness	Critical consciousness
Empowerment stage
Awareness	Understands facts and their obvious cause at ‘face value’	Accepts facts as presented, and without question	Understands that clarity about facts requires a logical process
Response to facts	Free to interpret facts as he or she thinks or believes is best	Assumes that facts are derived from a superior, pre-eminent power	Motivated to take action to manage facts or problems
Impact on action	Judges oneself to be ‘above the facts’ and impermeable to challenge situated outside particular basic needs	Lacks personal power to effect change—more likely to develop a fatalistic view	Open to on-going testing to verify, revise, or reconstruct facts

An empowerment approach and self-management education aim to help patients in gaining some knowledge about their disease as well as to increase their self-confidence to face the disease to apply the acquired information. Since chronic diseases change over time, Kate Lorig maintains that only a patient who lives with his illness every day knows its effects and how it impacts on his life. By observing the course of the disease and reporting accurately to their healthcare providers, patients offer information that is essential to face their condition (13).

The empowerment approach benefits by a narrative approach that links process to practice and attends to the voices of the patients (9). Educational processes aimed at patient empowerment should be tailored to the individual, taking into account age, culture, health status, social and family environment, needs and expectations, in a holistic approach. A therapeutic relationship and continuous support of the patient are crucial to create a partnership with the patient, specifically concerning long-term behavioural changes (14).

In fact, the patient with one or more chronic conditions is the real master of his own health and well-being. He decides about his lifestyle, physical activity, diet, taking medicines, and integrates external information to his attitude, culture and expectations. Ultimately, the problem is not ‘if’ patients manage their diseases, but ‘how’ they manage them. Family medicine is in a strategic position to help patients increase their ability and self-confidence in managing chronic conditions, and in acquiring a critical consciousness according to Paulo Freire's suggestion.

THE EUROPEAN DEFINITIONS OF GENERAL PRACTICE/FAMILY MEDICINE

In 2002, Wonca Europe issued the European Definition of General Practice/Family Medicine, describing its essential characteristics and tasks, regardless of the organization of the health systems (15). In 2005, the definition was revised by a working party of the EURACT Council to improve their clarity. These definitions guide and are reflected in the development of related agendas for teaching, research and quality improvement, and are a reference for European health institutions as well as general practices. In many European countries, the essential elements of the discipline are included in laws and national agreements.

While the 2002–2005 definitions of general practice/ family medicine do not make specific reference to promoting patient empowerment, a review of the eleven characteristics show that they relate to this concept directly or indirectly. Though patient empowerment overlaps with features of other disciplines, like few other characteristics of general practice, literature and experiences show that family medicine is the most suitable setting to promote patient empowerment, for person-centred and holistic approach, collaborative care, longitudinal and continuous relationship based on trust, management of illnesses and risk factors at their initial stage (Table 2). Furthermore, family medicine, because of its widespread distribution, can ensure the generalization of empowerment-oriented care and self-management education to the totality of patients and communities, according to the principle of equity of the European national health systems.

Table 2. Incorporating empowerment into the definition of general practice/family medicine (1).

Characteristics of general practice/family medicine	Evidence/benefits of patient empowerment and self-management education
(a) Is normally the point of first contact within the health care system, providing open and unlimited access to its users, dealing with all health problems regardless of the age, sex, or any other characteristic of the person concerned	• Patients have a point of reference for health problems, a ‘medical home’• Patients are more comfortable and proactive about contacting their doctor (13)
(b) Makes efficient use of healthcare resources through coordinating care, working with other professionals in the primary care setting, and by managing the interface with other specialities taking an advocacy role for the patient when needed	• Patients are actively involved in coordinated care, taking part as team members regarding their own care (17)• Patient/provider partnership allows for better assessment, more appropriate referrals (18)
(c) Develops a person-centred approach, orientated to the individual, his or her family, and their community	• Patients are viewed as experts on the impact of their illness have on their life, their family, and their situation (19)
	• Patient-centred education addresses individual needs (20)
(d) Has a unique consultation process, which establishes a relationship over time, through effective communication between doctor and patient	• Enhanced communication through consistent, ongoing care relationship (10)
	• Partnership offers the opportunity for patients to become active in managing their health (21).
(e) Is responsible for the provision of longitudinal continuity of care as determined by needs of the patient	• Provision of care is based on the specific needs of the patients (22)
	• Care is on-going, individualized, and responsive to specific needs over the entire course of the illness
(f) Has a specific decision making process determined by the prevalence and incidence of illness in the community	• Patients are more aware of opportunities to participate in decision-making with their doctors (20)
(g) Manages simultaneously both acute and chronic health problems of individual patients	• Comprehensive approach and good management of chronic conditions requires attention to any acute healthcare problem (22)
(h) Manages illness, which presents in an undifferentiated way at an early stage in its development, which may require urgent intervention	• As a philosophy of care, empowerment offers patients support for coping with all aspects of their health
	• Empowerment can be applied at the earliest stage of a disease and be incorporated into primary, secondary, and tertiary prevention practices (20)
(i) Promotes health and well-being both by appropriate and effective intervention	• Patients are able to participate in care planning because they have awareness of the disease and treatment options (effectiveness and appropriateness)
	• Patients are aware of the rationale, timing and expected results of treatment choices based on evidence-based guidelines (23)
(j) Has a specific responsibility for health of the community	• Applicable to individuals, groups, and communities (9)
(k) Deals with health problems in their physical, psychological, social, cultural and existential dimensions	• A holistic approach empowering patients to recognize three key components involved in living with a chronic condition—medical, behavioural, and emotional management (20).

IMPLICATION

The inclusion of patient empowerment as one of the essential characteristics of general practice fills a conceptual gap and clearly suggests to the European health care systems a tested model to face chronic diseases: involving and empowering patients in managing their own conditions to improve health and well-being (16).

Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.