efficiency vs patient centred care - can we have both?

Having worked in healthcare for nearly 20 years, I recently had the opportunity to be a patient during pregnancy and the birth of my daughter. Let me tell you, it wasn't an entirely positive experience. Going in, I understood that there is strong evidence that when women feel empowered to make decisions in the birthing process, they have a more positive birth experience and are less likely to experience birth trauma. Yet, despite having gone to bat for many patients over the years, I struggled to advocate for myself when I was the patient. The system I encountered was designed to prioritise efficiency over patient-centred care, and in doing so, it failed on both counts. Now that I've had time to reflect on what happened, I'm ready to share what I learned. 

When I got pregnant, I was sceptical about developing a birth plan because my experience led me to believe that having rigid birth plans would set women up to be disappointed rather than empowering them. However, the more I learned about the labour and delivery process, the more I realised having a birth plan was simply a process to help me understand my options and feel empowered to make informed choices at various decision points. So that's what I set out to establish—a flexible plan with informed decisions for several possible scenarios. 

My patient journey began in prenatal clinics, which seemed driven by checklists and relied heavily on templated documentation. The top priority seemed to be fast appointments, which followed a specific script and provided standardised care based on the woman's gestational age. Specifics regarding my health and wishes were absent from the appointment notes I accessed, and obvious cut-and-paste errors in the documentation were not confidence-inspiring. 

Any requests to deviate from the standardised care plan were met with what felt like judgment. At earlier appointments, there was limited interest in a birth plan; I was simply told to bring it to the hospital if I had one. At one of my last prenatal visits, I was asked by the clinician, "Is there anything I would be interested in in your birth plan?" Which seemed like code for "Do you have any weird expectations?" I offered one potential scenario for which I had strong preferences and was told flatly that my preference was not an option as it was inconsistent with hospital policy.

As a result of being told that this hypothetical decision was not an option, when it became a reality, I was taken down a care pathway that was very much not my preference. I engaged with many different clinicians over the next two weeks, and it wasn't until after I had been admitted for two days and received multiple interventions that two exceptional clinicians created space for me to share my experience thus far and took the time to listen to my fears. While I firmly believe in looking at issues from a systems level, I think, in this case, these two individuals positively changed the trajectory of my care. They told me that the original advice I had received was wrong and that patient choice should have been the priority from the start. I'm not sure what would've happened if they had not been working that shift; I doubt I would have had the positive birthing experience I ended up with.

So, how do we balance the genuine need to create efficient healthcare with the equally vital need to ensure clinicians have time to listen and understand the needs of our patients? Patient-centred care can't just be a catchphrase and clearly can't be delivered through a tick-box approach. Clinicians should not have to go out of their way to advocate for their patients and make rare exceptions to provide patient-centred care; rather, our leadership, systems, and processes need to support clinicians to do so.

First, let's look at the impact of leadership. Efficiency is a much easier metric to understand, measure and correlate to budget. To overcome this, healthcare leaders must find meaningful ways to express the value of delivering patient-centred care. Patient surveys and feedback are powerful tools, but so is staff feedback. Several staff I encountered either implied or directly stated that providing me with evidence-based information that was inconsistent with hospital policy would probably "get them in trouble". This negative feedback from leadership fosters a culture where following policy is valued more than providing individualised and appropriate patient care. The behaviour and decisions clinicians make are influenced by what they perceive the organisation to value. So, patient-centred care needs to be recognised and rewarded, not penalised.

Now let's think about the influence of systems, in this case, one of my favourites, the policy system. Our system for developing policies must emphasise the importance of flexibility and support decision-making based on individual rather than population-level risk factors.  Yes, we need systems that prompt clinicians to identify high-risk situations and act accordingly quickly. We also need systems that enable clinicians to be responsive and adapt their care to specific, but perhaps less urgent scenarios. In addition, there needs to be a mechanism to identify when we have policies that contradict one another. In my case, any policy regarding patient-centred care was undermined by the clinical policy that stated all patients should receive specific interventions once they reach a specific gestational age. Ideally, this particular clinical policy would state we offer patients XYZ on these dates of their pregnancy; however, we can provide alternative options and support the patient in making informed choices. At first glance, this seems like an evident decrease in efficiency. However, I argue this is a false economy. Acknowledging that I am only a sample size of one, if we bring this back to my experience, I was hospitalised for multiple days and given treatment that would not have been part of my ideal birth plan. This could have been avoided if we had only a slightly longer, more meaningful conversation in the prenatal clinic rather than my preferences being firmly dismissed. 

Finally, I want to consider a specific process with a significant impact - consent. As clinicians, we can become desensitised to how intimate and invasive the procedures we are performing are, which can spill over into our consent process. I think we can do more to ensure that the consent process is not just a box tick on the way to a planned intervention but that it supports the patient in making an informed choice about their care. In multiple prenatal resources, I encountered BRAIN, a decision-making model to help families ask questions when making decisions during labour and delivery. I am amazed at how simple and effective this tool is, but even more surprised that this is not something clinicians are taught more broadly.

So, I'm curious: how do you balance efficiency and patient preferences in your health service?