‘It takes three to tango’:: a framework for understanding patient partnership in paediatric clinics
Introduction
The notion of partnership between patients and their doctors has increasingly been advocated in health policy circles in the UK in recent times and is now a key element of the present Labour government's modernisation agenda. It seems to be assumed that it is equally relevant to all patient groups and that its desirability should be accepted as a matter of course. Yet little is known about the relevance and practicality of achieving partnership in health care. In particular, little attention has been given to the differing age groups, including children, who may be involved in health-care partnerships, and what this might mean for routine clinical encounters. This paper sets out a framework for developing empirical work to explore assumptions about partnership in health care, especially in the context of paediatrics.
The paper starts by outlining the basic ideas involved in partnership that have been advocated in policy and academic circles in the UK in recent years and then considers their applicability to children. The work of Charles et al. on decision making and partnership is given particular attention as it provides some useful suggestions for developing a framework for analysis. However, we take a broader view of partnership which goes beyond decision making in the clinic.
Several steps are then taken in developing our own framework for analysis. First, it is argued that the potential for partnership between child patients and their doctors is shaped by the organisational and legal setting that creates boundaries for the consultation. This may either promote or restrict the fostering of partnership in health care. Second, the differing perspectives that the three parties involved—child, doctor and parent—bring to the clinical encounter are considered. Clearly, partnership involves at least a degree of agreement, or at least mutual respect for the different ‘agendas’ that each may have. The process of reconciling these agendas is likely to influence the dynamics of the triadic relationship in the consulting room and the coalitions that might be generated. The idea of coalitions in the face-to-face consultation forms the third part of the framework. This approach to analysing partnership in paediatrics, and whether it is accomplished between child patient, parent and doctor, is thus contingent on paying attention to a number of contextual and interactional factors that need to be established empirically. Partnership may be achieved (or not) as the result of factors outside of the consultation and the dynamics of interactions inside it. The methodological issues involved in understanding the process of accomplishing partnership with children are explored in the final section.
Section snippets
Ideas about partnership
The details of what partnership is and what it involves are still under negotiation, but this has not stopped it becoming a vogue word in UK policy circles. The Department of Health (1999), for example, has suggested in its circular ‘Public Involvement in the New NHS’, that it involves at least four elements. First, it is noted that people want more information about their health and illness, and they want it contextualised to their particular circumstances. Second, it is suggested that
The organisational and legal setting
It has long been recognised that formal relationships in health-care organisations, and their legal underpinnings (Dingwall, 1994), establish the boundaries for legitimate behaviour and influence the content of social interaction, independently of the characteristics and perspectives of the individual participants (Freidson, 1970). Strong (1979) took this as the starting point for his comparative study of paediatric clinics in the UK and USA. He found that while there was a certain continuity
Participants in the paediatric consultation
Moving from the organisational and legal setting to that of the consultation itself, the assessment of the opportunities for partnership with children is the realisation that shared decision making in the paediatric consultation may well be between more than the physician and patient, as noted above (see also Dixon Woods, Young, & Heney, 1999). As Charles et al. (1997: 285) acknowledge in relation to another patient group to which this also applies—the elderly—decisions in health care may well
It takes three to tango in paediatrics
The above discussion of the perspectives of parent, doctor and child highlight the ways in which each actor in the paediatric consultation brings certain assumptions and experiences to the consultation which have a bearing on the accomplishment of partnership. In the clinic encounter these perspectives, along with the power differential between the actors and the organisational and legal setting, shape what is achievable. Parents, for example, may fulfil the role of ‘information gatherer’,
Methodological issues
So far we have discussed different aspects of partnership and then suggested a framework for exploring the limits and possibilities for partnership with children in paediatric clinics. This framework incorporates factors outside and inside the clinical encounter. If we are to test the value of such a framework in relation to children, however, we need to confront the basic problem of how to go about conducting research with this particular social group. What special issues, if any, does
Conclusion
In this paper we have considered ideas surrounding partnership in health and noted the general lack of consideration given to children. Whilst existing approaches highlight some of the dimensions of partnership they fail to provide an adequate basis for understanding the constraints and opportunities for partnership in paediatric clinics. Our paper offers a framework for exploring partnership, focusing on three elements: (i) the significance of the organisational and legal setting; (ii) the
Acknowledgements
We should like to thank Mildred Blaxter and the three anonymous referees of the journal for their comments on previous drafts of this paper.
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