Who rules the centre of care? : an institutional ethnography exploring patient experiences within the New Zealand primary care setting : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing, Massey University, Manawatū, New Zealand

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Improving ‘patient experience’ is at the forefront of international quality improvement agendas and is prioritised by dominant frameworks such as the Institute for Healthcare Improvement’s ‘Triple Aim.’ To gather knowledge of this priority measure, New Zealand developed a set of ‘system level measures’ to benchmark and compare data between local, national and international health systems. The primary care patient experience survey, introduced as a system level measure, is purported to measure ‘patient experience.’ The survey produces official reports of a person/patient-centred primary care system. However, the findings in this report differ from what I learned talking with patients about their actual experience. This project uses the tools of institutional ethnography to begin an inquiry from the accounts of patients. To generate these accounts, I asked people about their experience of being a patient (N = 10). The intention is to learn about what patients say, know and do. I then asked seven clinicians (general practitioners, nurse practitioners, and registered nurses) about their experience, again focusing on what they say, know and do. The analysis reveals that some frontline patients and clinicians reported care practices that explicitly challenge their ability to be at or put patients at the centre of care. In some instances, practices purported to enhance person-centred care instead appear to place the person at an even greater distance from the centre, generating new work for patients without a clear benefit for the patient doing such work. Examples investigated include ‘GP triage’ and ‘team-based practice.’ From these findings, I followed what patients and clinicians say, know and do into the institution of primary care. At this level I talked with other key stakeholders of primary care and patient experience; people in management and governance, practice owners, strategy writers, survey writers, and primary care researchers (N = 11). I asked people in these positions about what they say and know, with the intention of using this knowledge to make sense of what can be said and done at the frontline of primary care. I found that standardising practices (e.g. 15 minute appointments, consultations limited to one issue per appointment, fee for service) constrain the clinician (and by proxy the patient) to what can be said and done during an episode of primary care. These practices are powerfully controlled by the private business model of primary care despite significant public funding. I found that patients and clinicians undertake significant workarounds to support care priorities such as continuity of care and timely access to care. Yet, the measurement of the “person-centredness” of primary care (the survey), renders invisible these actions of both patients and clinicians. The implications of these findings suggest that primary care, as it is presently organised, reorganised and protected by its principle protagonists, shifts the work of person-centred practices onto the frontline of primary care. The frontline of primary care is, at present, invisibly attempting to save this system from failure through their best efforts at addressing patient need.
Patient satisfaction, New Zealand, Medical personnel and patient, Primary care (Medicine), Patient-centered health care