Patient preference and choice
One issue often raised when considering implementing a standardised system of care is that it takes little account of the preferences, needs and wishes of individual patients, and primary care has long prided itself in being focussed on exactly these issues.
However, there is room for patient choice within the proposed enhanced care model.
Patients may make choices within steps. For example, when patients enter step 2, they may choose from a number of equivalent interventions, such as guided self-help, exercise on prescription, and computerised therapy, dependant on what is available locally. Patients entering case management can choose whether or not to have a combination of medication and psychological interventions, or medication or psychological interventions alone.
Patients may also be able to choose between steps, and choose to bypass lower level steps, if there is a good reason that they are inappropriate.
However, it is important that patients’ decisions are made on the basis of good information. Patients who initiate treatment for depression should be offered information on the services currently available within the enhanced service, as discussed in the section on patient assessment. Patients’ treatment preferences should be part of the initial assessment, and patients should also be encouraged to discuss their evolving treatment preferences with the case manager or primary care clinician during treatment.