Spiritual care is stagnating in general practice: the need to move towards an embedded model

(NON-)EVOLUTION IN THE LITERATURE

Primary health care (PHC) journals have published numerous articles about spirituality and spiritual care since the early 2000s. Illustrating this literature, Anandarajah and Hight present a review and a concrete tool (HOPE questions) for integrating spirituality into medical practice.¹ In turn, Vermandere et al offer a systematic review of qualitative evidence.² They discuss GPs’ perception of their role as spiritual care providers and the factors that facilitate or constrain their practice.² By contrast, Hamilton et al discuss the evidence and ethical issues around the integration of spiritual care into general practice.³

These three review articles address similar themes and share the same definition of spirituality.⁴ They regard GPs’ provision of spiritual care as beneficial in terms of health and whole-person care, a common view in the PHC literature on spirituality. They also identify a set of qualities that may help GPs to address their patients’ spiritual needs — including communication skills, awareness of one’s own spirituality, and a respectful, confidential, and patient-centred approach.

However, the articles highlight some limitations to the provision of spiritual care in general practice. Although several studies have shown positive effects on health and wellbeing, these findings have been called into question by issues of scientific biases, lack of standardised practices and protocols, and inconclusive results. Moreover, GPs might doubt their ability to assess and respond to their patients’ spiritual needs due to a lack of time, information, and specialised training, and a fear that the doctor–patient relationship might be disrupted by a perceived invasion of the patient’s privacy.

The articles propose three ways to directly address these issues: 1) providing GPs with training in the use of structured tools, including scales of spiritual needs assessment such as FICA or HOPE,³ and unstructured tools such as spiritual history;² 2) providing GPs with interdisciplinary training³ and chaplain teaching¹ to gain spiritual care experience and skills; and 3) developing tools to assess the efficiency of spiritual care provision and highlight its relevance.³

Our purpose here is not to debate the evidence or proposed solutions, but to highlight that the three articles illustrate a general lack of evolution in arguments around GPs’ provision of spiritual care. Authors frequently note that more research is needed to identify and evaluate the links between spirituality and health. Consequently, although the literature has reflected an aspiration for spiritual care in general medicine, it has not outlined concrete ways to operationalise it. To develop concrete solutions, we propose to take a step back.

EXISTING MODELS

We have identified four models implicitly used in the literature to make sense of spirituality in general practice. We propose that they can be understood as follows:

SPIRITUALITY AND PRIMARY CARE REFORM

The current package of primary care reform offers great opportunities to embrace spiritual care as benefiting patients’ health and wellbeing, and leading to increased efficiency and effectiveness for the whole health system.⁹

As laid out in the NHS General Practice Forward View,¹⁰ primary care must evolve to meet the challenges of caring for an ageing, multimorbid population. GPs will increasingly work in integrated and multidisciplinary primary care practices, where they will have the opportunity to formulate shared-care plans with other health professionals. The care team approaches patients in a more proactive way — particularly in cases involving the long-term follow-up of patients with chronic diseases, for instance — which eases the integration of spirituality into general practice.

Indeed, because many patients wish to discuss their spiritual needs,¹¹ it becomes GPs’ and health system leaders’ responsibility to consider how to best meet these. We have developed an embedded model that will enable GPs to endorse such responsibilities. In this model, spirituality becomes part of the care plan in a health system, rather than depending on the shared motivation of people interested in spirituality, as in the collaborative model.

WHAT FUTURE?

The embedded model includes spirituality and offers whole-person care, rooted in: 1) a biopsychosocial-spiritual view of the person;¹² 2) the interdisciplinary coordination of interventions; and 3) the integration of care settings, mainly community, hospital, and nursing homes.¹³ This model offers a coordinated care plan of the biopsychosocial-spiritual network, with the GP at its centre.

In the embedded model, spirituality is addressed by spiritual care providers and health professionals, which helps with building care plans that offer a better understanding of the patient, lead to better shared decisions (empowerment and autonomy) and increased resources (coping), and take into account potential suffering (spiritual distress).

We believe that the embedded model will be beneficial because it provides a mechanism to formally collaborate with spiritual care providers and other professionals. This will enable GPs to consider and include spirituality in patient care plans. This might lead to more efficient and compassionate care delivered through well-designed, coordinated interventions that prioritise impacts on patients’ quality of life and avoid unnecessary interventions. Overall, the embedded model guarantees professional medical attention to spirituality and is particularly well suited for an ageing and multimorbid population.

CONCLUSION

It is necessary to conceptualise and implement a model of care that integrates spirituality and takes the patient’s complexity and wholeness into account. In so doing, the embedded model would provide compassionate and optimised care, which would reflect the integration ethos of NHS reform, and would give some answers to GPs as well as care and training institutions faced with ethical issues raised by the dazzling technical advances of medicine.