Wes Streeting the Health Secretary in Westminster has opened up a national conversation about the future of the NHS. He is consulting widely – patients, health care professionals, allied professions, ancillary staff, everybody really, for who is not a stakeholder in the NHS? The consultation will run into the New Year, and lead to the formulation of a ten year plan which will apparently presage the biggest reform of the NHS since its inception in 1948. The NHS is broken. Mr Streeting has suggested that three broad evolutions are necessary. Briefly these are: complete the change of data management systems from analogue to digital, change the focus of health care from treatment to prevention, and change the locus of health care from hospital to community.
Mr Streeting does well to consult. North of the border, I feel a certain detachment from the process, as Health is devolved. Yet the problems up here, much as, by most parameters, the NHS fares rather better in Scotland than in the other nations of the UK, are largely the same. The demand outstrips the supply. In approaching this problem the Health Secretary clearly has some fundamental ideas of his own, but I hope the medical profession in England will be clear, and robust, in providing some leadership. This is what I would say to Mr Streeting:
Analogue to digital, as a plan to save the NHS, we can dismiss immediately, because we have been pursuing this false chimera for the last twenty years, and it has been a disaster. Of course that is not to say that Hi-Tech doesn’t have its uses. You can’t operate an MRI scanner without a lot of computer power. But the invention of the MRI scanner was in response to an investigatory and ultimately a therapeutic need. We needed a technique for imaging that was at once high resolution, non-invasive, and non-toxic. The scanner responded to the clinical need. But Information Technology was thrust upon the NHS, just as it was thrust upon other publically funded bodies such as policing, and education. It was a solution in quest of a problem. Now, in Artificial Intelligence, we see the same phenomenon. AI has its doleful eye upon the ailing NHS. The accumulation of massive amounts of data readily available via hyper-connected systems is the latest NHS panacea. But the NHS needs to do precisely the opposite, and restore the sanctity of the medical consultation, with its inbuilt confidentiality. Most of the time, all the doctor needs in order to make an accurate diagnosis is a quiet room, the skills to take a history and undertake an examination, and some tender loving care. Medicine is an intensely human, one-on-one activity.
Shifting the focus from treatment to prevention sounds very plausible. It is said that we don’t have a National Health Service, but rather a National Disease Service. And prevention is surely better than cure. That’s true, but it is also a truism. You could summarise the whole of preventative medicine on a postcard, or on the back of an envelope:
- Get vaccinated.
- Don’t smoke.
- Don’t drink too much.
- Don’t get overweight.
- Eat a varied diet.
- Get plenty of exercise.
- Get plenty of sleep.
- Switch off all electronic devices as often as possible.
- Be sociable.
- Oh – and whatever else you do, don’t be poor.
To state such recommendations briefly is not to downgrade their importance. They should be known, and understood, across the community. In addition to advice directed at the individual, there should also be a societal conversation about such public health issues as the importance of Health & Safety, the imperative need to adhere to the speed limit on the roads, and the inadvisability of resorting to interpersonal violence. But this is all in the public domain. Doctors and nurses can, and do, make such recommendations, but prevention cannot supplant their essential role of providing care to the sick and needy, by elucidating accurate pathophysiological diagnoses and initiating appropriate treatment plans. Like it or not, bad things do happen.
By contrast, I think the notion of “hospital to community” has merit. The Royal College of General Practice gives the idea broad support, but rightly points out that if General Practice were to take this on, it would need a bigger portion of the health budget. A community-based health service is integral to the nascent idea of a National Care Service. Successive governments have paid lip-service to the notion of an NCS for about a quarter of a century now, but nothing has come of it, undoubtedly because of cost. At the same time, there has been very little discussion about what a community-based health and social care service would look like.
So how about this for a pilot study? Let us consider a community of 10,000 souls. At its heart would be a health centre, with 10 doctors, as well as nursing staff, and various other professions allied to medicine, for example physiotherapy, clinical psychology, and so on. Some people might consider a doctor-patient ratio of 1/1,000 to be “pie in the sky”. Yet suppose you were on a cruise ship carrying 1,000 people. Wouldn’t you want a doctor on board? Or suppose you had a secondary school with a roll of 1,000 pupils. Would you not expect at least one of them to wish to become a doctor? Currently, a doctor might consider a flock of merely 1,000 people to be something of a luxury, but remember the considerable increase in workload that a community-based system would entail. In many ways, moving the hub of medicine from the hospital to the community would mean that primary care doctors would have to adopt some of the attitudes, and work practices, of hospital doctors. First off, doctors would have to take back the responsibility for providing 24 hour care, 7 days a week. With a per capita list of 1,000 patients, they would be unlikely to see more than 100 patients per week. A full time equivalent (FTE) doctor might see, for example, 25 patients on each of four days, be on-call one night per week, and have a non-clinical day following the night on call, for pursuit of special interests, research, administration, or if necessary to catch up on sleep. Such a workload would be sustainable in the long term.
The Health Centre would have an in-patient unit. Actually it would have three in-patient units, comprising a short-stay ward, a care home, and a hospice. Out of hours, the on-call doctor would be responsible for oversight of the units.
These are the beginnings of a model of care. The trouble with political discussion about such issues thus far is that they have been too abstract. How can they be otherwise if the Health Secretary studied History at Cambridge? This is why the medical profession needs to provide leadership.
But how do you fund it? I’ll leave that to Mr Streeting.
jamescalumcampbell 