Sunday, 2 September 2012

The imperative for change

Mark Porter (the new Chair of the BMA council) has been counselling against the impact of rationing on the quality of health care provided by the NHS.

From this article in The Guardian (, the rub of his argument would seem to centre on the impact that the shrinking of the services offered by the NHS would have on patients, and also the impact of undermining the clinical autonomy of doctors, GPs, in particular.

These two lines of argument may have merit. But they are worthy of deeper scrutiny, as they are built on assumptions that you may well not share.

To take the issue of the range of services and procedures offered by the NHS first, can we make the assumption that everything we offer to patients is worthwhile, cost-effective and necessary? Can we assume that all the tests we order on patients are indicated by their clinical presentation, and that all the referrals made to hospital needed in order to come to a satisfactory resolution of a patient’s spectrum of symptoms?

As doctors, we like to think that we do a good job for all of our patients, and we are quite good at presenting an argument in favour of doing an extra test. Some tests, particularly routine blood tests, become almost a reflex. Furthermore, we are never given a breakdown of the amount of money that we spend as doctors on the tests we order, and we are never expected to correlate our practice with our outcomes.

I definitely agree that if a patient needs a test, appointment or treatment for the condition that they present with, then it should be done. However, we must acknowledge that in a system that has hitherto asked from us no justification for the tests and treatments that we do carry out, there is almost certainly scope for tightening up practice a great deal. I am certain that with a little help, I could offer patients the same level of care and clinical outcomes, and spend less money. Perhaps, even by doing less, my patients would do better, shieded as they would be from the pitfalls of iatrogenesis.

For too long, clinical judgement has been the mask behind which doctors hide in order to justify clinical decisions that have no empirical basis. I acknowledge that for much of what we do, there is no clear evidence base, and we must call upon our collective experience and best understanding of the underlying science to guide what we do. There is often a high level of best intention that guides what we do. I also acknowledge that sometimes, your experience tells you to do something, even if you can’t clearly articulate why. The danger in this situation is that sometimes your gut feeling is the manifestation of your accumulated experience of similar cases, and on other occasions it is the manifestation of habit. Too often, our actions if life, and medicine in particular, are guided by the way we have done things in the past.

Furthermore, in every health service some value judgement needs to be made about the services we offer. Implicit in a nationally funded health service is the utilitarian idea that it will do the most good for the most number of people, but that in striving to achieve such a goal, it will not be able to do everything for everyone.

Over the last few years, it seems as if the focus of health care rationing has been on newer, more expensive therapies, often with marginal benefit - drugs for advanced cancers that improve survival for a few months, or drugs for dementia, that delay disease progression for 6 months. These are emotive situations, at the margins of what medicine can offer, and the whys and wherefores of engaging in expensive, and often toxic, regimens that confer little or no benefit can be difficult discussions to have.

However, the pressure placed on therapies at the fringes is heightened by the spending on traditional mainstream treatments, that have survived too long without being questioned. By saving money on treatments that we have offered on the basis of tradition rather than clinical utility, means that the money runs out before we get to budgeting for newer, more speculative therapies at the forefront of medical science.

A discussion about what should and shouldn’t be offered on the NHS is always divisive and emotive, but it needs to be done, with honesty, transparency, and with clear agreement on what the goals are. How would people feel if they knew that by not offering routine varicose vein stripping, the NHS could invest more in offering more advanced therapies for life-threatening illnesses, for example?

The current reform of the health service is overshadowed by politics, but beneath all of the manoeuvering, there is a real imperative: the future of comprehensive health care is dependent on our ability to spend the money we have more efficiently, and more effectively.

The risk of the current reforms is that healthcare becomes fragmented, restricted and profit driven. The opportunity is that healthcare becomes better coordinated and more effective. I am uncertain as to which way it will go, but that does not dent my certainty that the NHS needs to change.

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