Happy birthday, NHS. It’s been a year since I last argued for the politics to be taken out of healthcare planning and provision, and today I find myself in a more contemplative mood – why should politicians be the only ones forced to make the hard choices when it comes to healthcare in the UK?
So I’m going to look at the decisions all of us need to take in order to make sure we keep a health service that is fit for the future, and a good place to start is by looking at the emerging realistic medicine agenda. Realistic medicine is born out of studies that suggest modern medicine may be starting to overreach itself and could now be causing levels of hidden harm. Our propensity to provide relief from illness - the theory says - may be leading to endemic over-medication and over-intervention, and now could be the time to say enough is enough.
But what might this mean for you and me? For most of the population, the nearest they may have come to understanding how higher than necessary levels of treatment impact our lives is supporting an elderly relative through countless hospital visits and admissions when we know they’re not going to get better, or seeing a friend faced with a barrage of pills and a complicated dosing regime in order to treat multiple conditions. We may feel reassured that the NHS is doing everything it possibly can for that person, but how many of us have ever thought in the quieter moments: “Is this really the right thing to do? Is this really what they want?”
Realistic medicine’s intent is to create a treatment system whereby care is better connected; is based on shared decision making; and is more directly linked to an individual’s preferences and needs. What is also interesting is that by making these changes, experts hope that this will also enable the NHS to reduce harm and waste; reduce unnecessary variation in practice and outcomes; manage risk better; and create the space and resource to make real improvements to care.
So far, so good: and there is a lot to be said for leaving behind the ‘doctor knows best mentality’ which strips patients of taking any responsibility for their own care. The tricky part lies in all the discussions and decisions that are linked to this – and that means patients and professionals learning that sometimes ‘no’ is the right answer.
In reality, we shouldn’t have our local A&E department when there’s another, better-resourced one nearby. Treatment in the right place at the right time means that politicians and the public have to accept that resources need to be re-directed from over-provision of local services such as A&E or maternity units to well-resourced specialist centres. The vast majority of neighbourhood need is at primary care level – which requires better community-based social care and greater capacity at GP level. This shouldn’t be sacrificed in order to keep an under-used unit open, however significant its emotional resonance might be.
And without wanting to get too personal, the reason we are always tired and don’t feel well may be that we make bad choices. Taking a more hands on approach to preventative healthcare means patients hearing some tough truths from GPs on lifestyle and weight without feeling persecuted for it. And, sometimes, prescribing another blister pack of pills isn’t the right course of action, particularly when about half of us don’t take our prescribed medicines as instructed anyway. GPs and clinicians need to feel that they are working in a system that helps them to help patients, and that fundamental trust and support has to come from both the politicians and the public.
It’s not just individuals who need to change their understanding of the shift in dynamics that realistic medicine brings – companies do as well. Realistic medicine carries an increased focus on prevention, particularly of non communicable diseases like diabetes and heart disease. Companies involved in the production and retail of high fat, salt and sugar products, or alcoholic drinks, need to understand that yesterday’s approach of intermittent government intervention won’t apply any longer. Public health leaders will have a mandate to continually push to shape formulation and retail regulations in order to reduce the opportunity for unhealthy consumer behaviours. Companies are now part of the health agenda, whether they like it or not.
Underlying all of this is the central question – what can we reasonably expect the NHS to provide for us, and what should we take responsibility for ourselves? ‘A pill for every ill’ used to be the common belief, but endemic over-medication is a cultural, not a clinical, approach. America over-medicates more than any country in the world. Whilst the US has clear health challenges, the people there don’t differ from people in, say, the Netherlands, and yet Dutch prescription rates are significantly lower.
If it’s cultural, then it can be changed. If we can change how we relate and react to NHS service delivery, give it a bit more thought and a little less knee-jerk reaction, then maybe we can remind our politicians that there are significant gains to be made by them taking a similar approach. Sometimes more isn’t better. It’s time to get realistic.