Long read
Shared responsibility for health:
the cultural change we need
We believe that the relationship between the public and the NHS, and between patients and the staff who care for them, needs to be transformed. As well as ensuring that the resources (funding and workforce) needed to deliver care are available, national and local leaders must work to fully engage patients and the public in improving health and care.
Comments
ncbi.nlm.nih.gov/pmc/articles/PMC2648935/
Other assumptions that having small independent contractors providing less efficient are also not supported by evidence. The opposite, they produce better value for money.
ncbi.nlm.nih.gov/pmc/articles/PMC1927089/
Most of the variation in emergency admission rates can be explained by patient deprivation and age profile. These are not under control of the GP. Quality of care as measured under QOF has so far only shown to be a minor factor in comparison to deprivation.
journals.lww.com/ambulatorycaremanagement/Abstract/2008/07000/Quality_of_Primary_Care_and_Hospital_Admissions.7.aspx
In preparation for this I have been reading your recent paper - Transforming The Delivery Of Health And Social Care.
There are however two omissions and a general statement (About Care in Torbay) which mar this otherwise excellent paper.
(1) Increase in number of young people with learning disabilities (Pages 9&10) The figures given by the paper seem to take no account of the rapid increase in life expectancy of people in this catagory, or the subsequent increase in age of parents who are providing care. Problems connected with these two factors are very apparent to to a voluntary support agency such as Torbay Mencap.
(2) The approach developed in Torbay (page 21). We would recommend that before printing comments such as this you should take the advice which runs through the paper and seek
partisipent comment. The joint Health/LA Care Trust is regarded by many of its users as distinctly a "Curates Egg". The joint provision model ,excellent in theory has proved in practice to be problimatic for many people with learning disabilities and families providing care for them. The pace and scope of change has been rapid and for many uncomfortable and negative. In a short comment such as this it is not possible to give a detailed resume but Torbay Mencap would be happy to provide an accurate summary for interested parties.
What appears to be lacking in the analysis is an understanding of the social context in which health care services are operating in the UK at this particular point in time. The long term conditions and the altered demographics highlighted are indeed realities, but it is also a reality that the conception of the NHS as a health service, funded through taxation, accessible to all is no longer a belief necessarily shared by all of our public and perhaps more importantly by those who may have to contribute more towards the welfare and well being of others. A socialist ideal is unlikely to be supported by an individualistic, materialistic and self interested society. Indeed one can argue that many of the 'social inequalities' are in part a product of the very choices we as a society have made, the values that we have, the financial and economic inequalities that we are prepared to tolerate. It is perhaps why inequalities are high in countries like the USA with the UK arguably falling into a similar pattern.
The second issue is perhaps more to do with the suggestions that somehow one can take out something from Sweden and transplant it in the UK without the Swedish context to make it successful. Britain is not Sweden and its society most certainly is not Swedish even remotely in its outlook. A society that believes to an extent in egalitarian principles cannot be reasonably compared to one that sees the pursuit of wealth as 'aspirational'. An example of this unchallenged assumption of decontextualised reproducibility is the British railway system arguably one of the worst in the more prosperous countries of Europe. Now many of them have private railways, which run successfully. However, in Britain the trains are overpriced and pretty rubbish in comparison.
The suggestion of the embracing of technology by Banks has to be a tongue in cheek comment and not because the situation that banks find themselves in. Some of us do remember that very ambitious ill fated project NPfIT that crumbled under its own weight. The NHS was trying to embrace new technological advances. It just didn't quite manage.
Another assumption is that armed with information people will do what they should as understood by scientists and government officials. Smoking rates went down after smoking cessation treatments were offered in conjunction with significant changes in legislation. People knew that smoking was harmful but it took more than that for things to change. Obesity is another example. Allowing the spread of inappropriate foods (Burger chains in hospitals e.g.) and then hoping that people will eat vegetables might be close to the limits of optimism. The suggestion that people will just look after their health is not necessarily borne out of robust evidence. It is a nice thought though.
A couple of suggestions; it might be a good starting point to ask what sort of society do we wish to live in. What are our priorities as a society and what price are we prepared to pay for them. The discussion might include do we want a nuclear deterrent or.....Another question might be to ask what sort of services should the be provided through general taxation. This myth needs to be challenged that all is free as it is not. Some people pay for their prescriptions some don't. Certain treatments are refused on the grounds of cost-benefits and contrary to popular myth people can't demand what they feel is necessary, despite successive governments creating this impression.
Then the idea that suggesting that integration is a good idea, when everything is geared up to ensure fragmentation might be taken as ambivalence by some but outright hypocrisy by most on behalf of governments who may not wish to take difficult decisions. Then there are too many vested interests. The BMA laments the privatisation of the NHS, yet GP surgeries are perhaps best regarded as regional monopoly businesses. The pharma industry has become the big whipping boys of our era but hospital consultants and senior managers at the Department of Health and other bodies also have huge vested interests, not just in terms of their fairly inflated salaries but also in terms of the revolving door of lucrative advisory assignments and potential non-executive directorships, arguably means of buying insider influence.
So I would suggest that the analysis of health care needs to go beyond the usual bounds of health, social care, demographics and management and move into a more socio-cultural mode of analysis to decide what change to aim for and how to achieve that.
One of the 5 “aims” of the new commissioning approach is to prevent premature death – but there is no definition of what is meant by “premature”.
As a cardiac surgeon it is increasingly common for me to be asked to operate on someone in their mid 80s (and so has already lived beyond their “life expectancy”) who has a good quality of life with minimal angina, for “prognostic reasons” because a myocardial perfusion scan has shown some ischaemia. Is this preventing premature death? Or older patients being referred for heart transplantation or even mechanical circulatory assist devices (to prolong the act of dying).
We (not only cardiologists and cardiac surgeons) seem to have become lost in what we are trying to achieve with healthcare. It seems that patients are no longer allowed to die naturally without some form of intervention. Death is no longer an acceptable outcome.
Healthcare as we know and practice it in the UK is, as this report indicates, out of date scientifically and economically.
Even the way new ideas and approaches are researched and tested is out of date: driven by economic silos rather than cross-organisational, cross-sectoral, or even cross cultural approaches to R&D.
My personal commitment is to support better leadership - in the NHS and elsewhere - as I believe that transformation starts with each one of us. I'm not referring to position or profession: we're all taxpayers and it's our financial contributions that are being spent (nay, wasted) here.
It takes courage and determination to transform services - as well as the vision to see that there are many better ways and new possibilities.
I believe that we can create affordable health services, free at the point of delivery - globally - given sufficient courage and determination.
As the Huffington Post blogger, Mitch Ditkoff, says "If not YOU, who? If not NOW, when?"
How do we get the people with the Power to give the people with the Ability the Tools, Time, and Motives they need to make the required changes?
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