Abstract
2008 was the year that Barack Obama claimed the intellectual property rights on change. Inevitably, the definition of change depends on who is talking about it. Change in healthcare is frequently discussed but rarely seen. Would we know it if we saw it?
To answer this perplexing question, I asked an international panel of healthcare experts to share with JRSM readers what genuine change in healthcare means to them. Once you've read their views, why not send me yours? You can do it.
In the US: Health as a right for people in the USA would be quite a change; universal access to health care. On a global level: more transparency in research, with trial registration picking up and including outcome registration. And with results of research being published in open access media.
Change in health will be when decisions in global public health will be made: on the basis of need, social justice and equity; by those in the developing world; in international organizations led by the South … and the world actually follows.
Early detection of chronic disabling conditions based on a combination of genetic testing and new imaging techniques. It would be a major step forward if we could treat cancer, Alzheimer's, MS and schizophrenia before clinical symptoms appear.
As far as the NHS is concerned, and with long-term conditions like diabetes uppermost in my mind, I'd like to see a thrust – led by the profession and facilitated by the government – directed to dismantling the boundaries between primary and secondary healthcare and placing patients truly at the centre of care.
Change is change in the way you think.
The advent of quality indices potentially driving commissioning in the NHS is welcome. Clinical engagement in such change, from the shop floor to Darzi, must surely be reason to relish being a clinician in the new NHS.
From health to sickness, person to patient, calm to chaos, freedom to constraint, fear to resilience, cure to comfort, reliance to responsibility, ignorance to wisdom: medicine is change. In clinical ethics, change would be the greater involvement of ethicists in the hospital setting, not as ‘ethics police’ but as partners to clinicians and patients faced with troubling moral issues. Trusts, clinicians and ethicists must have the courage to experiment.
In my last decade and a half in medicine the most fundamental change in healthcare has to be ‘patient-centred care’. The changes in medicine and healthcare in the last decade along with accessibility to information via the Internet and increased expectation of people have resulted in the patient becoming ‘God’ (sorry, cardiologist). This in a way has diluted the control of purist and science but has resulted in greater patient expectation and more responsibility on healthcare professionals to deliver. The downside perhaps could be increased litigation but the upside is more universal standards of healthcare.
World life expectancy increased 25 years since WWII. The rate of increase is 10,000 times greater than before WWII. For every week since 1950, life expectancy has increased by three days. Citizens of the world are healthier now then we have ever been. Virtually all the increase has been due to prevention. Now we must attack non-communicable diseases (NCD). A major change will be the building of a global NCD workforce that is trained not just in the prevention of diabetes or heart disease or cancer, but an NCD prevention attack force. The health glass is half full, and we can continue the upward trajectory of life expectancy and improved health through NCD prevention.
No, we can't.
An end to the ridiculous mismatch which sees medics receive 40 times the career development funding given to nurses. It is nurses who are leading the development of most rapid, cost-effective changes to healthcare practice in the NHS and they should be better supported.
Having results of all clinical trials available on publicly accessible websites … and if that's too radical, then at least all trials about marketed treatments.
President Obama, using healthcare as a social weapon, could contribute towards eliminating health inequalities. Medicine could be his instrument of social change. Can we all work towards tackling world health inequalities by promoting cohesion within our own individual societies? ‘Yes we can.’ Societies can be Obamarised!
Let's stop being afraid of moving to a consumer-focused healthcare system. It's simply inevitable. We need to stop pretending we can deliver everything to everybody for free. But getting efficiency and innovation to reduce costs is vital to drive value. The budget airlines have revolutionized travel – we now need to do the same for health.
My proposals to change medicine and healthcare in India would be:
Increase the current budgetary allocation to public healthcare from 0.9% to 3.0%;
Enforce the rule that all private hospitals which have been sold government land at concessionary rates have at least 20% genuinely free beds;
Make sure all Primary Health Centres are staffed and provided adequate medical supplies. Provide major incentives to those who are willing to work in them for more than two years;
Change the systems of selection and promotion in health institutions to those which are transparent and based on merit rather than political influence;
Take action against doctors who are unethical – take kickbacks, kowtow to politicians and bureaucrats, and those in public hospitals who treat only the rich and powerful while neglecting the poor;
Do more to encourage good treatment, research and publication. Set up an Indian NICE and NIH;
Recognize doctors who are doing genuine good work by giving them national awards or plum jobs rather than those whose only merit is that they are servicing those in power.
Prescribed drugs designed to promote health, relieve pain and save lives are sold to
hundreds of millions annually in dull, plain boxes with only the name of the drug and
information about dosage. Cigarettes, which kill half their long-term users when used as
directed, are sold in carefully researched designer packs crafted to maximize their appeal,
particularly to young smokers ( The appeal of cigarette packets?
A deep change in healthcare would be if it became safe, evidence-based, truly patient-centred and concerned with health rather than disease. We've had the rhetoric for years but never the reality.
Let's change the culture of straw clutching towards evidence in advanced cancer care. During 2008 three endeavours evaluating desperate measures may have helped spare future patients burdensome but unavailing treatments: completing an RCT in mesothelioma surgery, developing an RCT of metastasectomy and reporting NCEPOD's study of near-death chemotherapy.
One of the most genuine changes in medicine and healthcare has been the development of an evidence-based approach to medical decision-making at all levels of health systems: clinical care, management and policies. The next major step will be to make all the new evidence available at point of care (and decision) in a quick and practical way.
We need to re-kindle an appreciation for the human side of our vocation. An empathic ear, a kind word and the gentle reassuring touch from a trusted friend have a healing power that we all-too-often underestimate. For those on the receiving end, however, such qualities may at times be priceless.
New intermediaries – large and small – buy capacity from healthcare providers and sell it through TV, the web and poster campaigns. Using customer recommendations and high profile service awards, thomascookhealth.com gets you into a leading teaching hospital, Abercrombie and Kent lines you up with a specialist in Harley Street while ‘triptothedoctoradvisor’ warns against a local GP.