Healthcare Reforms

by Richard Veryard

The UK Government recently published a white paper describing a range of proposals designed to improve access to community healthcare services. The intention is to improve healthcare outcomes (including longterm outcomes) for individual patients while reducing the cost pressures on the system as a whole. Proposals include more outreach clinics, a regular healthcare checkup, and “joined-up” care plans.

[Source: BBC News Jan 30th 2006]

The term MOT refers to the regular system of checks required for all cars in the UK.

These proposals appear to shift control of the patient’s healthcare experience closer to the patient, and at first sight might seem to be a sensible and appropriate response to the increasingly asymmetric demand facing the healthcare services.

But not surprisingly, the proposals have had a mixed reaction. One of the concerns is the assumption of triage. If we can separate simple cases from complex ones, then nurses and other professionals can take some responsibility for the simple cases, call in the doctors for medium cases, and send the most complex cases into hospital.

But this focuses the difficulty on the separation of simple from complex in the first place, which is not just an epistemological difficulty (what are the small signs that this might be meningitis or bird flu, rather than just a bad cold) but ontological (whose notion of complexity is to prevail). A nurse or pharmacist may deal with a backache simply as an acute pain; however, a doctor may be able to see the backache as the first symptom of a chronic disability. And a doctor with a longer-term responsibility for a patient may be able to see emerging patterns in the patient’s condition, that might not be adequately recorded in the patient’s health record.

Part of the difficulty is the conflict between the acute and the chronic. Dealing with a chronic condition as a series of acute episodes can be costly and ineffective for the healthcare organization, and typically produces inferior long-term outcomes for the patient. Indeed, acute treatment (such as painkillers) may interfere with (and therefore delay) the diagnosis of a severe chronic condition.

Of course, the doctors sometimes protest too much. They complain indignantly whenever they fear nurses invading their professional territory, but of course a lot of the triage is already done not by nurses and healthcare administrators but by the patients themselves – deciding whether a symptom is disturbing enough to justify seeing the doctor. After all, an unnecessary appointment with a doctor is not just a waste of the doctor’s time, it is also a waste of the patient’s time. Busy people often prefer to take a quick painkiller rather than hang around in a doctor’s waiting room.

And of course doctors are under extreme time pressure: they often spend their time prescribing painkillers and sometimes fail to recognize the chronic conditions. Clearly there’s a problem if the working practices of doctors are not conducive to the effective deployment of their expensive medical skills.

Much of the complexity of healthcare comes from the fact that health is (literally) embodied in the life of the patient; this means that doing healthcare properly means paying attention to the life of the patient. Think of the individual healthcare that a top sportsman gets – with every minor sprain carefully examined for its potential effect on sporting performance, and every medication assessed for its effect on energy levels.

But this is often the problem with asymmetric demand – a small number of highly privileged customers get an individually customized service, and everyone else has to accept a one-size-fits-all solution. Is there a way in which highly flexible and customizable long-term healthcare services can be made available to everyone, at a reasonable cost?

Oh yeah, technology. Health 2.0.

Taking power to the edge is difficult and fraught with resistance. The latest UK proposals are merely the latest in a series of similar proposals, going back over thirty years. BBC reporter Nick Triggle complains of Deja Vu, and lists some of the repeating initiatives from 1976 onwards.

Clearly, every reorganization has its perceived winners and losers. In an organization as political (small p) as the UK health service, every reorganization turns into a major battle about the control of healthcare. There is a legacy of suspicion and cynicism, sometimes interpreted as an institutional defence against anxiety. The centre talks about empowering the edge, while at the same time imposing further centralizing controls.

Is there any difference this time around?

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