JRSM >
Volume 94, Number 11 >
Pp. 559-562
Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
Correspondence to: Professor R J Lilford E-mail: r.j.lilford{at}bham.ac.uk
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The increasingly corporate nature of medical practice
There is another less widely recognized but more pervasive change in
healthcare. Even twenty years ago, the (admittedly implicit) contract between
patient and doctor was entirely personal. When the first author came to this
country in 1979, hospital administrators were loath to remonstrate with
consultants over the length of their waiting lists. Indeed, when an
administrator suggested that an established consultant should offer patients
who had been waiting for more than two years the opportunity to have their
operation under the care of a newly appointed colleague, he received a very
dusty answer. Today, waiting lists are seen as a corporate responsibility, and
managers' intervention in long waits is part of their performance review
function. In many countries, most notably the United States, the increasing
costs of medical care (driven largely by technology and subspecialization)
have also required concerted ‘organizational’ responses—for
example, the introduction of diagnostic related groups and the rise in health
maintenance organizations. Along with an increase in corporatism there has
been a fragmentation of the medical function, creating important tension
within the system.
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Interprofessional relationships
New tensions have been created not only at the interface between
professional and client but also between professions. As care becomes more
fractured, so more professions have come to play decision-making and
technologically sophisticated roles in patient care. Nurses, for example,
perform lifesaving interventions such as defibrillation and diagnostic
techniques such as endoscopy. Their increased responsibility and role in
decision-making is reflected in nurse prescribing and nurse-led clinics. At
the same time, many professions have sought to challenge the dominant status
of medicine and argued that they are equipped to give certain aspects of care
in better or more cost-effective ways. The maternity services, for example,
have seen a reawakening of old tensions between obstetricians and
midwives.
Why are doctors unhappy?
It is easy to think that problems are unique to our times, but the morale
of doctors does seem exceptionally low and we argue that their unhappiness is
linked with loss of power both at the level of the individual patient and at
the level of service organization. A large body of research shows that
unhappiness, stress and consequent ill-health are associated with a feeling of
loss of control over work for which the employee will nevertheless be held to
account. This discovery—of the harmful effects of ‘responsibility
without power’—was a principal finding of the Whitehall II
study3. Doctors are
increasingly the targets of complaints and rhetorical abuse, while exercising
progressively less control over the source of criticism. To make matters
worse, medical technology has outgrown the capacity of even the most generous
funders, and doctors often find themselves at the sharp end of rationing
decisions. Issues of the funding of care have increasingly been dealt with in
settings distant from most doctors, and their opportunities to influence these
decisions have declined.
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The ‘consultation’ as central component of health
practice
It would be wrong to think that, as medicine loses its professional
hegemony, the whole of healthcare will dissolve into amorphous and harmonious
islands of multidisciplinary practice floating in an egalitarian sea. Some
aspects of practice simply demand more expertise than others and
responsibility tends to rest here. Such expertise may be technical or
intellectual, and while technical expertise is currently on something of a
pedestal (think of heart surgery or interventional radiology), it is
intellectual and communication skills which will become the most crucial
competency in healthcare. Intellectual skills are ‘primary’ in the
sense that they determine the need for any interventions that may follow.
These intellectual skills consist of systems thinking (by which we mean
integration of many bits of disparate knowledge to reach a diagnosis or form a
plan of action). Communication skills are exhibited par excellence in
the consultation. In our opinion, the consultation will reassert itself as the
central encounter of health practice, and special education (see below) will
be needed for those who consult. The consultation is the intellectually and
emotionally most demanding part of clinical practice. It is here that the most
value turns—in both human and financial terms. Hence, it is also the
aspect of practice which encapsulates the greatest risk to patient and doctor;
we regard it as the apotheosis of responsibility. It is the most enduring
feature of healthcare, with roots that go back to the origin of human life
itself.
We predict that in the future, those who consult, while bearing the greatest responsibility, will receive commensurate rewards. Call those who consult ‘doctor’, if you like; the point is that the routes by which this position is attained will be multifarious. The links between what kind of initial undergraduate training a person has had and the kind of work he or she finally does, will be increasingly eroded.
In-built quality control
At the moment, doctors work in complex systems of care but feel
inadequately supported by their employing organizations—which, as we
have seen, are increasingly charged with responsibilities of clinical
governance. As care has become more complex and fractured, so the
opportunities for errors of commission and omission have risen. Furthermore,
they do so exponentially. If a patient's care consists of a hundred components
with an error rate of only 1% for each component, the probability of
experiencing no error is 0.99100. In other words, most patients
will be the victims of at least one error. Preliminary empirical
investigations have not only confirmed a high error rate but have also shown
that about 5% of patients experience an adverse but avoidable iatrogenic
problem4.
Third-party payers are responding to this threat and designing better systems.
Training incorporates drill and practice in ‘skills laboratories’.
For example, obstetricians and midwives are taught how to deal with shoulder
dystocia on models, not just on those rare patients who encounter this
potential catastrophe. The idea of compulsory near-miss reporting has gained
currency, but this is unlikely to succeed in an atmosphere of fear and a
culture of blame. Increasingly it is recognized that human beings are not
perfect—no matter how much training they are given—and that
systems have to be created to reduce errors.
Improved information systems, with an intelligence function to act as a medical ‘co-pilot’, could revolutionize clinical practice and reduce demands on consulting clinicians. Systematic reviews of such on-line action suggestions and reminders have shown them to be effective in improving quality of care5. Prescribing systems which warn of drug interactions and inappropriate doses must already have saved thousands of lives. However, systems that follow patients over time and integrate clinical, prescribing and laboratory information are long overdue. The construction of such systems is an enormous task—akin to a major space operation. The great majority of developers who have attempted to implement such systems have grossly underestimated the difficulties. However, this has to be the right way in the long-term and millions in investment will repay billions in dividend. We will realize in the next decade or so that developing algorithms to track patients through care pathways, by an appropriate mix of manual and electronic methods, will save far more lives and prevent more morbidity than all the advances emanating from molecular genetics.
Primary care and hospitals versus systems of care
Earlier, we described how the basic contract of healthcare had changed from
a private matter between doctors and patients to a more public one, between
healthcare providers—epitomized by hospitals—and patients.
However, increasingly hospitals are becoming places which you go to only when
you are very sick, and the balance of care is given in the community
where prevention is getting welldeserved emphasis. All this leads to a
prescription for healthcare arranged around client groups or disease entities,
rather than geography. As a result, we are already seeing the development of
networks straddling home, community facilities or hospitals and providing
systems of seamless care for diseases, such as
cancer6, or client
groups, such as those with mental
illness7. This means
that governance—both financial and clinical—is no longer properly
located in any one particular place. Managerial oversight of clinical practice
will therefore move away from being organized in units of hospitals and
towards organization in service units, such as the mental health or maternity
services. Hospitals can take on a simpler and more manageable role, of
providing facilities for consortia of healthcare providers. The Private
Finance Initiative will go some way towards separating the construction and
maintenance of buildings from the management of clinical teams which will
straddle facilities of different types. Prevention of acute illness will be
seen less and less as a ‘medical’ problem and will involve a wider
variety of actors.
Education
Education and training will, we predict, change utterly. Medical schools
will become part of broad schools of health. They will train people to consult
in contexts where complex (systems-based) thinking is required. These trainees
will all be graduates. Some will come from a direct-care training programme
(somewhat analogous to nursing training) and others will have done a degree
course in a generic academic discipline. They will do a core life-sciences
degree which will be modular and flexible (according to previous educational
experiences). People who have done the direct-care package could specialize in
some aspect of non-consultant care if they do not wish to take this route.
However, those who have done the core life-sciences degree will be eligible
for advanced life-sciences courses, leading to a technical or scientific
career. Those who want to become ‘consultant’, however, would
undergo a further training emphasizing systems thinking, clinical examination,
ethics, communication and social dimensions of healthcare. This group of
people would also get an enhanced package of mentoring/pastoral care.
Consulting work has been shown to make huge psychological demands on
individuals and the caring professions are commonly seen as failing,
especially in their duty of communication. The new course for a
‘consultant’, therefore, should concentrate as much on the
psychological as on the intellectual development of this crucial corps of
healthcare workers. A scheme of how the whole framework could look is shown in
Figure 1. Our thinking builds
on the ideas proposed by
Conroy8. She argued
for a restructuring of the NHS workforce in which traditional roles would be
replaced by ‘generic health practitioners’. We argue for an
extension of this concept, so that the consulting function is specified and
trained for, to complement the activities of practitioners who fulfil a more
traditional nursing role or whose tasks are governed largely by algorithms
rather than complex analytic and consulting approaches. Such changes in the
structure of training would not lead to the abolition of those workers with
more specialist skills, but would simply allow for the best use of all skills.
Such a framework could allow for greater flexibility in training and career
pathways for NHS professionals, a point emphasized in a recent Department of
Health document9.
Adoption of such a model is, we argue, the best way to develop a workforce
that is suited to delivering the best healthcare in the future.
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