The NHS is at a milestone and must embrace realistic medicine

Written by Dr Catherine Calderwood, Scotland's Chief Medical Officer on 4 June 2018 in Comment

Scotland's Chief Medical Officer Dr Catherine Calderwood marks the NHS' 70th birthday with a call to arms

Dr Catherine Calderwood - Scottish Government

It is a huge privilege to be Scotland’s Chief Medical Officer as the NHS approaches its 70th anniversary, an incredible milestone for a service we are so fortunate to have.

In Scotland, the NHS serves 5.4 million people. There have never been more people working in our health service than there are today.

Across the medical profession, it employs almost 5,000 GPs across almost 1,000 GP practices, almost 5,800 consultants, a further 2,250 doctors working in our hospital and communities, and around 6,000 medical trainees. There are also almost 70,000 nurses and midwives, with a total NHS Scotland workforce of over 163,000.

Our NHS is by far the largest employer in Scotland – and as the years progress, my vision is that it continues to grow and prosper. 

Since its birth, in a post-war Scotland where rationing was still being imposed, the NHS has been nurtured and grown into the largest public service organisation providing health and social care to the population of Scotland. 

There have been improvements in public health, clinical diagnosis, and maternity care, along with advances in medicines, surgery and technology, and a greater emphasis on prevention, health education and health literacy.

This has meant that NHS Scotland has had to adapt and evolve its service provision to meet the demands of a growing, more educated and ageing population, while still providing its service free at the point of delivery, a key impact of its establishment in 1948.

We are now moving into a new era of ‘realistic medicine’ in NHS Scotland – moving away from the current ‘doctor knows best’ culture to shared decision-making, with the patient and their healthcare professional working together to decide what their priorities are for their care. In ‘giving the NHS back to the public’ who so support it, I am certain that NHS Scotland can meet any future challenges.

Through realistic medicine we can build a personalised approach to care, changing our style to shared decision-making, reducing unnecessary variation in practice and outcomes, reducing harm and waste, managing risk better, and becoming improvers and innovators in our field.

All across the NHS, doctors work in a complex system which, in demanding times, is under pressure to change. Here in Scotland, we have an increasingly ageing population and a growing number of people who live with multiple and complex conditions.

The subsequent increase in demand for services in an age of austerity requires us to achieve more through better use of resources, and I cannot think of a better time than the 70th anniversary of the NHS to explore more ways in which we can do this.

There have been calls for a fundamental change in the way NHS Scotland delivers services to cope with these increasing demands and this has challenged us to increase the pace of change.

Services must adapt to the way in which people with multiple, complex and frequently changing conditions require to access care and support. Our current models of healthcare services are stretched and we need to examine how we can deliver person-centred and integrated healthcare with other agencies, statutory and non-statutory. 

Another priority is the early detection and prevention of illness – I strongly agree with Erasmus’s observation that ‘prevention is better than cure’.

We should be looking to a model of care with an empowered patient in a shared decision-making partnership with their clinician, where there is a co-creation of care packages that include prevention and rapid access to services when required. The growth of supported self-management is a key priority for me, as this allows patients to regain control of their own health.

We need to extend things far beyond the classic settings of hospitals, GP practices and hospices, and continue to reach more effectively into a person’s own home and community. 

As we approach this momentous milestone in our NHS’s history, we should be looking forward to what we can do to make the service it provides even better, even more streamlined, even more effective.

I know that will come with challenges. Building a more personalised approach to care, in partnership with people through shared decision-making, is perhaps one of our greatest challenges.

Evidence-based medicine remains at the core of informing best practice and guidance, but for it to truly take place, we must use best available evidence, clinical judgement and patients’ preferences together. 

This is especially true within our complex modern healthcare system and when applied to patients with multiple conditions. Knowledge requires integration with personal values and preferences. Clinicians – and I’m speaking from experience here – can become very risk averse at a system level, over-relying on scientific evidence to inform treatment choices.

Through shared decision-making we must get better at determining what matters most to patients. As our NHS evolves, so must we. Practising realistic medicine requires care that is co-produced in partnership with the people receiving it – person-centred, holistic care. We need to readdress the balance.

As I look to the future of our NHS, it’s my belief that people must be empowered to discuss their treatment fully with their healthcare providers, including the possibility that a suggested treatment might come with side-effects – or even negative outcomes. Everyone should feel able to ask their doctor why they have suggested a test, treatment or procedure, and all decisions about a person’s care should be made together.

I’m happy to know that many clinicians are already starting to take this approach, encouraging their patients to engage in shared decision-making and to have a say. Similarly, most patients want to discuss options and share their opinions about treatment with their clinicians, and clearly many seek to be, or want to be, more involved in clinical decisions.

Nevertheless, longstanding cultural norms can make it difficult for patients to speak up, ask questions, actively participate, or challenge clinicians’ expertise. That is why it is essential for healthcare providers in a modern NHS to encourage their patients to do this.

Clinicians best serve patients when we frame treatment and care options in terms of the values and goals that patients and their families articulate. It is also important to remember that doing less or no treatment can be the best option for some people. We know some patients later regret accepting treatment and that some treatments can add to the burden of illness, taking up time and energy, which could be more devoted to other activities that offer more meaning to individuals – time spent with loved ones, or on cherished moments.

This may partly explain why clinicians choose less healthcare interventions for themselves, and with that in mind, we should aim to provide the kind of realistic care we would want for ourselves and our families.

We are entering a golden era for our NHS – it must be celebrated, cherished and encouraged to move forward. It is through innovation and forward thinking we have come this far – we must continue that in order to see us through the next 70 years, and beyond. 

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