Professor David Oliver discusses clinical resourcing in the NHS, and how the Royal College of Physicians' (RCP's) new Our Future Health programme of events, activities and publications are being organised to provide a forum for debate.
At the start of our quincentennial year, celebrations coincide with stories of British health services under severe strain with waiting times lengthening, hospital overcrowding at the front door and an ‘exit block’ at the back door due to a lack of capacity and investment in community health and social care services.
We have a growing disparity between funding and the costs of health and social care provision. We are witnessing an increase in clinical workforce and rota gaps – certainly for consultants and trainee doctors in the 31 physicianly specialties comprising the RCP family, but also among other doctors in general practice and mental health, and nurses and allied health professionals equally vital to the clinical teams patients need.
All this is happening on a backdrop of rapid population ageing. When the NHS was founded in 1948, 48% of people died before they made it to 65. Now, in 2018, that figure is only around 12%. This year, a 65-year-old man in the UK can expect to live, on average, a further 18 years and a woman for a further 20 years. By 2030, the number of people aged over 85 will have doubled, with life expectancy at 88 and 91 respectively.
No longer can our focus be just on extending life, but instead on how to develop a system that will support an ageing population and its new requirements.
We are now far better at ensuring people don’t die in infancy and childhood, and that they survive conditions formerly fatal in mid-life. Death rates for ‘common killers’ such as infectious diseases, respiratory and cardiac disease and stroke have all fallen dramatically over the previous century. Death rates from cancer were more static, but rates for many common cancers are now also falling.This represents a success story for society, public policy, physicians and other medical professions. We have reduced poverty and inequality, improved our welfare safety networks, improved housing, diets, workplace safety and reduced environmental pollution. We have also advanced treatments for people living with long-term medical conditions, preventing deterioration or further complications. The third limb of success is better intervention for people who do become acutely ill, such as better interventions for people with heart attacks, strokes or trauma, all backed by the growing evidence-based medicine movement.
However, for all these successes we still have major inequalities in rates of amenable mortality and life expectancy between ethnic and socioeconomic groups, as well as discrepancies in different geographical areas. The World Health Organization has estimated that nearly half of all ill health in people over 60 years of age is attributable to (modifiable) lifestyle factors such as obesity, poor diet, smoking, alcohol, or a lack of exercise. There is a clear need to focus more on prevention of ill health, self-care and helping people who do develop conditions to live better with those conditions, supported in care planning by clinical practitioners.
Although growing longevity represents a victory for modern medicine and public health, it does change the very nature of modern medical practice and health service delivery. Physicians – and this royal college – have a key stake in this change, and the medical profession must recognise the need to adapt to this different environment. No longer can our focus be just on extending life, but instead on how to develop a system that will support an ageing population and its new requirements.
It requires honest, realistic conversations about what medicine can deliver and a move towards avoiding treatments or tests that add little value.
Increasingly, modern medical practice is about supporting people living with one or usually several long-term conditions, including those near or at the end of life, older people living with frailty, dementia or disability and often taking multiple medications. Such patients often use multiple services and suffer fragmented care. This in turn requires a focus on identifying the goals of treatment, and what outcomes and priorities matter to patients. It requires honest, realistic conversations about what medicine can deliver and a move towards avoiding treatments or tests that add little value.
All of this in turn changes the nature of medical practice. Doctors must retain good generalist skills, in order to help people who are living with multiple long-term conditions. We must also retain a holistic focus on biopsychosocial factors and support families and carers. They have a role in care coordination, care planning, prioritising treatment and in helping patients who use multiple services, see multiple professionals and cross multiple interfaces. They all need to be conversant with problems of ageing, with end-of-life care and be prepared to work as part of multi-professional teams.
At the same time, we still need to focus on highly specialised medicine for specific conditions, as new technologies and treatments emerge, and the knowledge base around individual conditions grows.
These generic challenges are not unique to the NHS in 2018 and its current political context. All health systems in developed and developing nations are encountering the same set of challenges – even those which spend considerably more than the NHS or have less pressing workforce gaps.
[We] still need to focus on highly specialised medicine for specific conditions, as new technologies and treatments emerge, and the knowledge base around individual conditions grows.
This all brings me back to the RCPs’ major policy project in 2018: Our Future Health and our focus on using clinical resources. Throughout 2018, we are planning a series of workshops, public debates and engagement events, roundtables, blogs, columns, and surveys of patients, public and practitioners.
In an environment where financial resources and clinical workforce are finite, and the cost of treatment and demand for care is growing, how can we use the resources we have wisely, responsibly and sustainably? What role should individual doctors (either as practitioners, service or system leaders) play in ensuring that high-quality care is also of high value per pound spent, and that services and systems are efficient?
We also plan to highlight the difficult dilemmas doctors face when making clinical decisions that may influence resource use; the reality of rationing in provision of health and social care and the need to be honest about this; and the need to be clear about what we are trying to achieve when we do make treatment decisions, and the inherent trade-offs that result. We want to address the balance between investing in treatment for people who become acutely unwell (including those near the end of life) and support for people living with long-term conditions, with the investment in prevention of ill health and reduction of inequalities through more ‘upstream’ investment.
Throughout our programme we will ensure that the voice of patients, carers and the public are given due weight and influence at every stage, and that we give a platform to those who are critical of current models of healthcare funding and provision in the four UK nations.
Professor David Oliver is the clinical vice president at the Royal College of Physicians. You can follow him on Twitter @mancunianmedic