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Martin McShane: Care and cure

24 Oct, 11 | by BMJ Group

Martin McShaneWe are coming up to the annual contracting round. This year it will be led by Clinical Commissioning Groups (CCGs). Last year GPs were involved in the difficult, detailed negotiations with the acute sector alongside PCT staff. As one of them said, emerging into daylight, somewhat pale and drained, “I never realised how hard it was.” This year will be even harder.

Any financial problems at the end of the year will add to the challenge for next year. Providers are trying to deal with a deflationary tariff and increases in activity, activity generated in many cases by system expectations such as bowel screening. Some providers have seen a 50-200% increase in two week wait referrals as a result of screening  – and the national Bowel Cancer Awareness campaign starts in January.

Adding to this are the difficulties facing social care: some adult social care funding is being cut by 20% or more. This will increase pressures on health services, especially on the flow of patients through the acute sector. Frail older people with a mix of medical and social issues don’t fit neatly into “care pathways” and require teamwork and collaboration and common sense to sort their problems out. The NHS needs to work urgently with social care to focus and target limited resources to best effect for the community both systems purport to serve.

In amongst all of this we seem to spend vast sums of money on heroic interventions which as a recent paper in the Lancet discussed, in truth, are of little value.

So we have less money, more demand and a system which remains predominantly focused on cure, often it would seem, to the detriment of care.

If we are to build a sustainable health care system for the future then perhaps we need to create a new narrative for the future; one which puts care at the centre of the system with cure as a secondary objective. We need a system which harnesses the power of the internet to realise the aspiration of “no decision about me without me.” How many GPs have started using the patient decision aids now available? All the evidence demonstrates that, when truly informed, individuals frequently choose care which is less aggressive and interventionist than that which a professional would choose for them.

Recent speeches and papers by thinkers in primary care have raised alarm about the drift towards a rational, conditional, market based approach for healthcare, which ignores the humanity and art of care. If their concerns are to be addressed, however, we do need to think about how commissioning (the planning, funding, and quality improvement of the system) can be harnessed to create a system that puts the patient at the centre, values professionalism and care, whilst delivering a cure whenever possible – but without generating unrealistic expectations and false hope with “cures” of little or no value.

The way we have approached these issues in the past will not provide the solutions for the problems we face now. The reforms may be considered to be flawed by many and have created turmoil and difficulties. Despite that, I believe that there is an opportunity to engage a cadre of clinicians in helping to lead the change that is needed, change which is needed across primary care as much as by other parts of the system. If we take care, we may be able to put in place a cure the system desperately needs.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.

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