Chapter 1 The Added Value of Do ctors in a Complex System
Doctors work in a complex system which, in these demanding times, is under pressure to change. Scotland has an increasingly aging 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.
Audit Scotland has called for a fundamental change in the way NHSScotland delivers services to cope with these increasing demands and has challenged us to increase the pace of change. Drivers for change will be and should be the needs and expectations of people who use our services. Services must adapt to the way in which people with multiple, complex and frequently changing conditions require to access care and support.
Current models of healthcare services are stretched and do not always suit the patients, their carers or the aspirations of the workforce. Delivering person centred and integrated healthcare with other agencies, statutory and non-statutory, is a challenge in the current configuration of our health and social care services.
In addition, our health services have tended to focus on urgent care rather than the early detection and even prevention of illness. Erasmus observed in the 1500s that "prevention is better than cure".
The training of doctors has been mainly in a traditional model of care with patients reliant on healthcare professionals for information, diagnosis and referral, and with interventions decided mainly by healthcare professionals.
The future model of care is one with an empowered patient in a shared decision-making partnership with the clinician. There needs to be 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, as this allows patients to regain control of their own health. Healthcare now needs to extend far beyond the classical settings of hospitals, GP practices, and hospices and reach more effectively into a person's own home and community. However, the expectation in the minds of many of our population remains that care should be hospital based, when the evidence tells us that this is not always the optimal location.
Professor Sir Lewis Ritchie, in his independent review of the Primary Care Out of Hours Service in Scotland, has begun to lay the foundations for an approach that will provide consistent urgent and emergency care that is sustainable throughout Scotland. The demand for urgent care is increasing, and many of the approaches recommended in his review are equally applicable when providing care during daytime, so that increasingly care will be given by well led multi-disciplinary and multi-sectorial teams in community settings. As we move to reform the approach to delivering primary care and orientate towards a community-led health service, these new models of care will be further developed in test sites across the country, and in both rural and urban environments.
The morale of some doctors is low and there is reported erosion of professional status. Although we must adapt to the needs of a changing system it is important for us as a profession to recognise and build on our added value throughout healthcare. The practice of medicine is not a pure science. It is a discipline with the concerns of people at its heart and therefore requires integrity, ethics and knowledge.
Medicine is a vocation. Communication and compassion are at the core of doctors' work. Developing these professional skills is an essential part of the development of an individual clinician, which adds to the ethical value of his/her work.
High profile failures in care have emphasised the importance of good clinical leadership which is clearly linked to good patient care. Strong leadership would have made significant differences to care and to outcomes The lack of this leadership from clinicians, managers and within governance systems was arguably the single biggest contributor to poor outcomes and experiences.
Doctors continue to have an integral role in leading and facilitating the multi-disciplinary team. However, we need better distributed leadership in teams where different individual team members may take on leadership roles, depending on the task being tackled and their individual expertise and experience. We need collaborative leadership, working across the traditional role and organisational boundaries, for the best interests of patients rather than the promotion or furthering of single aims or areas, and to promote the development of other professions to ensure a holistic approach. Well trained health and social care workers, nurses, allied healthcare professionals, physician's assistants, pharmacists, community members and patients themselves have clear roles in providing services. Doctors have seen some of the work traditionally undertaken by the medical profession very successfully delivered by other trained healthcare professionals. This up skilling of others requires us to further adapt and redefine our role, so that we continue to provide our care where it will have greatest impact.
"There is no better person to improve the role of doctors than doctors themselves. This is why I want to start a conversation among doctors about changing healthcare."
Dr Catherine Calderwood
Email: Diane Dempster