Chief Medical Officer's annual report 2024-2025: Realistic Medicine - Critical Connections

Chapter 4: Our Place in Our Communities: Past, Present & Future

Thirty-five years before the formation of the National Health Service in 1948, Scotland led the way in creating a state funded healthcare system to serve the specific needs of its remote and rural communities.

Ballachulish GP, Dr Lachlan Grant’s evidence to the 1912 Dewar report highlighted the plight of those needing medical care in the crofting communities who, with no regular income, were not covered by the National Insurance schemes of that time. The resultant launch of the Highlands and Islands Medical Service provided medical care to over 300,000 people, over an area covering more than half of Scotland’s land mass, for the first time. This network of expert medical generalists embedded in their communities, practising according to local need, formed the foundations of what we would now recognise as the modern General Practice and served as a model for others around the world, including the NHS.

Over a century on, the challenges we face in healthcare have changed, but the importance of our relationship with the communities we serve has not.

Given the increasing health needs of our population, driven by the growth in non— communicable disease and exacerbated by the pandemic, coupled with increasing societal expectations for convenience and immediacy, it is perhaps understandable that the speed of access to healthcare has become our primary focus. However, I am concerned that continuity of care, and the benefits that relational care brings both for those being cared for and for our wider system, are at risk of being compromised as a result.

What do we mean by continuity of care? This can be considered in terms of three intertwined domains:

• Management continuity – where there is an agreed and coordinated plan for who is responsible for each element of a person’s care;
• Informational continuity – where there is accurate exchange and capture of information which is readily accessible as a person interacts with us throughout their care;
• Relational continuity – where the same healthcare professional provides treatment and care for a person over time, allowing development of trust as well as an understanding of their biography as well as their biology.

Management continuity can be achieved through the effective collaboration of multi-disciplinary teams. Informational continuity can be achieved through good communication, supported by technology, which is also important in supporting careful and kind care. However, I want to focus on the importance of relational continuity. Relational continuity relies on the development of human relationships and trust, creating a connection, and as such requires time and space for them to develop.

“Care happens in the space between people, in an unhurried encounter. Only humans in interaction can care.” — Victor Montori

Benefits for communities

As a GP, I had the privilege of relational continuity with the people I cared for and highly valued these relationships. The human connection fostered through relational continuity is not only professionally satisfying but is simply vital, if we are to truly understand the sometimes complex needs of people we care for. It is the polar opposite of industrialised, transactional care and not just a mechanism for healthcare delivery.

There is a growing body of evidence that relational continuity of care positively influences clinical outcomes for people across the life course. GPs offering relational continuity identify more people at risk of cardiovascular events who will benefit from statins. People living with diabetes have better glycaemic control when they have relational continuity with their health and care team. In our older population, people living with dementia who have good relational continuity with their GP have been shown to have 10% fewer hospital admissions, 35% fewer episodes of delirium, and 57% less incontinence. I’ve shared this quote with you before, but it sums up relational continuity perfectly:

“It is more important to know what sort of person has a disease than to know what sort of disease a person has.” — Hippocrates

For the people we care for, the benefits of relational continuity are not just limited to better clinical decisions. Those who experience more relational continuity with their GP are more likely to report higher levels of trust in their doctor, which has an important bearing on the quality and effectiveness of the care given. People are more likely to follow advice from a professional they know, disclose their symptoms more readily and take medication as prescribed. There is also evidence of significantly better uptake of personalised preventative medicine, such as screening for breast and cervical cancer and vaccinations.

More relational continuity enables the development of this trust, which is essential for effective shared decision making, with real implications for the practice of Realistic Medicine, contributing to the delivery of careful and kind care.

Better value care and a more sustainable system

What are the benefits of continuity to the wider healthcare system? Given that a focus on speed of access to care has perhaps unintentionally eroded continuity of care, it is right to question whether redesigning services to promote relational continuity would result in slowing down access and perhaps even increase demand for care.

The evidence suggests however that the opposite is true. Chang and colleagues’ 2024 study examining 1.4 million episodes of care from Taiwan showed continuity to be associated with a reduction in the overuse of care that was of little or no value to those receiving it. Menec and colleagues’ study from Canada of 1,863 older adults receiving relational continuity from their GP were shown to be significantly less likely to be admitted to hospital for conditions which could be managed in the community, a finding which was replicated in the UK context in a study of 230,472 patients. The benefits of continuity to the wider system are obvious in terms of the potential for reduced financial costs of , but there are also benefits in terms of reduced . Relational continuity provides us with the foundation to practise Realistic Medicine and support a more sustainable health and care system.

And yet, despite clear benefits for our system and the people we care for, there is less relational continuity, not only within General Practice, but across Scotland. Whilst the number and longevity of the relationships within General Practice make it the most important place to foster relational continuity, there are also examples of its value in secondary care.

Continuity may be more challenging to provide in secondary care when multiple professionals and specialties provide care for individuals with complex multisystem problems, however there is evidence that the connections that relational continuity creates between patients with chronic kidney disease and the wider specialty team is valued by those being cared for— they have a better care experience and feel like they are treated as a person, rather than a number. In paediatrics, parents of children with chronic health conditions describe feeling that they take on a “necessary though uncomfortable coordinating role” when services are compartmentalised, and the child being cared for isn’t as well known to those providing care.

Simply put, continuity, and relational continuity in particular, should not be regarded as “nice to do”. Nor can we say that we simply do not have the time. The care we provide must be centred on what matters to the people we care for, not what matters to our system. The evidence is clear, relational continuity is vital if we are to understand and deliver the outcomes that matter to the people we care for, use our resources more wisely and create a more sustainable system.

Given the finite resources of our health and social care system, we must consider who will benefit most from redesigning services to foster more relational continuity.

In my annual report last year, I discussed the concept of “missingness”— a person’s repeated tendency not to take up offers of care such that it has negative impacts on their life chances. Missingness is a significant risk factor for negative outcomes but has clear causes that can and must be addressed.

We have a moral obligation to start here.

Proportionate universalism means providing universal services, but with more provision for populations with higher needs. The inverse care law states that the disadvantaged populations need more health care than advantaged populations, though receive less. How can we put our understanding of these concepts into practice to create services that truly serve our communities?

Case Study: Newfield Medical Group

Newfield Medical Group is a GP practice in Dundee serving an area of social deprivation where patients have struggled to access traditional healthcare. Newfield has sought to address this by creating a service which removes access barriers for people and aims to meet the needs of the community. GPs answer phones, dealing directly with people from first contact, and people can speak to a doctor anytime during the day.

The group operates as a cooperative, with the profits supporting a charity, the Newfield Community Group SCIO. They have opened a cafe and social prescribing hub staffed by volunteers co-located with the practice and employ a coordinator to oversee these. In addition to a clothes bank and food larder, Newfield have worked collaboratively with:

• Barnardo’s to make a Job Shop accessible to the local community;
• Dundee City Council to make benefits and income maximization advice easily accessible; and,
• Feeling Strong (a young person’s mental health charity) to offer services including an Art Group, youth drop-in and one-to-one coaching.

Newfield staff understand and respond to the needs of the community they serve.

After IT literacy was identified as an issue, a drop-in group was established. When a patient with a stoma noted there was limited support in Dundee, a support group was formed. One of the hubs volunteers, a veteran, established a veteran’s group providing peer support, reminiscence and introductions to new people. These volunteers also contribute to teaching medical students in the practice’s innovative undergraduate teaching clinic.

Newfield represents a bold and different way of serving the community which is improving access to care and achieving the outcomes that matter to the people they care for, as well as enhancing the area they serve.

What might continuity of care look like for individuals? I strongly advocate the Getting it right for everyone (GIRFE) approach.

Case Study: Getting it right for everyone (GIRFE) approach for “Sean”

Getting it right for everyone (GIRFE) provides a personalised approach to care, and improves access to the right help and support, by placing the person at the centre of all decision making that affects them. It’s a collaborative, multidisciplinary approach, founded on continuity of care.

“Sean” (not his real name) is a young man with paraplegia because of a head injury and fractured spine. He has a history of alcohol dependency, self-harm and seizures. Between May 2023 and May 2024, he was admitted to hospital fifteen times. In May 2024, he was discharged following treatment for severe anaemia, osteomyelitis and ungradable pressure ulcers.

On discharge he had no accommodation, no clothes and no access to funds. He was socially isolated, with no involvement in wider social and community networks.

GIRFE pathfinders applied the “Team Around The Person” toolkit and involved Sean in conversations about his care, allowing Sean and his health and care team to develop trust, share information, understand his preferences — what matters to him — and support shared decision making between Sean and his multidisciplinary team.

Sean trusted that his choices would be respected as he was involved in the decision making process. Sean now has regular support from the community nursing team and social work.

As a result of the GIRFE pathfinder, Sean has had only one 24-hour hospital stay, for an unrelated health condition. Continuity of care, guided by the “Team Around The Person” toolkit, has resulted in Sean now engaging with his plan of support and substance misuse programme. In applying the GIRFE approach to his care, Sean is also no longer confined to his home and can access local amenities independently.

When asked about his care since the GIRFE approach has been adopted, Sean said, “I have got my life back and never felt so safe.”

“We have to be very careful not to blame the patients. A lot of the conversation [around patient engagement] has been, how do we get them to do stuff? To me, that’s not engagement.” — Victor Montori

How can services deliver Value Based Health & Care today

Whilst parallels exist between the success of the Highlands and Islands Medical Service, and our future success in meeting the challenges we face, there are also some striking differences.

A myriad of scientific and technological advances have transformed healthcare. Whilst progress is to be celebrated, we should recognise that our role as health and care professionals in providing care to the communities we serve is more complex today than it has ever been. If we are to succeed, we must recognise the importance of the human connections between us and the communities we serve.

Providing Value Based Health and Care today requires a continually evolving depth and breadth of knowledge and training. The importance of promoting a culture of stewardship over our finite resources means the skills of experts in the navigation of uncertainty are more important than ever — not only for the sustainability of our system but in order to achieve “personal value” and in preventing harm arising from wasteful and unhelpful care.

This is part of the challenge of medical generalism which is both a joy and an awesome responsibility. Truly personalised care requires more than just deploying our growing armoury of investigations and treatments. Doing the right thing requires recognition that each person we care for is unique with their own biography and biology. As Professor Andrew Elder writes: “What could be done may be relatively straightforward, but what should be done requires studied listening, enquiry, exploration, and judgement.”

Being able to hold and manage risk, use time as a diagnostic tool, and help the people we care for navigate uncertainty are essential elements of the way we must practise today.

They will become even more important in the future.

Our future place in our communities

Having considered the benefits of rebalancing services to focus on longer term human relationships, we should also consider how redesigning services to foster more meaningful relationships will benefit wider society too.

In Scotland, clinicians have long enjoyed a position of public trust, which is essential in allowing us to serve our communities well. However, if we are to retain that trust, we must also be ready for the changes and challenges that lie ahead. As health and care professionals we cannot, and must not, fall into the trap of inadvertently becoming distant from the people we serve. We must value the relationships not only with those that we care for in our consulting rooms, theatres and wards, but also our relationship with the public more widely. The word “doctor” is derived from the Latin “docere” which means “teacher”. Regardless of our profession, we all have a role in teaching and educating the public about their health. This role has never been more important than it is now.

The ubiquity of the smartphone means that the same information, guidelines and resources that were once the preserve of the professional are now at everyone’s fingertips. Understanding how to best use this information in the context of what matters to the people we care for, understanding the limitations of what evidence does and does not tell us, and keeping up to date as things change, will remain one of our key responsibilities.

However, just as high-quality information has become more widely available, so too has information which is of low quality or even harmful. Misinformation and disinformation (MDI) can cause harm, and compromise decision making processes as well as health, environment or security.

• Misinformation: is the spread of false information without the intent to mislead. Those who share the misinformation may believe it is true. They have no malicious intent towards the recipients they share it with.
• Disinformation: is spread with full knowledge of it being false (information has been manipulated), with the intention to deceive and cause harm.

The term “infodemic” has been used to describe situations during public health crises where an overabundance of information — both factual and inaccurate — creates confusion to the detriment of public health. The spread of MDI during the Covid-19 pandemic — predominantly via social media — brought this emerging threat to our health to the fore.

It is no coincidence that we are seeing a rise in the power and influence of false narratives whilst simultaneously seeing a decline in the availability of a meaningful human connection in healthcare. The evidence tells us trust is fostered through continuity of a meaningful human connection.

Our responsibility to the public as teachers of health literacy and advocates for critical thinking will be fundamental to meeting the challenge posed to the nation’s health by misinformation and disinformation. We must build on our trusted relationships with the people and communities we serve and use our knowledge, skills and expertise to help them understand and overcome these threats to their health and wellbeing. We can do this by practising Realistic Medicine and delivering careful and kind care.

What lies ahead

There can be little doubt that Artificial Intelligence (AI) will play a significant role in the delivery of healthcare in the very near future. Whilst it has been speculated this will ultimately lead to the replacement of doctors and other healthcare professionals, I would point again to the strength of the evidence regarding the importance of the human relationship in providing careful and kind care.

We must be mindful of the distinction between knowledge and wisdom. Knowledge can be defined as the awareness of facts and information accumulated through learning. Wisdom however can be considered as the quality of being able to apply knowledge and make judgements and behave accordingly. In the context of the evermore complex world of healthcare, in which human relationships are essential, using our wisdom to make decisions in partnership with the people we care for will remain of paramount importance. Furthermore, it must be done in a way that maintains and strengthens our relationships through knowing when to listen, when to offer comfort and when to show we care. Technology will never be able to hold a hand or broach difficult conversations.

Given the ability of AI to make sophisticated predictions based on large amounts of data, it will likely play a key role in streamlining processes and directing healthcare professionals to where they are needed most. For example, in identifying people who will benefit most from preventative medicine, those most likely to deteriorate in real time, and in assisting with care in people’s homes. However, given the ever-growing complexity of clinical decision making, and the need to understand biography as well as the biology, AI cannot replace the human element of providing care. AI will always need clinical (human) governance. The Potential for AI to misinform or misapplication is real and there will therefore always be a role for human healthcare professionals.

Successful applications of AI in the interpretation of imaging such as x-rays and other investigations are increasingly being described in the literature. Whilst increased diagnostic speed and accuracy are welcome progress, with obvious benefits for the people we care for, we must remember that AI using knowledge in this way cannot replace the wisdom and compassion required to provide careful and kind care.

A call to action

I have spoken of the importance of the human relationship in providing care — whether that be for our health and care system, our planet or the people and communities we serve.

The future is uncertain — but exciting. It is hard not to be struck by the plethora of technological and societal advances since the beginnings of our modern NHS in the North of Scotland in the early 1900s — and more will come. While this has accelerated progress in ways our predecessors cannot have imagined, we cannot afford to allow current and future advances in technology to obscure our role as humans who care. To underplay the value of human understanding and connection in providing care risks accepting transactional, depersonalised interactions becoming the norm.

The rise of social media, the increasing immediacy of information exchange, and the expanding capabilities of medical technology risk giving rise to a vacuum in the absence of human care and advocacy. It is only by being human and establishing connection with others that we can provide the care that matters to people, our communities and society.

And so I call to action everyone in our health and care community, regardless of your role, your discipline, or where in Scotland you work. No matter what happens in the future, being human, understanding both biology and biography, serving as advocates for our communities and champions of health literacy will remain at the core of our purpose. To overlook or underplay this will be at the expense of the people we care for, the public and ourselves.

We must not let this happen. Holistic care and healing have human connection at their heart and remain the only way to provide careful and kind care.