Realistic Medicine - Doing the right thing: Chief Medical Officer annual report 2022 to 2023

Chief Medical Officer's (CMO) third annual report, and the seventh on Realistic Medicine. It reflects on the challenges our system is facing and asks professionals to practise Realistic Medicine, in order to deliver value based health and care and a more sustainable system.

Chapter 1: Being Human

It feels that the NHS and social care systems in Scotland have reached a fragile and pivotal moment. The signals of concern have been intensifying for some time, and whilst they have undoubtedly been accelerated by the impacts of the Covid-19 pandemic, this is not the only influence on the problems currently faced.

There are four concurrent challenges to population health in Scotland.

There will be ongoing threats posed by the spread of infectious disease – not just COVID-19, but more familiar threats such as those we have faced recently due to influenza and group A Streptococcus. The threat of further zoonotic infection emerging, such as a pandemic Influenza from an avian source, is not receding; nor is the impact of anti-microbial resistance.

Second, there is the enduring challenge of improving health, particularly at a time when disparities have been made worse by the pandemic and recent price inflation, particularly for food and energy, which has hit those with least hardest. The improvement in healthy life expectancy observed for decades had begun to slow even before the pandemic struck, and there is now evidence of it stalling, even beginning to reverse. The reasons for this are complex, but it is certain that a response wider than the provision of healthcare alone is necessary to rectify this and address these widening health inequalities with urgency.

Third, there is a sustainability challenge facing health and social care services at a scale and intensity not seen before. There was a substantial decline in the number of people who received most types of healthcare during the pandemic that is now manifesting not only as a backlog in the elective programme, but to later and more complex presentations in both elective and urgent care. And beyond this, there are also continuing workforce pressures that multiply fatigue and exhaustion from the last three years.

Whilst this produces immediate pressures, what lies ahead is even more concerning. Recent work by Public Health Scotland demonstrates the impact of demographic changes on the burden of disease in Scotland over the next 20 years. Despite an overall projected reduction in the population over this period, the burden of disease within the population is estimated to increase by 21%. Allaying this projected increase will be equivalent to eradicating the entire disease burden of cancer in 2019.

The fourth major challenge is the increasing urgency with which we must act to address the climate emergency. We must reduce harmful emissions and air pollution and restore biodiversity. NHS Scotland has set ambitious net zero targets by 2040 and it is imperative that we achieve these, playing our role as part of an international response from healthcare in over 60 countries following the COP 26 held in Glasgow in 2021.

These four challenges are not separate and distinct, but are interlinked. Unless we restore balance with nature and our environment, it is likely that future health protection threats will become more common. These may be direct effects from extreme weather events, or indirect effects due to changing patterns of disease. The impacts of infectious diseases will continue to fall disproportionately on those who already experience disadvantage in our society. All of this will place additional pressure on our services, and risk displacing other health needs.

There remains harmful, unwarranted variation and waste within the services that we provide. The Organisation for Economic Co-operation and Development estimates that 20% of healthcare spend does not actually result in improvement in health. This consumption of resource without benefit is more likely to prevent those who are disadvantaged from receiving the care that they need. It is also a drain on our natural resources and increases harmful emissions – wasteful care is poor care for our patients and our environment and increases the potential for harm to them both.

Realistic Medicine has challenged these issues and offered a way of addressing them since its inception in 2016. Collectively, we have developed and championed this approach since that time, all centred around 6 key principles that describe how we can all contribute to the solutions by:

  • changing our approach to shared decision making;
  • building a personalised approach to care;
  • reducing harm and waste;
  • reducing unwarranted variation in practice and outcomes;
  • managing risk appropriately; and,
  • becoming innovators and improvers.

No matter your role within our health and care system, these six domains remain resolutely important to the response that is required to these system and societal challenges. There has been great progress in adopting these principles and across the country, and we can see very tangible evidence of Realistic Medicine influencing the way that care is provided. I would argue that incorporating them into our response to the way that we provide care systematically has now become even more imperative, but they are not enough by themselves. It is time to go further.

Concentrating greater efforts on the prevention of disease, by tackling the social and commercial determinants of health, as well as reducing the impact of established disease, needs to have a greater urgency and priority in our future if we're to meet the challenges shown within the Scottish Burden of Disease study.

We must, therefore, strengthen our approach to primary, secondary and tertiary prevention, especially if we are to counter some of the impacts of the pandemic on the identification and management of chronic diseases. Here, there is a particular and pressing need to restore and extend our approach to secondary prevention. In a recent editorial, the UK CMOs, the Chair of the Academy of Medical Royal Colleges and the National Medical Director NHS England, proposed the need for a comprehensive response to address the excess mortality being seen, especially in circulatory diseases.

Whilst considerable efforts are being made to restore this approach already, it is not enough to simply go back to our pre-pandemic ways. It is essential that we extend these approaches to reach those with historically low uptake, using the lessons learned in the pandemic to engage and communicate the benefits of such an approach, as was done with, for example, Covid-19 vaccination. This necessitates a whole system response if we are to recapture the improvements that secondary prevention in particular has enabled us to make over recent decades. This may involve using existing health infrastructure in different ways, such as community pharmacy, or optometry for additional prevention opportunities and interventions, or extending identification of problems, such as hypertension, in workplaces or other 'non-traditional' healthcare settings.

As healthcare systems attempt to recover from the pandemic, there is a risk that our approach to recovery causes us to lose the essence of what it is to provide care. Care is human. It is about personal interaction, uncertainty, co-creation and compassion in managing risk, anxiety and hope. It is about the power of the relationships and being able to jointly identify issues that affect us, our preferences and our goals. Care is as much about alleviating as it is about fixing, and always with honesty, kindness and consideration of others life experience. Care is not just biomedical, it is biographical too.

Care is not an industrialised process and it cannot be provided by chasing numbers of ever increasing activity alone. It is not, and can never be a reductionist approach aimed simply at finding the most efficient way of providing treatments; the unthinking and indeterminate application of guidelines for people like me, without the acknowledgement and appreciation of human uniqueness. Identifying and appropriately treating those with the greatest need remains critical and is a priority, but it must not be done at the expense of losing the wisdom of kind, considerate and careful care. Losing this demeans those providing care and risks their moral injury. This is not the approach to care we should aspire to.

"Doing the right thing" reflects our purpose and values and requires us to care empathically and wisely. Doing the right thing returns us all to the original premise of evidence based medicine described by Sackett et al; the need to combine evidence and science, together with professional judgement and the knowledge of what matters to the people we care for to form a careful approach to care and manage the risk associated with it. The misdiagnosis of disease is tragic, but so is the misdiagnosis of a person's wishes for their care.

Doing the right thing weds scientific understanding and progress with the artistry of human understanding and relationships. It is a value based approach to health and care, allowing all these elements to blend so that meaningful care, that's more likely to provide personal and technical value, and less likely to lead to futility or regret, is realised. This approach in turn, leads to better use of resource and greater societal value. This is the culture of stewardship and careful, kind care I want to foster and promote in Scotland. This is the wise and thoughtful approach to care that will help us to tackle the combined problems of inequity and sustainability, and will reawaken the sense of purpose and privilege we experience caring for others.

And yet we cannot ignore that practising this way is not always easy. The incessant rise in the intensity and volume of practice, more complex and acute presentations and workforce pressures combine to make providing compassionate and kind care more difficult. Heath and Montori argue however that careful and kind care in itself, the pursuit of caring wisely, is something that sustains people in their careers and helps to reduce burn out. Focusing the system response to ensure the environment nurtures, promotes and values careful and kind care, has to be a major component of recovery.

This must involve better support for those giving care too, whether that be simple basics like providing lockers and hot food, the means to work in supportive and appropriately staffed teams, or the time and space to reflect and process events. It is especially important that progress is made here and that civility, trust and belonging are consistent characteristics of our experience. We have witnessed the greater use of digital technology in care; this is often very helpful and with innovations such as colon capsule endoscopy, there may be very real and tangible benefits for patients and staff alike. But digital technology and artificial intelligence are not replacements for the human element of caring – they must be seen and used as adjuncts that support people in their roles to provide the careful and kind care that matters.

It is 10 years since the General Medical Council last updated "Good medical practice", but later this summer we will see the latest version published. In these 10 years, much has happened across the health and care landscape. I was pleased to see the GMC consulting on changes to Good medical practice which emphasise the role of doctors as part of a multi-professional team; the importance of establishing a more equal partnership between doctors and patients within compassionate cultures of practice; and the role of leadership, tackling discrimination and encouraging kindness and sustainability. I view these "duties" as privilege of the professionalism that we seek to preserve. Without these, we risk allowing ourselves to become a fragmented profession governed by transactional approaches to care. I look forward to the publication of the updated version.

In his paper "Era 3 for Medicine and Health Care", Berwick proposes the need to embark on a new epoch for care, where features of Era 1 professional protectionism and Era 2 reductionism are replaced by a fresh approach – a moral era guided by values. This may require an honest evaluation of at least some of the data-gathering, measurement and bureaucracy within our system, especially by clinicians, to accurately assess whether it adds value. Some exponents of these previous eras may view this as naïve, but whilst we have been fortunate not to see some of the excesses associated with these eras observed in other countries, there remains a strong case to recalibrate our approach further towards one that has this careful and kind care as its defining feature above all else before it is too late.

Era 3 care, careful and kind care, has Realistic Medicine as its foundation, and this is the care we must aspire to consistently across Scotland.

None of this is easy, especially at a time when our complex system is so pressured. But by pursuing the values and approach that Realistic Medicine encapsulates; by caring with compassion and doing the right thing; by recognising that we are all human and all have our limits; we can create our own culture of stewardship and achieve the sustainability we need. Value Based Health and Care, and caring, is our best hope to help us achieve this, providing optimal care for those who need it, in line with their preferences and what matters, and allowing us to be the care givers we aspire to be.

I propose six principles for action that our health and care system must adopt to help us achieve this:

1. As care providers we often enter people's lives at a moment of vulnerability; we must respect this, and hear and seek to understand the voice of those we serve in order to deliver the outcomes that matter to people we care for. Shared decision making sits at the heart of doing the right thing.

2. We must ensure the right balance between the science and the art of care; the best care has biometric and biographical care in equilibrium, balancing evidence, professional judgement, people's preferences and compassion.

3. We should give way on professional and personal prerogatives in order to be part of something greater; define what we do as individuals as part of a wider multidisciplinary team and nurture and protect civility, trust and belonging within it. Our teams are greater than the sum of their individual parts, and they will help to support and sustain us.

4. However well-intentioned, some care can be wasteful, risking harm to people and the environment; using a value based approach allows us to balance personal and population-based care better so maintaining, and making best use of, all our resources.

5. Measurement works best when it is meaningful, proportionate, transparent and used for the purpose of improving quality; when measurement drives transactional care it risks moral injury and harm to staff and patients and must be avoided.

6. We are all human and vulnerability is exhausting; we all have physical and emotional limits and a tolerance to risk that is dynamic as a consequence. We should reasonably expect the people and system in which we work to acknowledge and respect this, ensuring that we are supported to practise compassionately and manage clinical risk appropriately.



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