The following text formed the basis for a speech I gave to the Junior Members Forum of the BMA, which met in Brighton on Saturday 7 April 2001.
It's a great honour to be asked to address this forum, which is generally acknowledged to provide the meeting place for the best and brightest minds in the BMA, and whose discussions and motions provide a weathervane for the future of the profession.
My task this morning is to stimulate some ideas in your minds and points of debate for the small group sessions later in the day that will lead to motions and proposals to send out to the wider profession, so I've titled my talk, rather grandiosely, and perhaps unwisely, the future of the medical profession. We all need to think about the future, but futurology--the formal study of the future--is, as far as I can see--a somewhat dubious field.
A BMJ seminar once invited an eminent futurologist who, naturally, lives in California, to tell us about the future of healthcare. I say "naturally" because the editor of the BMJ, Richard Smith, got his MBA in Stanford, and is always asking his old course mates and tutors over to tell us what's what. Personally, I'd have a little more time for the American way of health if it was better, and if they managed to provide care for all of their population, rather than just the richest 80%, but maybe that's just my little Britisher personal prejudice.
Anyway, my only recollection of the futurologist's talk was a story he told about being driven with his son to the airport. His son expressed pleasure at the quality of the car they were in, to which he replied: "Son, college equals limmo."
I think we'd all agree that education is the key to success in future life, and so all teachers must be futurologists, for presumably the work of the teacher is to try to anticipate the skills and attitudes that will be helpful for the recipient in the future. Certainly in medicine, courses, curricula, and training schemes are places where future radical values jostle uneasily with the exigencies of the present and the legacy of the past. And to an extent, trainees must be futurologists too, choosing the actions that they hope will enable them to achieve their ambitions and desires.
I presume that the reason I was invited to speak this morning was as a result of my work at the BMJ on Career focus, and also possibly because I was a fairly early enthusiast for the use of the internet. And having worked as a journalist, I suppose I have something to say about the future, because if journalists are anything, they are slaves to fashion. The prime responsibility of the journalist is to report on what's new, and in order to find out what's new you need to swim with its creators. It is very true that the best way to predict the future is to invent it, and the next best way is to be in personal communication with those who are inventing it.
I have now left the BMJ to return to clinical practice, and yes, this fact does reflect my reading of the future. Perhaps you should understand a little bit about my motivation.
I am old enough to have suffered the abuse of working a one in three rota with prospective cover, a fact that at the time made me alternately angry and depressed. I suppose I could have sought psychiatric help, but as I never lost my reason or my will to live I judged it inappropriate. I was very curious about how the professional organisation that was supposedly representing me had allowed this to happen, and decided to infiltrate it and find out more.
What I found in the Junior Doctors Committee at that time was a bunch of colleagues playing sharp debating society tricks, perhaps appropriately: the rather lukewarm grassroots support the BMA tended to enjoy did not allow anyone to harbour the illusion that the grassroots were pressing for radical action. I observed the then chairman of the JDC Stephen Hunter sign the unambitious new deal in 1991, and be appointed consultant a few months later. I called this phenomenon "senior registritis": you join the medicopolitical establishment as an angry young SHO; as you rise through the ranks to be sufficiently influential to take decisive action, it is no longer in your personal interests to take the action that needs to be taken.
My view at that time, and my view remains the same--was that the culture that says you have to keep working to stop working (out of hours) needed to change. Junior doctors' hours and working conditions in hospitals will always be poor as long as senior doctors are non-resident yet responsible for patient care.
I thought instead there should be a consultant-based service that paid for out of hours work at a level appropriate to recognising the adverse effects that working out of hours has on health, and that there should be more doctors to spread this load. One effect of this would naturally be to end the falsehood that one person can be medically responsible for a patient's care "24/7".
This led me into an interest in the issues of communication, both between doctor and patient as I trained to be a GP, and between doctors, as I realised that civilised and sustainable working conditions that also had the best interests of the patient at heart would require much better information systems that the paper notes I was used to working with. Networked computers offer the tantalising prospect of improving on this, but the reality has been disappointment until very recently, and there is still a long way to go.
The ground is shifting under our feet, because at the same time that networked computers offer doctors the prospect of better intra-professional communication, the very same technology is at the behest of patients and governments is also increasing dramatically the pressure on individual doctors. It is a very real power struggle, and those with an interest in power--and I certainly include the BMA in this, have had a fundamental jolt to their assumptions and systems over the last five years as we have all seen the internet adopted with a rapidity unparalleled in human history.
There is one central concept that I want to discuss from this that has implications for all doctors. The internet, par excellence, enables disintermediation. This rather unpleasant jargon, simply means that existing intermediaries, whose main function is informational, have new competition on their hands. A example that is neutral for this audience might be the estate agents. Estate agents are classic intermediaries between buyers and sellers, taking a fairly substantial slice of the value of your house along the way; the internet offers the potential to cut out the estate agent and sell direct to other buyers.
Healthcare transactions are not so simple. Healthcare transactions, are in the jargon of the economists "impacted:" there is a very steep gradient in knowledge between the buyer and the seller of the service, which would be very expensive for any individual to address. Many people value having a personal relationship with their doctor. Geographical limitations are important--the sick do not travel well, and in Britain at least, there is a fairly solid system, that for all its faults, ensures a reasonable degree of quality of healthcare delivery across the entire population.
While the internet may not change secondary care all that much the implications for primary care are profound. Much of primary care involves dealing, not so much with disease, but illness, and the human desire to attach a meaning to that illness. It is an understatement to say that there is considerable pent up demand for GP time. In Britain we leverage this desire to achieve an exceedingly efficient system for screening for disease; but leave many along the way who are dissatified with the explanations they have received, or who have not been helped to the utmost possibility of the system (though generally they will have received adequate basic care).
The average consultation in general practice lasts for around eight minutes for the simple reason that there are about 30,000 GPs in the UK, about 60 million Britons, who on average attend the doctor four times a year--that is how much time there is, and that is how time they get. For all the frustrations of working in the NHS, if you believe in its principle that healthcare should be freely accessible to those who need it irrespective of financial clout, then you believe in this system of rationing time: and if you want more medical time, then you need more doctors
The internet is going to change this a lot. For those with the educational ability and technical wherewithal are going to use channels other than speaking to an NHS GP.
Sir Edward Waine described the "maladie du petit papier"; now we have the "la maladie du grand print-out" It can be a real problem. You all no doubt have your own stories, but the one that comes to my mind is the patient, of slightly below average intelligence who came in to see me in considerable distress having struggled through a whole lot of info about IBD (inflammatory bowel disease): unfortunately he had IBS (irritable bowel syndrome). An easy mistake to make, but a world of difference: a very time-consuming encounter...
As this story illustrates, the potential of the internet to do harm as well as good is obviously marked. It seems to me that just at the same time as services like NHS Direct and the NHS Primary Care Walk-in centres are degrading the role of general practitioner as gatekeeper to a range of services, the need for a trusted personal intermediary between the person, the patient, and the world of medical knowledge increases.
This is good news for the profession. While it might seem obvious in the short term that compared to most public sector activities, doctors' work is both well-paid and secure, the long term security on the profession depends on it continuing to maintain and develop its relevance to the needs of society.
Doctors who believe that the traditional rights and privileges of the profession--for example--to prescribe--are, or should be, ossified forever are sadly mistaken. For one thing, the legal act of prescribing could still be removed at the stroke of the Queen's pen (subject to some democratic process). For another, there is a lot to be said for the libertarian argument that suggests that patients should be free to buy whatever drugs they want, and the role of the doctor is to advise the patient what the best course of action might be, not to control his or her actions. And of course, we have already seen many flourishing businesses selling drugs such as Viagra and Xenical on the internet. And as regulators have traditionally worked along geographical boundaries it may not even be possible or practical to control such supplies of pharmaceutical substances to individuals, even if it were considered desirable to do so.
The reaction of patients as they emerge blinking into the brightly lit world of unlimited information and increasingly liberal access to treatments is not always going to be easy. I liked a comparison I read in the British Journal of General Practice between such patients, and truculent adolescents: at once aware of their rights and potential, but also fearful of their responsibilities. And our task as a profession is to help them mature into sensible users of this new potential; though first perhaps we have some learning to do for ourselves.
At the same time as patients seek diverse sources of medical information, and multiple opinions, doctors themselves may be taking advantage of the new potential of the technology to enhance care for patients. As much as 40% of a clinician's time is spent search for information about a patient--much of the efficiency of traditional general practice was that the task of assimilating such information needed to happen only once, and could be done with reasonable confidence of its reliability from the Lloyd George record. The prospect of sharing that life long health record across primary care/secondary care boundaries is at once liberating and worrying.
We are all well aware of the risks that information, given in the confidence of a medical consultation will leak into places where it shouldn't, most obviously the public domain, but also to commercial or political interests. There are solutions to these problems which I cannot dwell on this morning, but I will say this: if doctors are to maintain their valued place as influential advisers of both individuals and wider society they will have to take personal charge of mastery of the new informational tools. It's a long story that I don't have time to address this morning, but the software problem is not really technical, but political: we need software that is free--not necessarily financially free, but free in the sense of being freely available and modifiable. Follow the links from my homepage to find out more.
If we can get the software right, we have the prospect of having the patient's medical record to hand whereever you might be--which not only offers the potential to do better service for patients by not duplicating tests, and avoiding drug errors, having all relevant information to hand, but also the tantalising prospect of working from home for some of the time, or in making better use of time through teleconsultations.
Employment conditions would reflect this new found flexibility, and the prospect of a flexible market for a doctors' time is a very real one, with doctors possibly existing in chambers, doing sessions for various organisations, (and physically locating there) while remaining in touch with a collegial atmosphere of mutual support, and a market rate for their services. Demand for out of hours could be contained, and risk management would be shifted from doctors, who in effect are forced to ration their time by the size of the population group that they care for, firmly shifted on to the payor for the service. A system with greater sessionality could ensure that all doctors would be willing workers within the system: and we know that what is stressful about work is not stress itself, but lack of autonomy to act in the face of stressful stimuli.
Conscious or not, the rise of the National Association of Non-Principals reflects the recognition by many vocationally trained general practitioners who have already judged the responsibility for risk management of demand from a typical general practice list does not equal the rewards involved; their proposal for virtual practices is likely to be echoed through the rest of the profession.
There are a couple of downsides: the profession and the government have already anticipated these changes: medical student numbers are planned to increase by an unprecedented 50% by 2005; and in 2015 they will be diluting the pool of medical manpower. Rare skills are expensive skills; the corollary also applies. Given that the present number of doctors willing to work in the NHS seems to result in working conditions best described as abusive, the likely relative reduction in pay seems a price worth paying. There is an American folk saying that time ain't money when all you got is time; the corollary also applies: that money isn't wealth when you have no time to enjoy it.
In summary, the fragmentation of primary care caused by NHS Direct and primary care walk-centres, combined with much wider access to medical knowledge is going to place unprecedented strains on the doctors working within the national health service over the next decade.
But the same forces that have caused the strain can also provide the solution. One of the reasons why the NHS is so cheap and efficient is that doctors have traditionally taken it upon themselves to absorb the risk of rationing time and patient workload.
New methods of working that take advantage of the networked electronic patient record offer the potential for doctors to structure their work with the rest of the lives, and pass the risk where it correctly belongs: with those who determine the level of funding for services.
The strategy I propose is evolutionary, not revolutionary, and harnesses the energy of the self-interest of doctors and the needs of patients while enhancing public transparency of rationing decisions.
First published 9 April 2001. Minor corrections 11 May 2001
Copyright Douglas Carnall 2001 You may freely distribute this entire article in any medium providing this copyright notice is also retained. I welcome constructive comments and discussion on the issues raised. Email me at firstname.lastname@example.org
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