Two paths for medical practice

THE LANCET VOL 340: SEPT 26,1992

ADDRESS: Gelli Deg, Penmaen, Swansea SA3 2HH, UK (Dr J. T. Hart, FRCP).

Worldwide, medical practice is becoming recognised as a mode of production, its inputs and processes, and occasionally its health outputs, subject to critical measurement and accounting. This historic development creates a parting of ways. With social imagination, it could move us toward clinical practice which not only uses medical science but also becomes part of science, subject to the same rigorous self-doubt and permanent impermanence-a mode of production transcending commodity industrialism. Without social imagination, clinical practice will become only another variety of commodity production for the market; the directions for accountability will be to management and consumers, practice will be industrialised, and our tradition of social responsibility for universal medical care may die. Governments everywhere are now dragging us toward this second option, in which services are driven by market forces.1-7 By accepting it we may destroy the only successful experiment in taking from all according to ability, giving to all-according to need, and thus learning to share the world rather than grab what we can.

Markets and process inflation

Although all commodities are products, not all products are commodities. This notion, however, is alien to the language of the market. The elementary units of medical practice are consultations, where patients’ problems are first (and often definitively) translated into solutions. In a market system the measure of output attracting reward is process, not health outcome; thus concepts of consultation become vulnerable to an apparently rational stripping-out of all that impedes faster process.

Commodity markets work best when the transactions take place in a context of permanent instability and brief contract. Episodic care fits neatly, continuing care hardly at all. The explicit rationing system for the poor in Oregon,8developed only for episodic care, revealed the inherent difficulties of translating continuing care to commodity terms. The examples chosen by advocates of the market are always episodic medical care for acute illness and cold surgery, which operate fairly well as services to passive consumers.

Within wide bounds of regulation, markets promote scientistic medical technology as indiscriminately and uncritically as they do any other commodity. In 1980, US patients were more than twice as likely as UK patients to have a hysterectomy, prostatectomy, or cholecystectomy, eight times as likely to have a tonsillectomy, and ten times as likely to have a coronary bypass.9 By 1988, cholesterol lowering drugs had penetrated the US prescription market about eight times more than in the UK.10 Such differences are systematic and must in part reflect market pressures on clinical decisions-which are difficult enough 11 without such pressures.

Because the NHS was isolated from market pressures, clinical procedures developed cautiously and sceptically. Though it offered unlimited care to the whole population, total per caput medical spending in the UK was 2.9 times less than in USA, and per caput pharmaceutical consumption was 1.56 times less.12 We have more than four decades of experience of free, tax-funded medical care without tuition fees, patient fees, or billing. Administrative costs were a steady 4-6% of total spending (before NHS “reform”), compared with a rising 22% in the USA.13,14 UK price inflation for medical care 1975-87 was half as much as in USA. 15 Such empirical experience, and the results of at least one inadvertent randomised controlled trial,16 indicate that free public service is more cost-effective than marketed care.

Somatisation and the interface between primary and secondary care

Besides inflated process, the most obvious weaknesses of all care systems are somatisation of unhappiness and failure to provide continuing anticipatory care for recurrent and chronic illness.

In the 1960s, British GPs were not well equipped to handle unhappiness and its effects. Offloading of somatised illness was therefore a serious problem for hospital specialists in the early years of the NHS. Typically, Gottlieb 17found that 39% of all general medical outpatient referrals had no identifiable organic disease. As general practitioners became more interested in problems patients actually had, and less in trying to exclude what they did not have, new outpatients referred by them fell steadily from 302/1000 population in 1962 to 161 in 1976. This was followed by a slow rise to 186 by 1986, still 38% below the 1962 level (Metcalfe D, personal communication).

This important success went largely unnoticed because of a continued rise in total outpatient load, caused not by new GP referrals but by increased specialist cross-referral and outpatient follow-up,18 regarded by many GPs as largely unnecessary .19 Over the same period, GP direct requests for laboratory and radiological investigations rose from 120 tests/l000 population in 1972 to 352 in 1986, 20 with higher yields of abnormal findings than similar investigations ordered by junior hospital staff. These two trends suggest that NHS GPs accepted increasing responsibility for dealing with both unhappiness and somatic disease over the two decades preceding the new contract, though they were rewarded only by the self-respect generated by more effective work. Cooperation, and the scepticism of medical science uncorrupted by trade, seemed to stem the tide of somatisation. Market competition will restore priority for patients’ wants over patients’ needs.

Unlike the USA, and more than almost all other developed economies, the UK has a well-defined referral system, with a modal 6.5% of primary contacts referred for specialist help.21 Half of NHS doctors are community generalists, who handle 90% of patient contacts within primary care while incurring only 6% of NHS costs, excluding medication (or 13% with medication, much of this specialist-initiated). Compared with their US colleagues, UK specialists were relatively free from economic pressures to subspecialise,22.23 and from litigious consumer pressure to practise defensive medicine,24.25 though this is beginning to change as the medical market revives. Because specialist care tends to be more procedural and episodic than early and continuing anticipatory care by community generalists, our referral system probably accounts more than any other factor for the cost-efficiency of the pre-reform NHS compared with entrepreneurial care elsewhere.

However, if population needs are ever to be met cost-effectively a further shift of responsibility for management of most chronic and recurrent disorders from specialist to community generalist care will be essential. Both government and professionals continue to underestimate the scale of unmet need by roughly half. In the UK, about half the hypertensives for whom treatment would be effective are still unknown, half those known are not treated, and half those treated are not controlled. As an order of magnitude, this Rule of Halves 26 seems to apply to most chronic and recurrent problems; wherever we look, we find the same scale of omission.27-31 Community management of chronic disorders therefore begins from low standards, but remember that these figures include all of the people. Audits in the past decade (long before internal markets) showed rapid improvement in detection and acceptance of continuing responsibility.32-39

GP fundholding (whereby GPs are given money to purchase services for their patients) could and probably will be used to accelerate this shift of responsibility for chronic disease from hospital specialists to community generalists. We do not yet know whether this will be encouraged mainly by new income incentives or by provision of new resources, but the market strategy is already concentrating investment on successful practices. Inevitably this favours those under least pressure. Adjustments that raise the income of practices serving poor populations provide no guarantee that this extra money will be invested in more resources for patients; experience suggests that most of these doctors will use it to compensate themselves for their harder work. Population units for fundholding, starting at 7000 and rarely exceeding 15000, are an order of magnitude less than the 50-100,000 required for cost-effective administration. Thus, GP fundholding may well be intended more as a curb on high-spending by hospital specialists, than a means of redeploying resources from secondary to primary care.

Patients as co-producers

In the past, consultations were regarded as transactions between active providers and passive consumers. We now recognise that patients supply at least 85% of the information required for diagnosis,40 and that their participation and understanding are essential for management of illness.41-43 Accurate diagnosis requires that patients give intimate confidences to health workers, creating personal relationships on which continuing mutual responsibility can and should be built. We have good evidence that the quality of these continuing relationships profoundly affects compliance,44-46 dropout rates,47 investigation rates and willingness to “wait and see”, 48 hospital emergency admission rates, and average length of stay.49

Cost-effective practice therefore requires that patients be helped to evolve not as consumers in episodic relationships, but as co-producers in continuing relationships. This will entail a long and difficult learning process for both patients and health workers, aimed at understanding the nature of disorders. and how improvement or decline can be measured, 50 agreement on targets and feasible plans for reaching them, and discussion of the risks as well as the benefits of treatment. It will also require changes in practice organisation that put more emphasis on personal care. 51

All this requires time, continuity, and labour-intensive rather than technology-intensive strategies throughout the NHS – not denying the value of appropriate technologies, but discouraging their use as substitutes for getting accurate and comprehensive histories, with diagnoses relevant to patients’ problems in real social contexts; intelligent pursuit of outcome, not thoughtless replication of process. It will work, but it will not pay.

The currency of primary care is time

Industrialised practice measures efficiency as throughput, process, and immediate satisfaction of wants. Its logical outcome will be a speedier and more standardised process, with loss of autonomy for producers and episodic relationships at all levels. Average consultation time is a poor measure of clinical wealth but a good measure of poverty even in the industrially developed world. In government clinics in Hong Kong average face-to-face consultation times are 3-5 minutes;52 in Spanish ambulatorios they are 2-5 minutes (up to one-third of this going to administrative tasks),53.54 in UK general practice 7-8 minutes, and in US family practice about 15 minutes. 55

Little can be achieved in less than 5 minutes unless a strict algorithmic approach is adopted, suitable only for detection and management of gross disease. 56 Otherwise the tendency is to satisfy immediate wants. Longer consultations are needed to search for needs, create new understanding, or convert patients themselves into producers. 57-59 Extra time will not always be well used,60 but is a precondition for advance. The target of a 10 minute booking time for general practice was proposed in 1973 by Buchan and Richardson 61 as a first step toward generalising the sort of care we expect for ourselves; 18 years later, family doctors in areas with the worst health must still work at intolerable speed, often for intolerable hours.62,63 More than any other single reform of the NHS, unstressed primary consultation time could rally professionals and patients to the cause of more thoughtful, more cost-effective clinical medicine, closer to science through more selective use of technology.

Time is the real currency of primary care, and under the extreme constraints of traditional industrial working class practice each consultation is hurried in the hope that time may be gained for the next crisis. In understaffed public service, clinicians have perverse incentives to cope with inadequate consultation time by inappropriate prescribing and referring. If medical responsibilities are confined to somatic disease, the emphasis will be on a costly process of exclusion-rather than an imaginative search for understanding, including wider health issues and the patient’s own potential resources for dealing with them.

Industrialised management knows only two strategies to contain this; administrative controls (sticks), or income rewards (carrots). Neither will result in the more thoughtful and time-consuming patterns of shared decision (with patients) required for cost-effective practice. Whether punitive or incentive, these investments are in irrelevant currency; without more consultation time, decisions remain evasive and inaccurate.

Can science and care converge?

Industrialised management regards community generalists chiefly as gatekeepers who ration scarce resources against the infinite consumption at zero price predicted by economic theory (but never found in practice). For primary health workers to develop as advocates for their patients they must reverse this role, helping patients to avoid inappropriate entry to the pipelines of secondary care-not because these are costly, but because they waste everybody’s time, incur unnecessary risks, and divert attention from more relevant and effective solutions. At its best, the beauty of experimental science lies not in display of technology but in simple solutions to complex problems.

Information technology, and the attitudes consequent on recognition of clinical medicine as a socially accountable form of production with measurable labour inputs and health outputs, make mass clinical audit possible, so that practice in whole populations can for the first time become routinely self-critical, and care can begin to merge with science. This requires that audit data be used only to discover the truth, not to reward or punish competing entrepreneurs whose incomes depend on data they record. Without this guarantee, audit data will be as close to the truth as a tax return.

Health economists promise that all these damaging consequences of an economy fuelled by greed can be avoided by regulation and pricing. How this can be done in an era of deregulated markets where prices find their own level is not explained. Is there any example of a large regulated market that does in fact serve rational social ends? If medical markets can be regulated to solve health problems rather than maximise profit, why have we failed to regulate the construction industry to build homes rather than office blocks? Such regulation challenges the present distribution of wealth and power, and is simply not credible in the current political context. If we have a duty to learn from the failures of command socialism, should we not learn also from experience of unopposed capitalism?

If the test of cost-effectiveness is health outcome rather than process, cooperative production is potentially superior to market-driven care. We shall be all the better for recognising that our work is real, measurable, and accountable, but this need not require that we compete for market demand rather than cooperate to meet human need. Though the internal market may well accelerate throughput, it will destroy goodwill, promote demand, raise cost, and penalise sceptical learning. Its product will be more process, not better and more cost-effective health outcomes.

I thank David Metcalfe for unpublished data on use-rates; and Sir Douglas Black, Leon Eisenberg, Dennis Pereira Gray, Conrad Harris, John Horder, David Morell, Kerr L. White, David Himmelstein, and Leone Ridsdale for comment on earlier drafts. This paper is based on a lecture at the international course on primary care at St Mary’s Hospital Medical School, July 7,1992.

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