Relational primary care

Phil Hanlon, Pauline Craig and John O'Dowd

Twenty-first century health challenges

As we move into the twenty-first century we face new challenges to health and wellbeing. Despite improvements in material circumstances and unprecedented levels of expenditure and interest in healthcare, modern life is not conducive to good health. The dis-eases of unhappiness, lack of fulfilment, relative poverty, and the stress of contemporary life have resulted in new challenges to health. Moreover, despite the fact that many are materially rich, we are constantly reminded of the inequalities which pervade contemporary society.

As a result of the way in which we live our lives, the pattern of health problems is changing, with some risk-states and illnesses becoming much more common. These problems include alcohol related harm, depression, various forms of addiction, and obesity. When Sir Derek Wanless, a banker, was asked to head a review of the NHS in 2002, he concluded that unless the population of the UK became ‘fully engaged’, even the large increase in funding he was proposing would be insufficient to meet the projected needs. [1] More recently, he has reviewed progress and concluded that currently disease trends and the inability of the NHS to adapt will severely compromise our ability to meet projected care needs. [2]

It is well understood that we need to cope with the care of an ageing population with high levels of chronic disease. Typically, heart disease, respiratory disease, diabetes and other chronic conditions are first manifested in middle life but, because of prolonged survival, require decades of complex care. Other problems like dementia are becoming more common because a larger proportion of the population are surviving longer. Improving life expectancy creates a need for ‘anticipatory care’ (where interventions are provided in advance of or in anticipation of complications and difficulties arising) and continuing care once the disease is well established. [3]

The reason for such pessimism is that we face an array of chronic problems for which there are no simple cures or interventions that make a difference to outcomes at a population level. Instead, the health challenges of the twenty-first century will require complex and multiple interventions at many stages of the life course. Professionals can provide some of these interventions but, more typically, outcomes depend on an ongoing cooperation between the person with the condition and team of professionals, with patients and healthcare professionals working together as co-producers. [4] Professional care can be excellent but if the patient does not attend to self-care, and the wider environment does not support change, outcomes will be poor.

How the current system seeks to deal with this complexity

The NHS is a product of the modern period: it is a child of modernism. As a consequence, it deals with this complexity of the twenty-first century’s health challenges with a modernist mindset and employs tools that are typical of modernism. This has led to:

Bureaucracy. When confronted with complex health problems, bureaucracies break down the complex task of care into component parts and allocate specialist to each to these tasks. They then appoint managers to integrate the process of providing care and multiply the mechanisms needed to monitor the quality of care.
Managerialism. Recent years have seen dramatic rises in expenditure on healthcare. This expenditure has failed to reduce the rise in unhealthy living. Since the Griffiths Report in 1984 introduced the concept of general management, the NHS has been led by a managerial ethos, which believes that increased managerial controls with effective planning are key to solving the problems faced. [5] The language of the NHS excludes all but the managerial elite: health is seen as a deliverable commodity whose trajectory can be analysed, mapped and then created. The complexity of lifestyle choices and behaviour are seen to be outwith the sphere of NHS influence: too difficult and contentious to matter.
Evidence based approaches: policy and evidence. The scientific method is a key underpinning of Western medicine, and health care decision making is based on good evidence. The work of Sackett underpinned evidence-based healthcare, which emerged in this country during the early 1990s. Sadly, evidence has been used not only to inform policy, but to limit policymaking, to excuse policymaking, and finally as a form of marketing. With an NHS which needs evidence to make decisions, interventions, such as drugs, which are heavily investigated, will be preferentially used to those with little evidence. The rise of statins in the treatment of high levels of cholesterol as a case in point. Little time is spent on lifestyle modification. Statins have evidence, and are therefore used.
Consumerism. In recent years the argument has been made that the health service needs to treat patients like ‘valued customers’ using the tools for market research and improved customer satisfaction to impact on the patient experience.
Economism. This refers to a philosophical process in which the financial perspective is elevated above all others. So, investment in health is seen as good for the economy, economic analysis is increasingly used to determine priorities and financial considerations are more prominently a part of the day to day life of professionals.
Incentivisation and controls. Financial incentives are increasingly used to influence behaviour (e.g. the Quality and Outcomes Framework for the new GP contract) and performance management employed to monitor processes and outcomes.
Marketisation. Experiments have been made with the artificial construction of market conditions or the introduction of private sector companies into care provision.

In essence, the NHS has become a parody of itself: it deals in sickness, not health, and attempts to reduce care to a commodity. This has resulted in a health service in which health is at best, peripheral, if not irrelevant.

Why these approaches are not enough

Much can be said in praise of all seven of the tools identified above. Yet, each is problematic. Consider the example of evidence-based medicine. The evidence-based approach is not simply a neutral tool that leads to unbiased conclusions. It is an influencing tool wielded by a powerful minority. It might once have been sufficient for those with power to say ‘trust me, I’m a doctor’. Since that power was eroded, the plea is more likely to be ‘trust me, I’ve done the systematic review’! So, the problem is that evidence-based approaches can be used as instruments of power to allow those groups with access to this resource more say over decision making and resources. Access to knowledge by those with resources, therefore reinforces inequalities within society.

Equally consumerism can make the experience of contacting the NHS easier and more efficient. These aims are laudable but the danger is that components of care are turned into commodities that are ‘provided’ to meet ‘consumer need’. The question is whether health care is best conceptualised as a commodity.

Also, while financial incentives and performance management have their advocates, they create a system of external motivation and control that may undermine intrinsic motivation (empathy, professionalism, compassion). One of the dangers is that both patients and staff begin to see themselves and each other as abstracted entities within a complex process that has external incentives and controls rather than as individuals in all their complex humanity.

In the business sector young managers have self-consciously abandoned the idea of loyalty to the firm and instead see a mutually opportunistic process whereby they gain opportunities for training and experience and reciprocate by providing services to the firm. If opportunities are greater elsewhere, both parties would expect them to move on. While this approach may work in a business setting it is counterproductive in a health care setting where a different ethos is needed. Yet, there is anecdotal evidence that, for example, some young doctors do now see this kind of mutual trade-off operating in terms of their training.

The concept of care is notable absent from the tools which modernity brings to healthcare.

Why a relational and co-creational approach is needed

The criticisms set out above of the modernist tools used to organise health care are open to debate. Importantly, they are not the key reason why the modernist approach is not succeeding in combating the twenty-first century’s health challenges.

Wanless, in his King's Fund report, argued that the epidemic of obesity could on its own bankrupt the health service if steps are not taken to reverse its progress. A central argument of our thesis is that the approached described above currently being employed by the NHS will not be sufficient to engage the population in any manner that will be necessary to bring about improvement in problems like obesity and one of its main clinical consequences diabetes. The example of diabetes is illustrative. Someone who contracts diabetes needs a decades-long relationship with a team of carers who, however expert, depend upon the patient being dedicated and indeed expert at their own care. Therefore, good outcomes from diabetes are co-created by the patient and his or her carers. The questions are, therefore, what leads to co-creation and what organisational circumstances and what ethos within the health care system help foster it? Our argument is that co-creation arises out of relationships and that relationships between carers and patients embedded in a community setting is what is required if co-creation is to be made manifest.

A strong relationship between patient and carers leads to trust and creates opportunities that wouldn’t otherwise present themselves in a more fragmented and commodified model. Context is also vital. The family and community that can supply support and social capital is fostered by relationships and destroyed by bureaucratisation, commoditisation and abstraction. Relational approaches to care also foster rewards that are internal and based on relationships. The job satisfaction of feeling in a co-operative and ongoing relationship with your patients and experiencing positive feedback from them as a result of those relationships has been an important part of the historical ethos of the caring professions which has been eroded by recent attempts to superimpose payments for activity and performance targets as an alternative set of rewards.

Arguably, relationships can compensate for the inevitable need for financial rationing. Or, put another way, even if you had unlimited resources it would be possible to deliver some aspects of the quality of care which arise out of strong interpersonal relationships. Strong relationships can also lead to empowerment. It should be emphasised that they don’t always have to do so but there is the potential for relationships to be empowering where a bureaucratised and impersonal approach is often deeply disempowering. Strong relationships develop within the health context also help to foster social capital and wider trust within the community.

How the current system has eroded relationships and reduced co-production

We will use primary care as a case study to explore this question. One could either analyse how the current system drives out relationships or how a new relational system could help build them. In essence, one can see that the current system leads to:

Larger practices
A break down in the continuity of care
A loss of out-of-hours care from the same team that looks after you during the day
An increasing number of short-term salaried medical staff
The incentivisation of cheap and large throughput activities
Targets which skew the balance of clinical care and influence the nature of the individual consultation
The substitution of external, financial and managerial incentives for internal incentives based on relationships.

In short, the current system delivers radical de-professionalization of primary care.

In all of this analysis, where is care? One of the main problems with care is that the market finds it to be unprofitable. It is hard to commodify. Good care is necessarily expensive in terms of time. Quah, [6] Perrons, [7] and Folbre and Nelson [8] have contrasted ‘high touch’ occupations, such as healthcare delivery with ‘low touch’ occupations based on the knowledge economy, such as IT workers. Care delivery is intensive, and there is little margin for economies of scale in comparison with those available to a software programmer. One healthcare professional can only provide high quality care to a certain number of people. At a given point, further increases in the ratio between care-recipient and care-giver will lead to worsening quality.

The professions who deliver healthcare have the care of their patients as their principal concern. [9] Consider the new General Medical Services contract. GPs will be paid to deliver care services according to a national contract. They deliver predefined care which focuses of the structure and process of care, with little regard to the outcomes. The sums involved for each patient are relatively small, but there is a clear incentive to the practices to deliver the care as cheaply as possible. Whilst this could be construed as unethical, the competition of the market has lead to large corporations undercutting traditional GPs to provide these services at an operating loss in order to gain a share of NHS care provision.

Therefore, the new contract favours fast healthcare delivered by a bulk provider, in which the personal relationship with the patient, and the idea of mutual trust is largely irrelevant. Combined with this, the government has castigated GPs for making too much profit and for accepting the offer to opt out of 24 hour care of patients. This has served to further undermine trust in healthcare. Anecdotally, the market ideas embedded in the new contract have dramatically modified the perspective of GPs, particularly younger GPs, who see themselves as small business people, where the contract dictates the limits to their covenant with patients.

Ordinary people know that the quality of care provision has fallen, with traditional relationships undermined, whilst the Government produces evidence of activity from the new contract to support a claim that quality is in fact rising.

The need for a new model

Again, we will use primary care as a case study to illustrate the key principles. Although the focus is on primary care we recognise that secondary and tertiary care as well as the inter-relationships with other sectors like local government need to be addressed. Also, wider societal issues need to change if the modern epidemics are to be reversed.

It is also important to recognise that our desire is not to return to some imagined golden era of the past. In forming a critique of the current system it would be easy but misleading to pretend that all was well before the current system was invented. If we are to respond to the new health challenges of the twenty-first century we need to design a new approach that will foster relationships over decades to allow the co-creation of good outcomes — not regress to the past or put up with the failings of the present.

Complexity versus simplicity

Complexity has been misused by the NHS to justify local diversity. When systems are complex, it becomes difficult to ensure that equity is delivered. The antidote to a complex NHS is the simple NHS.

The NHS is a complex system. Complexity theory and its companion chaos theory provide insights into the challenges faced by the NHS. The key insight is that the complexity of these systems that seems so great and makes prediction so difficult is in fact, created by simple ‘order generating rules’. Historically, the NHS had two order-generating rules. First the allocation of a personal list of patients to a GP for whom he or she was responsible on a continuing and on-going basis. At the same time the creation of consultants as specialists in defined area of expertise but with final clinical responsibility created a second level of organisation. By defining these two roles much of the rest of what we now recognise as the NHS began to grow out of those two order generating rules rather than being planned in detail by politicians and managers.

Part of our critique is that we have now lost both of these order generating rules and that we are compensating poorly by attempts to manage (using the tools of modernism set out above) a system that is too complex. Therefore, rather than design a detailed primary care structure for the twenty-first century the key task will be to describe a new set of order generating rules which would allow a new system to emerge which is more efficient, more relational and more fit for purpose.

The choice of order generating rules reflects the values of those establishing these rules. Therefore, we can see that the rules that created the 1946 health service came out of idealism, paternalism and socialism (or at least the desire to create equity of access and provision). Also, the financial and incentive driven order generating rules discussed above arise out of the values of the current system and the capitalist system than inspires it.

The order generating rules of the new health care system

We will establish continuing 24 hour and on-going responsibility of a defined group of patients by a primary care practitioner who functions within a support team. This continuity is, above all, to enable the establishing of strong relationships so that issues of positive heath and well-being as well as episodes of disease can be dealt with in a manner that is characterised by co-creation of health.

The second rule is that the administrative structure that supports these teams that are in direct relationships with patients are overseen by directly elected local representatives. In short, we would establish an effective local democracy as a mechanism of governance.

The third order generating rule is that financial incentives should be taken out of the equation. This might be achieved by creating salaried primary care practitioners and considering genuinely open and democratically accountable way of allocating resources at a strategic level.

The system we are envisaging would be characterised by local democratic decisions about broad strategic directions and priorities, strong administration and a flow of resource to the neighbourhood level where the key will be the establishment of relationships of trust between professionals and patients who are co-creators of outcomes.

It should be emphasised that the above would replace the managerialist approach that characterises the current system. Managerialism suggests that those who are in a hierarchical management arrangement with the front line workers direct their priorities and whereas we are looking for the reverse where it is the intrinsic motivation of the professionals in relationships of trust with their patients that determines how priorities emerge within a broader strategic framework.

It is equally important to emphasise that the paternalism and unhelpful professional autonomy that characterised the NHS in 1946 will not be a feature of the new system. The genuine desire would be to foster the empowerment of local individuals and communities to take responsibility for decision making and to ensure that these are implemented through their local democratic structures. In short, the health professionals would be the servants of their patients in the most productive and positive sense of that word.

What might the simple NHS look like?

Cuba spends less than 10% of the UK’s expenditure on health, yet it has similar levels of life expectancy. As a result of politically motivated trade sanctions, the Cuban health service has access to few of the modern drugs available to the NHS. The thrust of healthcare in Cuba is based upon interpersonal relationships between healthcare staff and individual patients. Citizens must see their GP twice a year. GPs have equal status to their patients, having been elected to medical school, and being required to live within the community in which they were raised and which they now serve.

We are not arguing for reduced expenditure on healthcare per se, but we are suggesting that a system where relationships of trust are central to the endeavour may be better placed to create health than the sickness service which is in operation today.

References

1. Wanless D. Securing our future health: taking a long-term view. London: HM Treasury, 2002.

2. Wanless D. Our future health secured? A review of NHS funding and performance. London: King’s Fund, 2007.

3. Kerr D. Building a health service fit for the future. Edinburgh: Scottish Executive, 2005.

4. Coulter A. The autonomous patient. London: Nuffield Trust and Stationery Office, 2002.

5. The NHS Management Inquiry (the Griffiths Report). London: Department of Health and Social Security, 1983.

6. Quah D. The invisible hand and the weightless economy. London: London School of Economics, 1996.

7. Perrons D. New economy and earnings inequalities: explaining social, spatial and gender divisions in the UK and London. London: London School of Economics, 2005.

8. Folbre N, Nelson J. For love or money — or both? Journal of Economic Perspectives 2002; 14: 123-140.

9. Duties of a doctor. London: General Medical Council, 2006.

Text © Phil Hanlon, Pauline Craig and John O'Dowd (2008) and licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 2.5 Licence.