|
|
|
|
|
|
|
|
|
|
|
|
|
The Royal College of Physicians UK published its vision of future doctors in May 2010. The aim was to define the contours of society within which healthcare will be delivered over the next 20 years. While the core values of trust, consent, care, competence, confidentiality and professionalism will prevail there will be many changes to how we practice. Current medical students and newly qualified doctors will be the group most affected by how things will evolve over the next two decades. In the introduction it is stated that if we don’t build the future others will. The medical profession has been slow to address the future, the reasons being professional tribalism, institutional inertia and political reservations. In the second decade of the 21st century doctors should make renewed efforts to achieve what matters most to them, high standards of care and service to patients. The agenda between now and 2030 should be shaped by three themes. The first is well being and the idea of a good life which is about maximising the years of good health. This initiative involves health promotion combined with disease and disability prevention. The second is the reconfiguration of the doctor-patient relationship with emphasis on an open partnership and the demise of paternalism. It needs to be realised that patients are becoming increasingly risk adverse and they place great emphasis on safety. The third is leadership and the need to be an integral part of the planning of the future. Doctors will be pivotal in ensuring that the current era of cutbacks do not expose patients to a disproportionate degree of hardship and sub-optimal care. Measures to apply blunt productivity calculations to healthcare procedures and personnel must be resisted as they frequently ignore the importance of the quality of care. The Report states that if doctors do not face up to the challenges, they will not deserve to lead.
Doctors have been on the back foot for too long. Many appear to be unhappy. The reasons include cuts in services, threats to the continuity in patient care, the mishandling of EWTD including confusion about future training and anxiety about the stricter Medical Council regulations including revalidation processes. There is disquiet about the regulatory burden and the degree of central control. The profession is faced with increasing demands for the alignment of professional, organisational and regulatory systems. The reduced service commitment of junior hospital doctors is placing an increased workload on more senior doctors. Some of the profession perceive themselves as victims in the changing healthcare system. The authors of the Report feel that there is an opportunity to dispel the malaise. Demography will continue to have a major influence on the delivery of medical care particularly the increasing proportion of older people. In 1968 only 20% of men and 30% of women lived beyond 80 years but in 2008 the corresponding proportions were 42% and 61%. Older individuals are major consumers of medical services.
Those over 85 years are 14 times more likely to be admitted to hospital than those aged 15-39 years. There will be increasing numbers of people with dementia living in the community. The elderly frequently have multiple disease pathology and the Report states that there will be a need for more generalists to co-ordinate their care. These generalist physicians will need to understand their patients in physical, psychological and social terms. They need to be able to guide their patients through the complex world of health and social care. If this does not happen GPs will be the only remaining generalists. The Report does not elaborate on how these generalists differ from geriatricians. The lifestyle issues of obesity and alcohol misuse are set to be continuing challenges for doctors. Obesity is leading to increased problems with diabetes, hypertension and musculoskeletal complications. Obesity related hospital admissions have risen fivefold in five years. Alcohol addiction and its treatment is costing almost £3 billion annually.
The future direction of science and technology is an area of uncertainty. Some commentators think advances will be incremental while others are more optimistic and forecast that there will be step change progress. Exciting prospects include the Delta scan and Sigma scan projects and proton therapy for cancer. With better understanding of cancer cell biology more targeted treatments with reduced side-effects are becoming possible.
Other areas of advance will include nanotechnology and robotics. The one certainty is that there will be a pressing need to educate and re-educate the profession so that it doesn’t fall behind. It takes 16 years for new clinical discoveries to move from research to general practice. There is doubt about who should drive forward innovation. In the UK the National Institute for Health and Clinical Excellence (NICE) has an important role in assessing the efficacy of new treatments. Its work has been controversial in that at times it has been accused of rationing expensive new drug therapies. It has, however, tackled the inappropriate variation in the quality of healthcare and the optimal use of finite resources. Clinical decision making and treatment thresholds will continue to come under increasing scrutiny.
Changes in working hours will result in greater centralisation of emergency services and a decentralisation of office based activities. Doctors will increasingly focus on diagnostic and care planning roles rather than the administration of treatment. Women will represent a majority of the medical workforce by 2020 and a majority of GPs far sooner. The introduction of flexible work practices must be speeded up. Currently only 15% of posts in the NHS are part-time. There must be a more enlightened approach to continuing education and career development.
The Report set itself the difficult task of predicting the future. Its purpose is understandable because good planning can’t be implemented unless we reflect on how medicine is likely to evolve. Much of the Report is commonsense and reasonable. However some sections are aspirational and others are lacking in content. At times it appears to be asking too much of doctors. A medical student or newly qualified doctor may find it daunting. He or she is expected to be a clinician, a communicator, a scientist, a manager, a budget holder, a social services co-ordinator. The Report doesn’t sufficiently explore the reality that doctors have different strengths and weaknesses. There isn’t a ‘one size fits all’ medical model. Being excessively proscriptive could expunge the leadership qualities that the College so strongly calls for. The profession must remain sufficiently flexible and broad minded so that it can embrace individuals with different qualities, attitudes and skills. If this is not built into the medical selection process and training the profession could ultimately lose out.
JFA Murphy
Editor
1. Future physician. Changing doctors in changing times. Report of a working party. Royal College of Physicians London. May 2010. www.rcplondon.ac.uk
|
|
|
|
|
|