By Dr. Terry Maguire, a Northern Irish Community Pharmacist, senior lecturer at School of Pharmacy (Queens University Belfast) and Belfast LCG member.
Health’s Social Contract – Published previously in Pharmacy in Focus & Irish Pharmacist
A mismatch – what the ill patient emotionally needs and expects and what the practitioner has to offer – causes so much dissatisfaction within our health service. Good care requires good empathy yet when cash-strapped the health service first runs out of empathy. Patient’s need to get evidence-based treatment but, as emotional human beings, they also need reassured that those treating them also care.
For Joe and Jane Public, and all the little Publics who live down on Normal Street, health and wellbeing is not something they really think about much at all. They are relatively healthy and anyway when they get sick they go to the GP and when they get really sick they go to the hospital. Since the start of the NHS, health has been the responsibility of the Caring Professions; it’s got nothing to do with the individual because it’s far too complicated. More over the Caring Professions have the cures so why worry. But this ignores a central pillar of the social contract that underpins the NHS; the government agrees to provide a free health service and the citizen agrees to, as best as they can, look after their own health.
Derek Wanless’s insight from his work on sustaining the NHS into the future was that our Health Service will become unsustainable should we fail to bring balance back to the social contract by “fully engaging” the public.
Wanless called for a shift of 16% of the money we spend on our “sickness” services to be reinvested into public health and “wellness” services. We cannot medicalize ourselves out of social inequalities in health and, in the absence of public engagement, a “sickness service” free at the point of access can only flounder as it succumbs to the insatiable demands of the public it serves. Those less well off are failing to achieve the level of health enjoyed by the rich yet this is not because people do not have access to services rather they fail to appreciate their part in the social contract.
We see this in pharmacy practice every day. Jeanie had a prescription for her 19-year-old granddaughter who was rushed into hospital on Sunday and Grandmother was very worried and very disappointed with how she was treated. On waking Sunday morning granddaughter was; having difficulties swallowing, was being sick and could not keep anything down including water. It worsened during the day, and having collapsed in pain on Sunday night, she was rushed by Ambulance to A&E. At A&E she was kept waiting for 6 hours before being admitted overnight for assessment and observation. On Monday, having been seen by a consultant who, according to grandmother, didn’t seem to know what was wrong, she was discharged but was readmitted Monday evening dehydrated and again in severe pain. On Tuesday night, much better, she was discharged but Grandmother was adamant that the way she was treated in hospital was just unacceptable and we all agreed.
Afterwards in the dispensary one of my more sociable staff members confided that Jeanie’s beloved granddaughter had been on “a bender” from Thursday until she was carried out of a local nightclub unconscious on Saturday night. Alcohol induced gastritis seemed an appropriate diagnosis and with an antacid, bed rest and lots of fluids the health service would have been saved a lot of grief and expense and Jeanie would not have been so dissatisfied.
Yet we are told we should never blame patients for their behaviours and yet if we collude in this we cannot balance Health’s social contract on the patient side.
On the NHS side the imbalance in the social contract is implicit overpromise and then failure to deliver. Evidence-based medicine was supposed to stop this but Joe and Jane Public don’t much read NICE guidance. In an environment of implicit overpromise, unmet health need, the glossy name given to questionable diseases and their more questionable treatments, just gets bigger. Unmet health need is being uncovered more rapidly than lice in an infected child’s scalp. It is insatiable as doctors, health charities and Big Pharma conspire and sustain treatments merely to copper-fasten their own value and importance.
We might find a cure for cancer in 50 or 100 years when most cancers will be managed as long-term conditions; some already are. But for many cancers; small cell carcinoma, bowel cancer and pancreatic cancer, your options following diagnosis are pretty limited. You would not think this given the resource-pit that is cancer treatment. Why do American undertakers nail down coffin lids? To stop oncologists continuing treatment!
BMJ some years back featured a US article “How Doctors Choose To Die” which followed a physician after a pancreatic cancer diagnosis. The physician simply locked up the surgery, rang his adult kids and told them to meet him with the grandkids at the airport as he was treating them to a holiday in Florida. On returning from the vacation of a life-time a plan for his death is put in place and eventually it happens with the support of palliative care; more quickly than perhaps if he was treated aggressively but in what time was left the quality of his life was so much better and he used up very little health resources.
The NHS has done so many great things for the UK population but we have now reached a crisis point where the social contract is so out of balance to be unsustainable in its current form. Change is needed but change is proving impossible since citizens are refusing to accept their part of the contract and the service is overpromising on its part resulting in a exponential rise in unmet, and inappropriately treated, health needs.
Citizens, through their behaviours, need to start producing health and wellbeing and the service needs to be realistic and honest in what it can achieve. Only a poor death should be seen as a failure as we shift emphasis from curing onto caring.
