Health: Primary and Community Care

Lord Alderdice Excerpts

Thursday 24th June 2010 Lords Chamber

[Lord Alderdice]

My Lords, like other noble Lords, I commend the noble Lord, Lord Mawson, on obtaining this debate, particularly in this area of healthcare—the bringing together of primary and community care and learning practical lessons from the work that has been done.

Until my retirement from psychiatry and the NHS at the end of March this year, I had worked for many years in healthcare in Northern Ireland. As some noble Lords will know, we have had a fully integrated health and social care system since the early 1970s. This has been enormously beneficial. Let me give noble Lords some idea of what it means. When I was working as a psychiatrist, a patient would be referred to me by a general practitioner in the same trust. I would see the patient as an out-patient, and I would have at the clinic, as part of the multidisciplinary team, nurses, social workers, psychologists, as well as junior medical colleagues. Indeed, secretarial and administrative staff were very much regarded as part of the team because they would meet the patients. How the staff related to patients on the telephone or in reception was an important part of managing them. If they needed to be admitted to hospital, the same team would be able to work with those involved in patient care and the patients. All these teams included social care. Social services staff were as fully involved in the trust as the medical or other professional clinical staff.

With regard to the management of the trust, a manager of doctors might have been a doctor but they might also well have been a social worker, an experienced nurse or some other professional within healthcare. It meant that people were able to work together right across the disciplines with the single concern of ensuring the best possible health and social care for patients, whether they were at home or a daycare facility or whether they were short or long-stay in-patients.

My noble friend need not be concerned; I am not proposing that there should be structural changes in the healthcare system in England, but that structure facilitated us in working as multidisciplinary teams. However, we discovered that there was a limit to multidisciplinary teams, because after a time it became apparent that there still had to be an element of leadership. It was not enough to get the professionals to work together as though everyone had the same role and the same responsibilities; it became apparent that there was a need for leadership. Whether that came from the medical side or from social work, psychology or nursing was much less important than the skills that the individual had as a leader. Being a leader is not a particularly professional qualification; it is a personal one.

I say to the noble Lord, Lord Mawson, that for many of us a medical model is biopsychosocial. The notion that it is only about the physical and does not include the mental, emotional and relational is, from my point of view, a rather perverse idea of what medicine is really about. However, I accept that there has been a tendency for doctors and others outside medicine to push medicine in that direction, and it is down to those of us who believe in something different to open up the windows and to help people to understand that we are talking about not just the whole person but the whole person in their relationships with others. That is all part of good medical work.

We did not just find a limit to the notion of multidisciplinary teams; we also found a very definite limit to the notion of managerialism. Of course, as things became more complex and finance became involved, it became necessary to have managers and administrators. At the start of the process, they were seen as serving the requirements of professionals and patients. However, it was not long before they began to regard themselves as the bosses of the clinicians—and indeed sometimes of the patients as well. They would be far less concerned about the professional and clinical requirements or the requirements of the patients than about balancing the books or having a growing managerial empire. Every time there was a reorganisation and restructuring, the one group that never seemed to reduce in number was the managers. There always seemed to be places for them to go and none of them ever seemed to be made redundant in restructurings.

The truth is that an arrogance began to develop whereby the people at the centre, whether they were managers or in Whitehall, felt that somehow they had more real interest in, concern about, knowledge of and expertise in what was good for patients and patient care than the people who had committed themselves to that work from the beginning of their professional lives. Some of the managers came from business and had no real understanding of the complexity of healthcare. However, they were encouraged by Governments who saw a market model as being the way to run a healthcare system. That never seemed to make much sense to me because, if the bottom line was important for you, the best thing you could do was to let many of the patients die as quickly as possible so that they would not be a charge on the state.

The market principle just does not work when you apply it to healthcare. In fact, if you apply it too energetically, you provide perverse financial incentives to do absolutely the wrong things. I do not mean that there is no place for the market but I have always felt that a menu was better than a market—yes, there is choice, you make decisions and you understand that different approaches involve different costs; nevertheless, there is some kind of informed choice that is based not just on the cost but on the value of what you are trying to obtain for yourself or your patients.

Therefore, there is a limit to multidisciplinary teams that have no leadership; there is a limit to the notion of managerialism as the way to run a healthcare system; and there is a limit to the market as a model for running a healthcare system. Those are some of the things that we have learnt in healthcare over the past 10 or more years.

However, there are also a couple of major challenges that we need to address, one of which is the enormous change in the social patterns of the lives of the people with whom we are working. The noble Lord, Lord Rea, mentioned that we have an older population, and that brings with it increased challenges of all sorts—ethical and management problems and clinical difficulties. For example, certainly for a period of time, we were largely successful in getting rid of infectious diseases, and that let people live longer, so they lived longer in order to develop cardiovascular disorders. When you dealt with those, they then lived long enough to develop cancers of all kinds and, when you dealt with those, they then lived long enough to develop dementia. It is not as though when you deal with a whole set of problems they all go away. We live longer and experience other kinds of problems.

That does not mean that we give up but we have to be realistic that all sorts of changes need to be addressed. There are changes in social patterns, including the size of families, the type of family units and a range of people from all parts of the world with all sorts of different dietary backgrounds and physical backgrounds, infectious disorders, and so on. We have to deal with all those things. We have to be alert and aware of change, which is quite a challenge. As such patients come into your practice, whether it is a hospital or community practice, you have to become aware, if you were not before, of the complexities that they bring. That is not easy. There are cultural issues in dealing with patients that are very sensitive and difficult. It is not all about those in the community welcoming folk in from outside. It is not only about them understanding and changing; it is also about helping people who come in from outside to understand the community they are joining and the culture and requirements that that community has.

Those are challenges but there are also opportunities, many of which are provided particularly by information and communications technology. They change the way in which young people in particular—though not just them as many older people are increasingly adept at the use of information and communications technology—react to things, receive messages, relate to each other and the way in which we educate our clinicians. It is now possible to educate clinicians at a distance. For example, a skilled surgeon in one part of the country can assist someone conducting an operation on the other side of the world by using telemedicine. We can be in contact with patients in the community by staff using ICT.

Some but not all of this is extremely successful. Just because you have a new gadget does not mean that it is better; just because something works faster it does not mean that it always works better. A colleague told me about a wonderful new system that he wanted to put in that would ensure that immediately the general practitioner made a referral it would be in my inbox. I said that it was no use whatever because the waiting list is still six weeks. It does not matter whether the referral comes in today, tomorrow or the day after, it will still be six weeks before the patient is seen.

Not every piece of technology or new gadget is appropriate, helpful or an effective use of resources. Some approaches can be extremely helpful in allowing us to move on and to learn the lessons about what actually works, which was the whole theme of the noble Lord’s introductory speech. That is crucial but let us not dismiss the importance of research and academic work. It is not just about managerialism, although I do not dismiss that, as in a complex community management is extremely important. I have been encouraged by our new coalition Government’s commitment to get decision-making and responsibility back to the patients, their families, the communities and clinicians of all kinds with whom they deal—it should not be held back at the centre whether that is a management centre, a Whitehall centre or even a governmental centre.