I welcome Kramer's reflective paper1 on our work and its funding. I think he asks the right starting question, and that the answering questions go deeper still. They are obvious to any astute observer of general practice, and they are begging to be answered in every surgery we each do. Medical and other politicians are begging not to answer them as they are too difficult, and so stop them being ‘pragmatic’.2
They centre around the old philosophical problem of how we balance the needs and wants of the one with the needs and requirements of the many. So for example in morning surgery should we give our first patient an excellent thorough consultation and then be playing catch up with subsequent patients? Should we be aiming at one excellent consultation or several reasonable quality ones? Can we set a clear standard of quality that does not collapse under the weight of quantity? Is running late a sign of good listening or poor quality?
In public health and evidence-based medicine we see these themes in the Rose Paradox.3,4 This can be briefly stated as a small change in a modifiable risk factor (for example, reduction in population average blood pressure) will produce a major gain in public health outcomes (many fewer strokes and heart attacks) whereas a major change in the health of one individual (for example, after a heart transplant) is great for that individual, but makes almost no difference to overall population health. In terms of medical reward systems should we value doctors who do detailed operations (for example, a maxillofacial surgeon spending many hours taking out an oral cancer) more than those who persuade people not to smoke in the first place?
At the level of health economics or commissioning we then have to work out how many acts of individual good we can afford to allow our doctors to deliver. And the question is unavoidable as we only have a finite sized economy, and a finite sized budget to work with, and we are a finite workforce, of finite personal capacity. We cannot either individually or collectively do everything. How much is it reasonable to ask of us and the system we work in?
As a speciality and as a profession, and as the NHS as a whole system, we have not really acknowledged this tension between the deontology of each individual clinical interaction and the increasing utilitarianism that comes as we discuss the workings of the system.5 We still cling to the wreckage of Nye Bevan's rhetoric of ‘all care necessary from the cradle to the grave’ and hope that we, whether individually or via the system, will be able to achieve this.
At some stage we will need to try and answer the questions of quality versus quantity and the question as to whether our activity and interventions are really aimed at individuals or populations. We may not get a perfect answer to these problems, but at least acknowledging that currently unstable, and often poorly considered6 balances are being struck would be a start.
- © British Journal of General Practice 2012