The magic roundabout

Circle of change

So, Dougal the doctor, Florence the nurse, and Ermintrude the practice manager scuttled around reorganising everything. They went from general practice fundholding, through primary care trust commissioning, to practice based commissioning. Primary care trusts merged to become what had been known previously as strategic health authorities. Then, in 2008, Zebedee, convinced that giving most of the health budget to primary care was a recipe for inequity, pulled much of it back to be controlled centrally.

The target set by Zebedee in 2005, that anyone who wanted to see a doctor should be able to do so within two days, proved hopeless, making it more difficult for working patients to get appointments rather than easier. So it was scrapped and the status quo restored. In 2009, after several years of huffing and puffing about general practices having to open around the clock, which proved entirely impracticable, the idea was quietly dropped. Instead, the General Medical Services contract was amended to make commitment to working out of hours more attractive to general practitioners, and to link them to the by now excellent NHS Direct telephone and internet advice service for patients. And we found ourselves pretty much back where we had started. While all this was going on, Brian and Dylan, as patients, looked on utterly bemused.

Patients accept more responsibility

What has really changed during the past 10 years, though, and very much for the better, has been the growing awareness that patients have responsibilities as well as rights—not just in terms of leading healthy lifestyles, turning up for appointments, and conforming with care plans agreed with clinicians but also in terms of accepting the risks associated with treatments and using those treatments responsibly.

It is difficult to pin the beginning of this revolution to a particular event, but it probably began in 2007 with the ban on smoking in public places. Initial cries of “nannyism” from some sections of the media abated when, by 2012, the number of people smoking in Britain had almost halved, falling from 23% to 12%. Gradually, even the most liberal commentators began to acknowledge that the government is charged with managing the healthcare budget to best advantage, and that health promotion is a sensible and cost effective use of funds.

From the outset, the trend was accelerated by press and public repugnance at some of the scenes of binge drinking and its consequences after the introduction of 24 hour pub opening at the end of 2005. That law was rescinded two years later, but the ugly images remain in the public mind to this day.

Credit: GORDON SOUTHGATE

As people began to realise that preventing themselves from becoming unwell was infinitely preferable to having avoidable illnesses treated, they started to listen more carefully to the government's health promotion messages: eating more healthily, drinking more sensibly, taking more exercise, and avoiding unnecessary exposure to the sun. Generally, the media helped move the process along. In particular, they played a major part in making drug misuse completely unfashionable.

The resultant substantial reductions in type 2 diabetes, and in heart, lung, and liver disease, has greatly eased the burden on the healthcare system. Reversal of the rising incidence of skin cancer inevitably took longer, but it has now levelled off and is slowly beginning to fall.

New services

The introduction of wellbeing centres in 2012 has also proved helpful. Popular with an increasingly health conscious public and staffed by dietitians, fitness advisers, and nurses, they provide sensible, practical advice on healthy living.

The establishment of NHS new age clinics in primary care has been welcomed both by patients and by initially sceptical clinicians. Offering acupuncture and chiropractic, and dispensing benign pills, potions, and dietary supplements on prescription, they have brought alternative and complementary treatments into mainstream health care. As bonuses, they are putting quack doctors out of business, encouraging research into the safety and efficacy of complementary treatments, and helping to deflect the worried well from general practitioners' surgeries.

All this allows doctors and nurses to spend more time with patients, listening to them more carefully, and explaining treatment options and their risks and benefits more clearly. Clinicians now understand that people, especially those with long term illnesses, have much to contribute in terms of knowledge and experience both of their conditions and of their lifestyles, and that, given proper and sympathetic support, they are usually more than happy to self manage their conditions. Increasingly, healthcare professionals are pleased to see well informed patients rather than being wary of those they once thought opinionated. “Patients being partners in their own healthcare” has ceased to be a sound bite and is becoming a most welcome reality.

These remarkable improvements were made possible, in part at least, by Zebedee's eventual realisation that change for change's sake helps no one, confuses most people, and demoralises health service staff. In 2013, he translated this into his widely applauded Healthy Britain white paper, promoting the concept of consolidation. No one has heard much from him since.