A rallying cry for medicine’s old ways

If you’ve never been hooked on Candy Crush, like Ilora Finlay in this week’s BMJ Confidential, you may never have heard of it (doi:10.1136/bmj.g3956). You might be stuck in an ancient groove, juggling and redirecting blocks in Tetris or even playing dominoes. Every fashion has its acolytes but brings a hankering for the past. You give me Neymar and Messi, and I give you Pelé and Maradona. This week’s issue is a rallying cry for medicine’s old ways, even an argument for the cyclical view of history.

Chris Ham analyses the first hundred days of Simon Stevens’ leadership of England’s NHS, and finds a desire to be radical about how services are delivered using new models of care (doi:10.1136/bmj.g3842). Stevens is a former hospital manager and Labour government adviser who understands the dynamics of the NHS and has the potential to unite people behind his vision, which will be published in a “Forward View” later this year. His most recent employment as a senior executive of UnitedHealth Group, a US based health insurer that also operates in the United Kingdom, will create some suspicion of the direction he will recommend, although Ham’s analysis is that Stevens prefers to change the physiology of the NHS rather than its anatomy.

Stevens has advocated a return to more generalism in medicine as well as joint commissioning of health and social care—proposals that might receive a sympathetic hearing. He may also want to listen to Ben Richardson’s plea for a renaissance in clinical skills (doi:10.1136/bmj.g2920). Other ideas that Stevens is mulling, like European style hospitals where medical care is delivered only by consultants and multispecialty provider groups, will be more controversial. How will these affect general practice? “The endgame is surely not just to rock the GP boat—but to tip it over,” writes Margaret McCartney in her column arguing that the destabilisation of the NHS is well underway (doi:10.1136/bmj.g4061).

Another debate that is likely to require Stevens’ attention is the rise in prescription charges in England. Wales, Northern Ireland, and Scotland have abandoned charges for prescriptions and, as John Appleby explains, these charges raised £400m (€500m; $680m) in 2012, 0.4% of England’s total NHS spend (doi:10.1136/bmj.g3944). Since a study in Wales has shown that making prescriptions free has no effect on access to and uptake of care and treatment, what is the point of prescription charges? Why not go back to the old days of no charges? Appleby suggests it might boil down to the value people attach to the principle that NHS care should be available on the basis of need.

More evidence might be a good idea here, although not evidence based medicine as we know it. Trisha Greenhalgh, whose name is synonymous with the evidence based medicine movement, is now resolved to damn it (doi:10.1136/bmj.g3725). The evidence based “quality mark” has been hijacked by vested interests, the volume of evidence is unmanageable, statistical significance tends to translate to marginal clinical benefits, faceless algorithms have replaced patient centred care, and evidence based guidelines struggle to contend with multiple morbidity. If evidence based medicine is broken what can replace it? Well, according to Greenhalgh and colleagues, it is the “real” evidence based medicine, a return to the movement’s founding principles of individualised evidence and shared decisions through meaningful conversations.

The arguments for Tetris over Candy Crush are presumably more straight forward.