Clinical futures

Are as important to health policy as economic and social futures

Speculation about the future of medicine often centres on anticipated or imagined breakthroughs in science and technology and on the possible impact of these advances in preventing and treating disease. Yet much of the thinking about health policy has stemmed from the perspectives of political, social, economic, legal, and organisational theory. It is time to move the two closer together.

This week sees the publication of a book of essays by a number of distinguished clinical investigators who were invited to take a freewheeling look at the likely trends in diagnosis and treatment over the coming decades.1 Our concern in undertaking this exercise was to redress a balance and to create a forum for the strategic thinking of clinicians and others engaged in pushing forward the boundaries of medical science and services.

Doctors, and particularly clinical innovators, have not suffered from a lack of critics from both within and without the profession. Zola, for example, lamented the “medicalisation” of society2 and Illich doctors' “expropriation” of health.3 In all this there is evidence of a fashionable cynicism about the good intentions of medical (and other) scientists, grafted on to a historical distrust of a powerful profession. These attitudes are echoed in public policy. In the past decade many of the shortcomings of the NHS have been blamed on the enthusiasm of doctors for biotechnical innovation. Indeed, the internal market was introduced largely to reclaim the service from such “provider capture.”

The likely scale of medical advance over the coming decades is such that the role of the doctor will need to change radically in response to new technologies and new demands. However, too little attention has been given to the nature of the metamorphosis that will be necessary to prepare the medical profession for the future or to the contribution that medicine could make to shape society.

The term “medicine” covers an ever widening set of activities as diverse as the functioning of health action zones, stereotactic neurosurgery, and forensic psychiatry. We share with many the conviction that there are important core values that link such kaleidoscopic elements of medical practice and that these need to amount to more than professional self preservation and self interest if common objectives are to be pursued in partnership with government, the public, and industry. Unless medicine is to be relegated to a largely technical function doctors will need to play a more prominent and creative role in developing health policy than hitherto and to discover a coherent voice to articulate physicians' values. To build the new relationships necessary for this more integrated contribution, the profession must first correct—with urgency—its historical tolerance of variable practice, standards, and outcomes.

Not only is medicine immensely diverse, but it is backed by a vast international research effort. To secure a more effective and imaginative harnessing of social as well as biological and physical science, we will need to rethink the organisation of conventional academic medical centres and reappraise the policies of research funding bodies.

By far the biggest challenge is to achieve a better fit between medicine and the health problems and aspirations of people. In a way the publication of our book, which was created on an internet site with comment from collaborators from far afield, momentarily interrupts our experiment just when it was getting interesting. Informal discussion with the authors and their networks of colleagues indicated that there are many here and abroad who are thinking imaginatively about the future. This week, the book is launched at a conference in London. The intention is to bring the imaginative conjectures of clinical investigators to the fore of thinking about the future of health policy. We want to start a process that will strengthen the sometimes muted voice of physicians' values in the debate about the future development of the NHS.