Delivering health with integrity of purpose
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4448 (Published 17 August 2015) Cite this as: BMJ 2015;351:h4448All rapid responses
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We agree with Mulley and others that modern healthcare has been derailed by a consumerist approach.[1]
That more doctors do not equal better health is amply demonstrated by the situation in the United States of America. Many countries have better health indicators despite considerably lower health expenditure.
Clinical trials may generate the best quality evidence, but only if they are well designed and executed. Poorly designed trials may have a significant risk of bias, and thus are unreliable. Moreover, not all conditions lend themselves to evaluation using a clinical trial. The establishment of causal relationships is a desirable end point, but not the only concern of clinical research. Further, mere generation of evidence without dissemination of the same is meaningless. While developed countries have robust mechanisms for the generation and dissemination of evidence, most developing countries lack the resources for the same.
In addition, qualitative studies help understand why intended beneficiaries refuse to participate in intervention programs, but are often ignored when formulating policies.
Time and again, we have seen examples of locally trained healthcare workers producing significant health improvements.[2] These influenced the Alma-Ata declaration and the primary health care concept.[2,3]
Most of the issues raised by Mulley and colleagues are amenable to resolution by the application of primary health care principles. Unfortunately, in an age when healthcare is highly specialized, influenced by insurance companies and political compulsions alike, the wholehearted adoption of primary health care is unlikely as it is in direct conflict with commercial interests.
When profit is considerably more important than the person, integrity and other similar values become subservient to the bottom-line. Any effort to improve upon the existing is to be lauded and encouraged, but all such efforts should be tempered by the ground reality, not divorced from it.
References:
1. Mulley A, Richards T, Abbasi K. Delivering health with integrity of purpose. BMJ. 2015; 351:h4448.
2. UNICEF. UNICEF web site. [Online]. [cited 2015 August 17. Available from: http://www.unicef.org/malaysia/SOWC09__Alma_Ata_Primary_Health_Care.pdf.
3. World Health Organization. WHO web site. [Online].; 1978 [cited 2015 August 17. Available from: http://www.who.int/publications/almaata_declaration_en.pdf.
Ramaprabha Prabhakar,
Associate Professor,
DM WIMS Medical College,
Wayanad 673577,
Kerala, India
Liaquat Roopesh Johnson,
Assistant Professor,
DM WIMS Medical College,
Wayanad 673577,
Kerala, India
Competing interests: No competing interests
We need a health system that meets “the needs of the person/patient”
We need a health system that meets “the needs of the person/patient”
“Over one billion people worldwide do not get the care they need.” [1] Health care traditionally focused on meeting the needs of the person/patient [2,3]. The advances resulting from medical technologies has shifted the focus of consultations towards specific diseases and their specific interventions [4]. As a consequence the personal experience of illness is ignored, resulting in the medicalization of day to day experiences and the inevitable rise in overdiagnoses and harmful interventions [5-7].
Medicine needs a value shift – refocusing on what really matters – the person/patient. Most people are healthy most of the time, as White et al [8] have shown in the 60s, community health follows a Pareto distribution, i.e. 80% of the community is health or at least healthy enough not to need medical care, 16% require primary, 3.2% secondary and 0.8% tertiary care. The need to refocus on the person/patient is especially important with rise of chronic illness in an aging population [9]. Person/patient-centered consultations are complex, having to navigate at times competing needs without there being any one correct strategy [10], however, we need to acknowledge that the consultation is production unit of healthcare – the place where decisions are made about the use of limited healthcare resources [11].
Person/patient-centered health systems recognize [12,13] that
• they are complex adaptive systems, i.e. they continually and dynamically adapt in response to the core system drivers (attractors);
• the core driver for is the improvement of people’s health is the “personal experience of health”, regardless of organic abnormalities;
• a patient-centred health system requires flexible localized decision making and resource use; and
• the prevailing trend to use disease protocols, financial management strategies and centralized control of siloed programs is fatally flawed, as:
o people’s health and health experience as core system drivers are inevitably pre-empted by centralized and standardized strategies;
o the context specificity of personal experience and the capacity of local systems are overlooked; and
o in line with CAS patterns and characteristics, these strategies will lead to “unintended” consequences on all parts of the system.
References
[1] Mulley A., Richards, T. and Abbasi K. Delivering health with integrity of purpose. BMJ 2015;351:h4448. doi: 10.1136/bmj.h4448
[2] Sturmberg JP. The personal nature of health. J Eval Clin Pract 2009;15(4):766-769. doi: 10.1111/j.1365-2753.2009.01225.x
[3] Sturmberg JP. Health: A Personal Complex-Adaptive State. in: Sturmberg JP. and Martin CM (Eds). Handbook of Systems and Complexity in Health. 2013. Springer – New York, pp 231-242. http://www.springer.com/us/book/9781493922550
[4] Sturmberg JP. and Martin CM. Diagnosis - the limiting focus of taxonomy. J Eval Clin Pract 2014; Feb 18. doi: 10.1111/jep.12113
[5] Goldacre B. Bad Science. 2009. Harper Collins Publishers – London.
[6] Moynihan R. and Henry D. The Fight against Disease Mongering: Generating Knowledge for Action. PLOS Medicine: published 11 Apr 2006. doi/10.1371/journal.pmed.0030191
[7] Heath I. Combating Disease Mongering: Daunting but Nonetheless Essential. PLOS Medicine: published 11 Apr 2006. doi/10.1371/journal.pmed.0030146
[8] White KL., Williams TF. and Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885-892.
[9] Martin C. and Sturmberg J. Complex adaptive chronic care. J Eval Clin Pract 2009;15(3):571-577. doi: 10.1111/j.1365-2753.2008.01022.x
[10] Sturmberg J. and Lanham HJ. Understanding health care delivery as a complex system. J Eval Clin Pract 2014;20(6):1005–1009. doi: 10.1111/jep.12142
[11] Hart TJ. Expectations of health care: promoted, managed or shared? Health Expect. 1998;1(1):3-13. doi:10.1046/j.1369-6513.1998.00001.x
[12] Sturmberg JP. Martin CM and O’Halloran DM. Understanding health system reform–a complex adaptive systems perspective. J Eval Clin Pract 2012;18(1):202-208. doi: 10.1111/j.1365-2753.2011.01792.x
[13] Sturmberg JP. Martin CM and O’Halloran DM. Healthcare Reform: The Need for a Complex Adaptive Systems Approach. in: Sturmberg JP. and Martin CM (Eds). Handbook of Systems and Complexity in Health. 2013. Springer – New York, pp 827-853. http://www.springer.com/us/book/9781493922550
Competing interests: No competing interests