Medical model of care needs updating, say experts
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1034 (Published 02 March 2018) Cite this as: BMJ 2018;360:k1034All rapid responses
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It is pleasing to note recognition by this team of experts that the current model of healthcare needs to change and at least recognise the social determinants which contribute to the onset of disease. This issue has been bouncing around for many years e.g. the polyclinics proposed by Lord Darzi; however, it is only in recent years that the issue is being taken seriously because the current solution of 'more of the same' is leading the NHS towards a disastrous end-game whereby it will not be possible to provide a satisfactory level of healthcare.
Recognition of the social determinants which contribute to pathological onset raises a number of issues, not least the role of the brain. Stress leads to pathological onset in the visceral organs yet we experience stress through the senses and the brain so what is the mechanism which links brain function to the autonomic nervous system. We use our senses to select what we eat and how we eat. If we become diabetic and obese because we eat and drink too much of the wrong things: what is the mechanism which links brain function to the autonomic nervous system. Enterprising pharmaceutical companies have recognised that they can tap into this mechanism by developing the latest generation of leptin-agonists however they are less able to reduce weight than a course of weight management by Weightwatchers! Eric Lander of MIT addressed this issue when commenting that the genome is effectively the parts list - now we need the operating manual to understand how the body functions.
The EC sought to develop such a technology when it initiated the EUR1.2BN funded Human Brain Project. Nevertheless a solution has been developed - based upon a mathematical model of the autonomic nervous system and physiological systems - known as the Strannik technology being commercialised by Mimex Montague Healthcare
Competing interests: No competing interests
The current episodic and reactive medical care model is not patient centred, comprehensive or sustainable. The increase in population and ageing in association with multi-comorbidities related to non-communicable diseases in combination with expensive diagnostic and therapeutic innovations is a dangerous association that threatens the viability of health systems globally. Availability of increasingly advanced diagnostic and therapeutic strategies is contributing to vicious cycles of over diagnosis and overtreatment. This then leads to both an impairment in clinician confidence and reduced trust in clinical skills.
Professor Marmot highlights the social gradients in nations, exposing confronting gaps in quality and expectancies of life that relate to economic disparities within nations. Interestingly, there is no such association when comparing affluent versus non affluent countries. We agree with Iacobucci that the future of healthcare must incorporate thoughtful consideration of the social determinants of health. Ideally this should be part of an integrated services model that considers maximising support and access with appropriately delivered health services. Social determinants of health are not part of mainstream clinical practice and currently limited to those working in the area of public health. It is therefore not surprising that medical care continues to be provided in such episodic manner within fragmented silos with little focus on the powerful socioeconomic factors that determine health. This is exacerbated by the episode-driven funding that underpins many healthcare systems. The WHO defines a multitude of concepts and themes that are intimately associated with social determinants of health including social gradient, food insecurity, gender equality and employment with health outcomes at its core.
Although healthy public policies focussed on making the healthiest choices the easiest choice such as road safety and tobacco control have achieved much to date, it is now time for clinicians to embed consideration of socio economic determinants of health when caring for all our patients.
Competing interests: No competing interests
Re: Medical model of care needs updating, say experts
Dear Editor,
We read with great interest the recent report from the Nuffield Trust Health Policy Summit which included discussion on shifting away from a medical model of care, placing more emphasis on tackling social determinants of health.
This reaffirms the thinking to date and the conclusions that have evolved from the collective opinion of the Bevan Commissioners. The Commission is an independent and authoritative think tank for health and care in Wales, made up of international experts which challenges current models and ways of working to find more sustainable and prudent solutions for future health and care.
The Bevan Commission published its first in the series, 'Exploiting the Welsh Health Legacy - A new Way of Thinking (2017), in which it called for a joined up, prudent and social model of health and care, moving away from a more traditional medical model. The second in the series 'A New Way of Planning: Working Towards a Prudent Model of Health and Care' (2018) sets out further details on the sustainable foundations needed to implement this new, social and cooperative model of Health and Care for Wales. The final paper in the series, due to be published in July to coincide with the Bevan Commissions International Conference, will set out real examples of how this can be achieved in practice, working together with others to do so. These papers are published on the Bevan Commission website www.bevancommision.org.
The model has been designed around the needs of people in Wales, not the systems, the processes or the professionals who work within it. It embraces the principles set out by Aneurin Bevan for a National Health Service, namely; comprehensive, free at the point of delivery and accessible by all, alongside the fundamental 4 Prudent Healthcare Principles. It builds upon the origins of the NHS whereby communities, people, professionals, patients and local employers all own and play a key part in taking responsibility to maintain health and in caring for its communities and the people within it.
The social model set out by the Bevan Commission recognises that health is everyone's responsibility and only by rebalancing the relationship between patients and professionals, the citizen and the state, will we achieve a sustainable system which is fit for the future.
Competing interests: No competing interests