Intended for healthcare professionals

Observations Reality Check

Reasons to be hopeful: streams of renewal in healthcare

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6042 (Published 12 September 2012) Cite this as: BMJ 2012;345:e6042
  1. Ray Moynihan, author and senior research fellow, Bond University, Australia
  1. RayMoynihan{at}bond.edu.au

Ten ideas that may produce a radical but coherent vision of future healthcare

Perhaps it’s simply because sweet spring and blue skies have returned to my home on the Australian coast, but it feels like a good time to celebrate some of what’s hopeful amid the constant chaos, change, and controversy that is contemporary healthcare.

The iconoclastic former BMJ editor Richard Smith has mused that medicine might need to feel utterly defeated for it to undergo much needed radical renewal.1 Whether or not defeat is imminent, a culture shift is being debated,2 and renewal is inevitable. The current medical-industrial paradigm—fragmented, technocratic, mechanistic, inhuman, and imperial—is neither healthy nor sustainable. While there’s much that is hopeful in debates about clinical medicine, public health, and beyond, I’d like to identify 10 streams of change that may ultimately coalesce to form a coherent vision of radical renewal.

Evidence informed approach

The evidence informed approach has helped provide a reality check to an overconfident medical establishment, identifying limits to effectiveness, sometimes trivial benefits, and often uncertain harms. It’s also helped sensitise policy makers and the public to the need for better informed decisions. Using the tools of this still evolving approach, while being aware of its weaknesses as well as its strengths, will surely aid any reconstruction effort.

Equity based medicine

Much has been written on inequalities in health, within countries and between them; and the notion of the “postcode lottery” has entered common parlance. The introduction of new technology or public health campaigns is now often debated in terms of how they will help reduce inequity in health status. This other EBM is certainly another reason to hope that healthcare may become more humane.

Citizen centred, collaborative care

Another healthy development in recent times has been the shift of focus from the professionals who deliver the care to the people receiving it. This “patient centred” approach is often combined with an emphasis on better teamwork among those involved, whether doctors, nurses, social workers, or local transport services. Accompanying this trend, and often driving it, is the rise of patients’, consumers’, or citizens’ groups, some of which are genuinely independent of vested interests.

Palliative care as a model

Some medical specialties are already embracing a “person centred” approach, characterised by less medical hubris and more respect for human dignity. The ascendancy of palliative care offers a multidisciplinary model of how to move away from an unhealthy emphasis on “heroic” and unnecessary technological interventions and return to simpler forms of care that relieve suffering rather than trade in false promises of miracle cures.

Independence from industry influence

Great advances are taking place making the ties between doctors and drug and device makers more transparent. Evidence continues to reveal the unhealthy effects of some forms of entanglement. Disentanglement is firmly on the agenda, though reform is still sporadic and isolated, as many health professionals fear losing the industrial largesse that lubricates lifestyles and careers.

Preventing medical harm

The desire to prevent iatrogenic harm is not new, but evidence of and concern about overmedicalisation, overdiagnosis, and overtreatment are burgeoning. Safety and quality advocates have racked up successes, though they still suffer from a central paradox: in current contexts “quality” care too often means more care, while improving safety may mean doing a lot less. The emergence of new alliances that challenge ever expanding corporate sponsored definitions of disease, and new structural disincentives against unnecessary care, are among other welcome developments in this stream.

Critiques from outside

As in other spheres of human endeavour, some of the most insightful criticisms of health systems come from outside. The sharpest and truest contemporary critique comes from the intellectual, philosopher, and cleric Ivan Illich and his work on the medicalisation of life.3 Although historians and sociologists tend to have quieter voices than those touting statins, their analyses of notions such as the social construction of disease can contribute much to a radical rethink.

Social media and wider networks

While social media networks provide new avenues for misleading marketing,4 they’re also offering chances for more informed public debates and decisions, networking, and new forms of public health activism. More open access research will surely only increase these developments.

Social and environmental determinants of health

Moving away from the medical obsession with surrogate markers in the blood and bone, evidence about social and environmental determinants indicates that much disease and early death are caused by transport policies, workplace design, national inequalities, and a host of other non-medical factors. Looking further upstream, public health thinkers are identifying growth centred economic systems as having an unhealthy impact on people and the planet and are envisaging the health benefits of “prosperity without growth.”5

Greening of healthcare

One of the more promising tributaries of change is the growing push to make healthcare greener—producing less waste and more health. Work on sustainability from groups such as Health Care Without Harm (www.noharm.org) and, more recently, Australia’s Climate and Health Alliance (http://caha.org.au) suggests that responding practically to climate change within hospitals and health systems can be a win-win situation, improving planetary and human health at the same time.

Conclusion

Clearly, this is not a systematic mapping of all waterways but rather a splash through some enticing streams. Just how they’ll flow into a coherent vision for healthcare’s renewal—holistic, humane, independent, sustainable, and with a whole new approach to defining who is sick—is unclear, particularly given the power of industrial and professional forces still thriving in the current paradigm. But perhaps now it’s time to swim to shore for a reality check. Optimism is fine, but I guess you can drown from too much of it.

Notes

Cite this as: BMJ 2012;345:e6042

References