Why over-prescribing is symptom of a deeper system issue
There was an interesting interview in the Guardian last week with new RCGP Chair Martin Marshall.
His observation about over-prescribing and its proximate causes (siloed expertise with differing views, hospital medics with an instinct to intervene, rushed GPs doctors finding it quicker to prescribe than advising lifestyle changes, demanding patients, etc) feels spot on.
But we’d argue that the root of the problem is far deeper. And it’s a good example of how having a longer-term, system-level perspective as developed in Beyond the Fog can help us to think more effectively about what we do about today’s challenges.
If you look at it with a longer-term perspective, over-prescribing by GPs for example is a symptom of a system that is not geared to the chronic condition challenges of the 21st century. The system was created to deal with acute, curable/healable conditions and NHS doctors were there to cure them. The training, organisational structures and incentives within the system are all geared towards that; the public expectation of the system is that if they submit themselves to it, their difficulties will be sorted for them; and keeping people healthy by preventing preventable illness is not a core part of the healthcare system — as many have said, the NHS is really a national illness service.
So, doing something else is to go against all of the ‘instincts’ of the system.
As Martin Marshall points out, from a GPs point of view, especially when time is squeezed, it’s easier to prescribe a medicine than persuade people to change their behaviour (especially when the patient expects to be cured, rather than to engage in managing their condition).
It may even be a rational and efficient response within the bounded rationality of the system if people are more likely to take a daily pill than to do regular exercise and cut out the unhealthy activities which they enjoy.
But what if you look outside the assumptions of the current system and think about what a system that would be fit for dealing with the challenges of 21st century healthcare? A system that has maintaining health (ie: prevention) at its heart; where the patient plays a far more active role in maintaining their health — supported where they needed it by healthcare professionals; and where healthcare professionals (doctors? Health coaches?) and their patients have an ongoing relationship and access to data at a population and individual level to enable a discussion about what is best for that individual person.
Beyond the Fog provides a system-level framework for thinking about what this might look like given the advances in technology and medicine that are here and now and on the horizon. It is an art-of-the possible description of a sustainable system geared around both maintaining health and managing conditions when health breaks down.
It’s the logical system-level conclusion of what many people across many disciplines see happening if the potential of the advances is realised; but that until now has not been articulated in a joined-up way.
When you look at it as a single story, it becomes clear that what is coming is a complete rethinking of the nature of healthcare. It may be a logical conclusion, but it won’t happen without a level of ambition on the scale of 1948 when the NHS was set up as it requires a complete rewiring of the instincts inherent within the system.
And asking doctors to prescribe fewer drugs and procedures will not work unless the context of the system which drives them to do it is changed.
Beyond the Fog is a call to action to embed longer term thinking into healthcare decision making. Download the summary report here and get in touch if you’d like to find out more or get involved with our plans.
