Michael Bosch

Michael Bosch is a GP in East Surrey​.

The central tenet of managing healthcare (at least publicly funded healthcare) is reducing unplanned hospital attendances.

A patient who attends hospital in an ‘unplanned’ way is seen as a potential failure of the system. The system should have looked after the patient better outside the hospital since once in the hospital, everyone could pay a high price for this failure: the public purse pays over the odds for quite possibly unnecessary care, and even iatrogenic damage to the patient.

The trouble is that despite all the attempts to keep patients away from hospitals when their problem shouldn’t really ‘need’ hospital care, their numbers keep going up and up.

Rethinking Medicine has recognised that the solution to this conundrum might be found in relationships and power:  the lure of medicine with its most powerful manifestation in the bricks and mortar of a hospital can act as an extreme pull into a world dominated by tests and treatments, administered by professionals firmly in charge, but at the same time scared to make mistakes.

Only a change in the power relationship between patients and professionals, enabling the patient to become more of an active partner in their care, can stop the powerful professionals. The professionals need to listen to the patient narrative and work with each individual on their personal goals.  Only with this more person-centred shared approach can the most rampant over-medicalisation be reined in.

Could it be that the lure of healthcare increases when people reflect and set personal goals?

It looks to me like Age UK’s ‘Personalised Integrated Care Programme’, or PICP, was an attempt to prove that providing “personalised, practical, community-based support” for over 50-year-olds with two or more chronic conditions could break the rise in unplanned attendances.

Nearly 2,000 participants received a ‘guided conversation’ identifying a series of goals that the patient would like to achieve, and a primary care-based multidisciplinary team (which included Age UK staff) provided support to get the plan in action for three months.

The Nuffield Trust’s evaluation, however, which was published in January, found non-elective hospital (A&E and inpatient) admissions compared with matched controls went up by a third (planned activity was the same as controls).

Could it be that the lure of healthcare increases when people try to reflect and set their personal goals? Maybe anxieties about death and disease increase rather than decrease when care is personalised and this drives patients into the arms of hospitals?

Are we fighting a losing battle with asking them to ‘rethink medicine’?

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