Empowering more patients with a new dose of realistic medicine
Doctors generally choose less treatment for themselves than they provide for their patients.
It’s a simple statement, but one which raises many questions as you start to consider what it means and the implications.
And the answers are at the heart of a major cultural change which is being pursued by many involved in healthcare – realistic medicine.
This principle aims to put the person receiving health and social care at the centre of decisions made about their treatment, recognising that a one-size-fits-all approach is not the best for patients or the NHS.
Dr Jeremy Rushmer, executive medical director at Northumbria Healthcare NHS Foundation Trust, which runs hospitals in Northumberland and North Tyneside, is a passionate advocate of the concept, which is really starting to gain traction.
His explanation for why doctors tend to have less treatment is that they act like knowledgeable consumers and ask the right questions.
An important part of realistic medicine is empowering patients to ask those same questions, including the one Dr Rushmer says is most important – is doing nothing the right option?
Patients have already started doing this to some extent, with the help of ‘Dr Google’ by searching online to find out more about conditions and treatments as well as others’ experiences of them.
Dr Rushmer said: “When buying a phone or a car, people take an active interest in the money they are investing in the purchase and you need to take as much interest in staying healthy and then making choices when you are ill.”
All treatments will have harm as well as good, he explains, with circumstances where treatment won’t work and others with a very good chance it will work.
“More commonly, there’s a grey area where it’s important to have a proper conversation.
“If the treatment isn’t going to be effective, the harm is what you will see most of.
“The purpose of what we do is to return you to health, not necessarily to cure you of something. There’s no point if it doesn’t return you to health.”
Therefore, the process of receiving medical care should be one of shared decision-making, using the expertise of the clinician to support the patient and their loved ones to make the right choices for them.
“We need to become much less paternalistic,” Dr Rushmer said. “I will always have a view of my recommendation based on my experience, but there’s no point if I don’t listen to the patient and their loved ones.
“If they have the capacity and have had the right information, they mustn’t take the same decision I would take and they don’t have to take my recommendation.”
One of the issues is that this level of dialogue ‘takes time and in a pressured health service, we are given less and less time to have those conversations’. But he adds: “It’s about making that time to talk.”
However, more fundamental to adopting a realistic medicine approach is the ways in which patients – and doctors – will need to think differently about health, illness and treatment.
Advances in medical care have got to the point where many people have unrealistic expectations about what can be achieved; it’s almost as if the absolute truth that we will all die has been forgotten.
Dr Rushmer says that medicine has certainly advanced, but it is limited by physiology and genetic make-up and not all of these factors are influenceable.
It is absolutely correct that we can cure some cancers, he adds, but that makes you live longer and get other cancers or have a heart attack.
This is particularly relevant in Northumberland with its ageing population, because the longer you live, the more cancers you will get and the more long-term conditions you will get.
“We should not necessarily have the same expectations for our unhealthy years as we have in our healthy years,” he added.
“And in Northumberland and the North East, we enter our unhealthy years a bit earlier. We should recognise that and do our best to prolong our healthy years.”
Put simply: “Medicine doesn’t have all the answers to getting older.”
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And so, there is a need to work much more in the public-health arena and on interventions on a whole population basis; a proactive rather than reactive approach.
Dr Rushmer said: “I always say – and it’s not necessarily focused on realistic medicine – one of the best things about the NHS is that it’s free at the point of demand and very open to all, but that is also its Achilles heel; it’s possible to come to it without being aware of whether you are accessing care in the right way.
“We have been focused on curing illness rather than promoting health. We want to talk earlier about healthiness.
“It’s all around engagement of the population about how they can best look after themselves.
“If there were a magic pill, it would be called exercise. If everyone did that all the way through their healthy years, it would have a much greater impact than many other interventions.”
Alongside promoting wellbeing rather than simply treating illness, social prescribing is another area of healthcare which should be used more widely, he says.
Loneliness, especially in older people, is very, very dangerous and can affect health, explains Dr Rushmer, but having a dog, for example, can increase your life expectancy, not just through the exercise, but also the companionship and the purpose it gives you.
Spreading the word about all of this and how it can improve our health is the key first step and a conference on the subject is taking place at St James’ Park in Newcastle on Thursday, November 8. It is hosted by Legacare, the charity which provides legal support for people with terminal or life-limiting illnesses.
“It’s now a topic that doctors are talking more and more about so we are pushing at an open door,” says Dr Rushmer.
But the profession getting behind it is one thing and the public another. Even if younger, healthier people accept the logic, are older, less healthy patients likely to be warier?
“I talk mainly to unhealthy people, but I don’t think the divide is about young and old, it’s about the philosophy people have,” said Dr Rushmer.
“Most people have a different relationship with their own mortality than they do with their loved ones’.”
Many people are pragmatic, he continued, but they won’t be if you don’t have the right conversations.
“This is a long journey,” said Dr Rushmer, in relation to how realistic medicine will be implemented at Northumbria Healthcare.
He explained that there are a number of strands of work taking place within the organisation, while going out to engage with partners continues to be a key element.
Policies and clinical guidelines are being examined to see how shared decision-making can become intrinsic to how patients are treated.
But Dr Rushmer said the most effective work currently taking place is in partnership with public health and through public-health messages within the trust.
Liz Morgan, director of public health at Northumberland County Council, was present at the October meeting of the authority’s health and wellbeing board where Dr Rushmer gave a presentation on realistic medicine.
She said: “I think this is a really important change of approach and it’s a really key element of our joint health and wellbeing plan.
“We should not underestimate the culture change that will be required in our healthcare professionals and the public, it won’t happen overnight.”
Another board member, Ralph Firth, pointed out that in an era of austerity with major pressure on NHS spending, some members of the public may question whether this is about ‘doing things on the cheap’.
Dr Rushmer rejected this totally: “I will not discuss this in any conversation about saving money, it’s about doing things better.”
By Ben O’Connell, Local Democracy Reporting Service