Alcoholism: heartsink or microcosm?

ImageFew GPs get excited by seeing known alcoholics walk into their surgery; they are the classic ‘heartsink’ patients, with a host of problems, often insoluble. They range from the physical (you really do destroy your body with long term drinking), through the underlying psychology (there are often personality disorders and depression), to the day to day consequences, such as social isolation, unemployment, and homelessness.

Dealing with all these issues is difficult, as it entails the interaction of many different people, each with their own rules, cultures, and bureaucracies: alcoholism is perceived in very different ways by say, policemen, social workers, and nurses. Moreover, the patients themselves are often unwilling or unable to take control of their own destinies, and this makes the oversight and management of alcoholism all the more difficult.

However, with patience, experience, and the ability to work across many professions and disciplines, progress can usually be made. It may not be possible to overcome the problem completely, but at least one may be able to reach some form of stable balance between alcohol and the external world, a modus vivendi that allows life to continue in a relatively sustainable way.

In that sense, there may be lessons to be learned from alcoholism as an example of modern medicine’s new Big Issue: the treatment of all long term conditions.

The first half century of the British NHS were dedicated to the creation of super-specialists, able to diagnose and treat ever more precise conditions, thus defining their patients not as people, but by their illnesses (‘the leg in Bed 4’, ‘the appendicitis in A&E’). This approach may be useful when everything is running smoothly apart from one small problem, but such a ‘Kwik Fit’ approach to medicine fails utterly when there are several major issues to be addressed at the same time, especially when they include social and psychological determinants as well as physical ones.

Increasingly, health services around the developed world are finding that it is these complex cases that are exercising their services (and increasing their expenditure) rather than simple mechanical failures. Managing a sixty year old lady who has diabetes, breast cancer, and has recently been widowed is very different from mending a broken leg, or even treating a straightforward heart attack, and it is here that there may be useful lessons from the enlightened management of alcoholism. The key messages in both instances are:

  • Take an holistic, person based approach to the problem, don’t try to fragment it into reductive components to be treated in separate silos.
  • Be prepared to work with other teams, disciplines, professions, and organisations, without assuming that only you have the answers
  • Care is at least as important as cure: many of these conditions will last a lifetime, so we have to move away from the idea that absence of cure is failure.
  • Work with the patient, and not at them; in the end, it is their illness, and their involvement and expertise are key to its management.

I wrote this piece for the blog site of the Health Services Management Centre (HSMC), where it was posted last week.

Open letter to Simon Stevens

writing-query-letterDear Simon


Despite the fact that most open letters probably never get read by their addressees, I thought that I would join the throng of correspondents writing to you: after all, if ‘crowd-sourcing’ can raise funds and drive international campaigns, maybe it can influence policies too…

As I’m sure you’ve recognized, the NHS is in a weird place at the moment. The cognitive dissonance we all accept as part of running a state controlled (i.e. politically sensitive) system in the 21st century has reached new extremes, with the rhetoric of localism (Clinical Commissioning Groups, local choices, patient involvement) being totally at odds with the reality of national inspection regimes, the imposition of ‘Clause 119’ and the central pressure to save costs that is currently exercising us all.

The short term ‘patch it and move on’ measures of the past few years have led to so many unintended consequences that we seem to be tying ourselves into ever tighter knots physically as well as politically. Here are just three examples, but there are many more:

Emergency departments are very busy because they’re available and GPs aren’t, so we try to discourage people from attending by….extending the range of services provided at A&E.

Lewisham Hospital is really successful, so its staff are rewarded by… their assets being threatened in order to prop up the failing South London Healthcare Trust.

CCGs are tasked with responsibility for the health of their populations, and encouraged by… having their resources cut and their nascent power diminished.

And so on and so on….

If we are ever to cut through this Gordian knot, here are just a few simple principles that might help:

  1. There should be clarity about the separation between procurement and provision of services: the Government is the commissioner, and the NHS is the provider. That boundary is where the strategic overview needs to be implemented, and where the money is exchanged. The NHS is then supposed to consider how services might best be delivered, with the CCGs intended to be pre-eminent in this process, providing what services they can through their GP networks, and subcontracting the rest to agencies such as hospitals and other specialized providers.
  1. Work with human nature rather than against it: people work best when they agree with their organisation’s overall purpose and when they can see some benefit from what they are doing. Thus, a consistent approach with obvious logic works better than a series of mixed and contradictory messages, especially when those messages are clearly disingenuous and even dishonest. NHS staff don’t have to agree with everything, as long as it is clear how decisions were made, and they can rest assured that there will be consistency and stability in their working lives.

Moreover, those benefits don’t have to be financial; people join the NHS because they want to make a positive difference to the lives of ill people, and want to be proud of what they do. Approval, appreciation, peer recognition, these are all useful and not nearly as inflationary as monetary markers, whose price has to constantly increase to retain their value.

  1. Make policy and stick to it, even if the Media pundits don’t like it: democracy is great, but where long term policies are concerned, the ballot box is a better place make judgments than the daily press. Populist government leads to uncertainty and instability, and in the end, loses the respect of the populace anyway, so the system should think in years, not weeks, when it makes policy.
  1. Society needs to acknowledge the clash between rising expectations and finite resources; efficiency is clearly a good thing, but no amount of cost improvement is going to keep pace with a population that expects everything, constantly, and for free. At some stage soon, we are going to have to grasp the nettle of putting the brakes on demand, whether by formally introducing the notion of rationing, charging, or excluding.

With these suggestions in mind, Simon, perhaps you should empower the CCGs to do what they are being asked to do? That’ll mean giving them more control of (and tighter accountability for) the mechanisms and the money; they’ll need a lot more development too, internally and in the way that they deal with the rest of the service.

Perhaps too, you should think of simplifying the fog of micromanagement and punitive regulation that has descended over the NHS? At a local NHS acute Trust for instance, the 200 pages of specific measures that have to be discussed at every Quality and Safety committee bring its members to their knees. Most clinicians have a positive intent, and are prepared to have their effectiveness measured, but to do it in such prosaic, reductive ways is not only counterproductive in the short term (the measures aren’t usually helpful) but in the long term too (they de-professionalise the workforce). A few outcome measures, measured by peers and patients, would pass the responsibility and ‘ownership’ of the service back to those who are best placed to run clinical services.

Another (albeit more difficult) objective would be to resist the pressure from the acute sector; crises are always more interesting and newsworthy than chronic and often insoluble problems, but they divert attention from what is truly important to what is often merely urgent. To achieve such an objective would be countercultural in today’s world of instant gratification, but if we don’t manage to stem this tide even a little, then the future of a sustainable service is bleak.

On a more positive note, almost everyone in the NHS (and most members of the public) are aware of these issues in some way, and would be willing to throw their weight behind policies that begin to address them. Sure, the traditional tribalism of the different parts of the service will always exercise us, but there is nothing like common purpose to bring people together, and there is plenty of that where the NHS is concerned.

It’s a daunting task, that will need stamina as well as a thick skin; but modernising health services is a worthy end, and we’ll all help where we can.

Good luck, and kind regards