Sunday, 7 August 2011


The relationship between doctors and their patients has changed dramatically over the past few years. Medical Beneficence became paternalism and is now near obsolete. Shared decision making is the new lofty ideal we should all be striving for. It is guiding  new health policy both in the UK, with the new mantra 'nothing about me without me', and in the US. We are at the start of the Century of the Patient. New appropriate societies have been formed such as the Society of Paticipatory Medicine and the Foundation for Informed Medical Decision Making.

This is all excellent stuff. As a doctor, I'd like to think that I have practiced so called partcipatory medicine all my life.
There are caveats with all of this. In a universal health service such as the British NHS, funding is through general taxation and whose levels are determined by politicians, albeit elected. Because of this, the NHS will always, whatever the protestations of different health secretaries, be controlled from the top.  Shared decision making, which surely also means an input into how much I want spent on me as a patient,  is clearly not possible.
With shared decision making must come the counterbalance of responsibility and accountability on the part of the patient.  Without this,  patient involvement becomes a sham. This has been recognized in the Affordable Care Act, the Health Reform Act introduced by the current administration in the United States. This will allow 'rebates' for good behaviour - and good healthy behaviour can easily be measured e.g. weight, markers of smoking etc. In the UK, we have the Downing Street Nudgers who will nudge (nanny state lite) all of us into behaving in a way that will not break the NHS bank in a few years. It does not need a Committee in the House of Lords to tell us that Nudge alone will not work. Being nudged itself is anything but being involved in decision making.
All the good ideas in health care are now coming from across the pond.
You just cannot have your cake and eat it and you just cannot have meaningful true Shared Decision Making in the British NHS and the way it is currently funded  - the 2 are incompatible - PERIOD