Reality checking: do it regularly for better health

There has always been something of a gap between the excited debates over the latest managerial buzz words at the top of the NHS pyramid and the reality of day-to-day patient care at the bottom. But as the general election approaches, don’t be surprised to see the gap widen to become a chasm.

Parties of both left and right will argue fiercely over the meaning, significance and implications of ideas like ‘the primary care-led NHS’, ‘hospital at home’, ‘health gain’, ‘delivering a national strategy for health’, ‘evidence-based health care’ and whatever other buzz words can be dreamed up during the election campaign. But politicians and pundits, media and managers alike will prefer not to ask people who know anything about the reality. To do so would reveal not only that such phrases have a very tenuous link with reality, but also that in some cases the real world is moving stubbornly in the opposite direction.

We do not have to look very far for examples. The looming crisis in general practice, highlighted by Brian Gibbons in this issue, is a case in point. While policymakers knot their brows and struggle to define what, exactly, they have in mind when they talk about ‘primary care led’, a struggle of a different kind is going on in the surgeries of the nation—a struggle to fill vacant partnerships, cover out-of-hours rotas and provide a good quality of care as morale in general practice plummets. Whatever ‘primary care led’ does mean, it is unlikely to refer to GPs. Yet interest in discussing the vision seems to far exceed any interest in solving the immediate problem.

A second example might be the idea of ‘hospital at home’ and the increasingly specialist role of the district general hospital. What will become of hospitals in the next century, the experts ask, when most health care will be provided in the home? The answer is simple: it won’t. There is no sign that either patients or their doctors are moving in the direction of increasing care at home for acute illness. Indeed, if anything the trend is quite the opposite, with fear of litigation and complaints, and increasing workload, making doctors more inclined to admit patients to hospital now than they were a few years ago. It seems that reports of the death of the general hospital have been greatly exaggerated.

England’s health strategy, Health of the Nation, provides another illustration of the point. Indeed, ever since its launch there has been a slight air of unreality about the strategy, with the government seeking views far and wide on which health targets we should aim for, yet resolutely refusing to listen to any advice from anyone about how to achieve them. The result has been that, by and large, trying to ‘deliver on’ the strategy has been left to the health service, while the rest of government policy carries on regardless.

While progress towards those targets for which the epidemiological trends were already favourable is being made, in other areas —obesity, teenage smoking and alcohol consumption by women—we are moving steadily away from the targets. In these circumstances, the question is whether the ‘strategy’ has actually made any difference at all.

What lesson can we take from all of this? Simply that many people would rather argue endlessly about the world as they would like it to be, than to understand the world as it now is. Developing a vision for the future shouldn’t mean turning a blind eye to the present.