Usually we think of medicines for diseases. It puts the focus on the disease and the disease at the centre of the consultation. We might use data to talk about the effectiveness of a medicine in changing a surrogate marker for disease activity and we start to assess the effectiveness of a medicine on its ability to change a surrogate marker per unit cost to achieve this. The drive towards cost-effectiveness simply pays lip-service to a patient
When we talk to patients, we set targets related to surrogate markers for example – ‘we are going to try and bring the HbA1c down a little’. And we even ask patients to return when they feel the disease has got worse, for example – ‘pop back when the pain gets worse’. All of this contributes to a discussion being disease centric.
Patient centricity means that the patient is at the centre of any consultation and treatment. We talk about it endlessly and every graphic has the patient clearly at the centre. When we use the phrase ‘patient experience’ it is often linked to compliance seeking reasons why people may not comply with medicines. We look at endless ways of improving compliance and reducing waste without making a simple discovery. Poor compliance may be an active decision – I never wanted this anyway – or a passive decision – I was never convinced that this medicine would truly help me. We may cover up these issues within a medical model and the need to provide population treatment in a cost-effective way.
Helping people to create health is the most important element of what we do. The focus should be on the patient, how they live their life, how they are managing and what they are not managing. And then consider what could be done to make that better.
Medicines may fit in three ways:
- A medicine that cures a condition and allows a patient to life the life that they once had. There may be no drop in function after cure
- A medicine that prevents a disaster from happening to someone who is actually living a normal life by their current standards
- A medicine that treats a symptom that may allow the patient to achieve a function that they had lost
We may want to ask what is normal. People wake up, get washed and dressed and go out. They may work or just meet people to fulfil a social need, settle down, go to bed and sleep. When you apply these thoughts to people you may get a very wide variety of responses back, but the most important question is ‘what matters to you?’. The goal of health creation is to give people control over their own life, meaning and purposeful social contact and activity and the confidence to make a positive impact on their own life and the lives of others.
Not all things that matter to people can be solved by a medicine. There are many things, such as social isolation and a feeling of worthlessness that don’t have a medicine for and we need a clear health creation solution as described in the recent NHS Alliance manifesto, but if that is the answer then I have a range of medicines that may play a part.
A near term target might be to get out to a coffee shop, pub, a neighbour’s house, a workshop or other social gathering. When asking, ‘so what is stopping you’, I may have a whole range of medicines that can reduce symptoms and enable small improvements in function that might enable to patient to reach this goal.
A mid term target might be to return to employment. We have to acknowledge that many conditions are sufficiently severe to prevent return to the same job, but with some help we may be able to help people return to an alternative vocation.
A long term target may be to still be alive and see your grandchildren. So with support we may have medicines that help people to live a longer life.
It is a big change. I am focussing on the individual and what matters to them. I am engaging the community to provide support in health creation. I am tailoring medicines to support living. I am evaluating the benefit of medicines on a different level. And I am booking the follow up at a defined and agreed interval to talk about progress and the benefits of treatments – not their failure.
Medicines are for life