These commentaries by John Macgill represent his opinions only and not those of any Ettrickburn client.

Community Pharmacy’s Leader in Scotland

CPO: On the Road to Achieving Excellence

Pharmacy technicians may become prescribers

Profile: Dr Norman Lannigan OBE

Profile: Jonathan Burton MBE

Profile: Clare Morrison MBE

Deep Dive Pharmacy

Mind the Gap - Diagnostic Skills for Pharamacists

Supporting Excellence - Alison Strath Interview

2018 Pharmacy Forum Agenda Launched

Which Referendum to Choose

Three Perspectives on Pharmacy and Mental Health

Pharmacy and the New GP Contract

Bordering on Problematic

Recognised by the Queen and her community

VACANCY Reporter/Researcher: Health and Care Policy in Scotland

Prescribing in Mental Illness – A Practice Pharmacist’s Perspective

What Matters to You? Communication in Pharmacy

Prescribing in Mental Illness – A Patient’s Perspective

Focusing the Vision: Dr Rose Marie Parr on the new strategy for Scottish pharmacy

All the things that could go wrong - looking ahead to the SNP conference

Ask Once, Get Help Fast? Pharmacy and Mental Health

Automation and Delegation in Pharmacy: Understanding the Moving Parts

Pharmacy First in Forth Valley One Year On

Initiatives Highlight Potential of Community Pharmacy

Trying to concentrate on the day job

Health and the Local Elections – a strange silence

The Pharmacist Will See You Now – The Growth of GP Pharmacy

Montgomery’s Review – Dr Brian Montgomery answers questions on access to new medicines in Scotland

An afternoon with SMC

Pharmacists at SMC

SMC – are drug firms voting with their feet?

Radical Surgery on the Horizon for Scotland’s NHS

The Future’s Bright – in General Practice

Community Pharmacy in a Changing Environment

Disclosing payments to doctors – has Sir Malcolm done the pharma industry a favour?

Health and Care in the First Minister’s Programme for Government

CMO: Scotland’s pharmacists “absolutely ideally placed” to practice Realistic Medicine

Profile: Maree Todd – MSP and Pharmacist

Scottish Parliament Health Committee Work Programme

Scotland’s new NHS – a Summer of Speculation

Scotland’s New Health Committee

Two million voices in Scotland – is integration the big opportunity to listen?

Medicines – levelling the playing field

Key appointment raises the bar for health & social care partnerships

What did our new MSPs do before?

SMC says no then NICE says yes – three times

SNP promises single formulary and a review of Scotland’s NHS

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Comparison of Funds: New Medicines v Cancer Drugs

Bonfire of the Boards? SNP signals NHS Review

A tribute to five retiring MSPs

New Medicines Review - Health Committee sends findings to Government

Medicines New & Old in the Scottish Cancer Strategy

Great Ambitions, Slow Progress – New Models of Care in Scotland

Scottish Minsters Demand Up-Front Medicine Price Negotiation

Opportunity and Disappointment: MSPs Investigate New Medicines Access

Scottish NHS Strategy calls for 'Realistic Medicine'

The Scottish Model of Value for Medicines: Taking Everything into Consideration

When SMC Says No: An Access to Medicines Lottery

Reviewing the Review: Access to New Medicines in Scotland

A day of psephology and kidology

Insulting the Lifesavers

Worthy of Mention – Health and Science in the Honours List

News Silence from North of the Border

A Christmas PPRS Present from Pharma

Thursday, February 18, 2016: Scottish NHS Strategy calls for 'Realistic Medicine'

The Scottish Government has unveiled a blueprint for the delivery of health and social care for the coming decade that seeks to shift both where care is delivered and, with significant input from patients, how it is delivered.

The National Clinical Strategy for Scotlandi sets out a series of reforms to improve and modernise how care is provided. And, particularly in a chapter on the 'Need for 'Realistic' Medicine', some of the deep seated attitudes and approaches of the NHS are called into question.

In its news releaseii , the Scottish Government says the Strategy outlines:

  • The need to provide more care where people need it, with as much care as possible delivered locally;
  • The transformational change taking place within primary care, which will be delivered by multi-disciplinary teams with strong links with local authority social services;
  • That to give patients the best possible outcomes, complex treatments may be delivered in specialist centres, with follow up treatment available locally;
  • The importance of supporting patients to fully understand and manage their health needs, with a focus on rehabilitation and independence.

A strong theme running through the Strategy centres on information: be it data on outcomes, the information needed to help patients see the big picture when making decisions, and how patients and their clinicians and carers can use technology to be partners in understanding and managing their conditions.

This is a meaty 88-page document written by Dr Angus Cameron, a GP before becoming Medical Director at NHS Dumfries & Galloway. The Strategy is co-signed by three of NHSScotland's most senior players: National Clinical Director, Professor Jason Leith; Scotland's Chief Medical Officer, Dr Catherine Calderwood; and the Chief Nursing Officer, Professor Fiona McQueen. Dr Cameron held numerous consultation meetings over a year to gather the thoughts of patients, clinicians and other care providers.

It is the chapter entitled The Need for 'Realistic' Medicine [the quote marks around 'realistic' being the authors'] that particularly seems to suggest that the authors have taken seriously the Scottish Government's call last year for 'transformational change in NHSScotland'.

The premise of the chapter is that:

"There is a need to improve the basis of clinical decision making to ensure that there is a clearer focus on the provision of healthcare of greatest value to the individual in a way that has the least potential to harm, and is most in line with the patient's wishes."

One concrete approach suggested is that Scotland should follow the lead of the Welsh Government's 'Prudent Healthcare' initiative that aims to match resources with outcomes, to deliver "healthcare that fits the needs and circumstances of the patient, and avoids wasteful or harmful care"iii.

The authors of the Scottish strategy are adamant that the 'prudent' approach is driven by a desire to 'co-produce' treatment plans and objectives with patients rather than to save time or money. They say the evidence shows that this results in greater satisfaction with outcomes and that, having been given all the information they need about benefits and disadvantages of particular options, patients tend to choose less rather than more treatments. With that in mind, the strategy proposes that "significant resources should be put behind a national collaborative movement… to understand and scope the issues and to influence both clinician and patient behaviour so that wasteful and ineffective care is significantly reduced".

Dr Cameron and his colleagues report that many doctors are uneasy about the level of tests, interventions and medications that they are prescribing for their patients – prompted by pressures that include adhering to clinical guidelines, the fear of litigation, peer pressure and patient expectation. The report states:

"We need to develop a medical culture that seeks to use the least invasive or the least interventional approach as a first step."

Guidelines themselves are called into question by the authors who say they are concerned there is: "excessive emphasis on a bio-medical model in developing guidelines – in other words concerns when treatment is aimed at, and measured by, physiological or biochemical targets, which may or may not have direct relevance to outcomes that people value."

Guidelines are also in the spotlight as one of the reasons that more medicines are being prescribed:

"The increased use of medicines has also been driven by a shift to treating risk, as opposed to treating illness. It can be seen that this has advantages for the manufacturers of medicines as a far greater proportion of the population will potentially be at risk from an illness than actually suffering from it. The treatment of risk is strongly promoted by medicine manufacturers, by expert opinion and evidence-based guidelines."

Concerns are expressed about how medicines are being used, citing the prescribing of medicines to elderly patients based on the findings of clinical trials in much younger people. These will have been single disease trials, the authors point out, that cannot tell the whole story for a patient with many different conditions and medicines.

Equally, the Strategy is clear of the benefits that medicines can bring. In an earlier section it looks forward to the advances that an increasing understanding of genomics will bring:

"Already we have developments that mean drug treatment can be tailored to individuals – so that fewer patients may need treatment. It is hoped that genomics will, in the foreseeable future, help stratify patients into low and high risk, thereby reducing treatment for some patients and focusing it more effectively for others. This may help some of the challenges created by high-cost but effective medications – we may be able to use them more wisely, with greater certainty of benefit."

Above all, the National Clinical Strategy for Scotland's vision of 'realistic' medicine is about changing the role of the patient, not only to become a partner in decisions about their care, but also be an active player.

The authors say they believe busy clinicians move to treatment too readily rather than address the hugely challenging option of getting their patients to change lifestyles and habits. In doing so, they remove that individual's responsibility for managing their own health.

Significant potential benefits are cited of equal participation of both clinician and patient in deciding on treatment options (co-production) that include happier patients, better outcomes and pathways, reduced pressure on care systems and better value for money.

And core to this, say the authors, is access for the patient and clinician to information:

"The NHS collects a huge array of information and this valuable resource can be put to use by creating the concept of a learning care system in which decision making is supported by outcomes of previous decisions as well as research and analysis."

The Strategy calls for the information gathered by professionals to be integrated with that collected by patients themselves:

"The long-term vision is for an electronic patient record which can be viewed and added to by both the health and care services and the patient, allowing a joined up approach to self-management and professional care. The content requirements could usefully include patient reported outcomes and selected self-monitoring data in addition to the professional data requirements."

iA National Clinical Strategy for Scotland

iiNews Release

iiiWelsh Government