Resources Lesson 1: Civic engagement
Civic engagement
Please take a look at this short video to introduce the Topic:
The Royal Australian College of General Practitioners has a page in its curriculum called Population health and public health. The rational for considering this is that: "General practice care goes beyond the individual patient to involve patient populations. General practitioners are ideally placed to implement population based health activities because about 83% of Australians attended a GP at least once during 2009-2010".
Does this extend to resource allocation at a population level? Should the use of expensive resources for an individual patient be considered in the light of population based priorities?
In the UK, The General Medical Council has said: "The GMC recognises the particular difficulties that face clinicians who also have a managerial role within health care...
Management in Health Care - The Role of Doctors, May 1999, paragraph 7.
"Conflicts may arise when doctors are called upon to make decisions about the use of resources and about patients' care, when the needs of an individual patient and the needs of a population of patients cannot both be fully met. Dilemmas of this kind have no simple solution. When taking such decisions, doctors should take into account the priorities set by Government and the NHS and/or their employing or funding body. But they must also be clear about their own role. As clinicians, doctors must make the care of their patients their first concern, bearing in mind the effects of their decisions on the resources and choices available for other patients. As managers, doctors must allocate resources in the way that best serves the interests of a community or population of patients. In both roles, doctors should use evidence from research and audit to make the optimum use of the resources available”
A provocative paper in the Journal of Evaluation in Clinical Practice - Arrow physicians: Are economics and medicine philosophically incompatible? - states: "The fundamental mission of medicine obliges physicians to practise science and compassion to serve the patient's best interests. Conventional (neoclassical) economics assumes that individuals are self-interested and that competitive markets will emerge optimal states. Economics is seemingly incompatible with the emphasis of putting patients' interests first. This idea is refuted by Professor Kenneth Arrow's health economics seminal paper. Arrow emphasizes that medical practice involves agency, knowledge, trust and professionalism, and physician-patient relation critically affects care quality. The term Arrow Physician is used to mean a humanistic carer who has a concern for the patient and acts on the best available evidence with health equity in mind. To make this practice sustainable, implementing appropriate motivations, constitutions and institutions to enable altruistic agency is critical. There is substantial evidence that polycentric governance can encourage building trust and reciprocity, so as to avoid depletion of communal resources. This paper proposes building trusting institutions through granting altruistic physicians adequate autonomy to direct resources based on patients' technical needs."
Debate on the possibility of conflict between the population and the patient
How can doing the best for individual patients be compatible with making sure that costs can be contained and the health priorities of the population are met? The paper Patient Care and Population Health: Goals, Roles and Costs identifies the issue nicely: "If society imposes on clinicians the expectation of the dual responsibility to serve simultaneously as advocates of patient care and overall cost control, we should watch for an attitudinal shift. In terms of ethics, this shift would represent a movement from the principle of beneficence (focused on the benefit of the patient) to the principle of utility (focused on the maximization of benefits across a population). In terms of goals, this shift would assimilate the economic goal of cost-containment into the set of clinical goals of care that have traditionally guided clinicians’ decision making. We should think carefully about the possible unintended consequences that can come with such a shift in attitudes and goals, realizing that what might be measurable as an economic gain could be accompanied by a far-reaching professional loss."
Implications of models of Medicine as a profession.
Kluge, in a rather long paper Resource Allocation in Healthcare: Implications of Models of Medicine as a Profession notes that the Hippocratic model of medicine, "means that the physician's duty toward the individual patient overrides all other considerations except insofar as these affect the physician's ability to fulfill her or his patient-related duties. Therefore, the physician must abstain from considerations, such as the social cost of the treatment, the likelihood that the patient will return to a productive life, the effect that ministering to the patient's needs will have on third parties, etc, except as they bear on the welfare of the patient."
And where do patient preferences fit in to resource allocation decision making?