healthandcare.scot asks whether the ‘realistic medicine’ campaign can survive the fall of its architect, former Chief Medical Officer for Scotland, Dr Catherine Calderwood.

The concept of ‘realistic medicine’ has been the signature approach of Dr Catherine Calderwood since she became the Scottish Government’s Chief Medical Officer in 2015. The basic premise is that the medical profession and the NHS need to have a firmer view of what a patient wants from their treatment, and work more closely with them to deliver it for them. It was a rebound from the idea that the medical profession – and possibly we as a society – are too quick to expect a pill or other treatment solution whatever our problem, without thinking of the wider issues.

The apocryphal story that the CMO used to illustrate her philosophy was of a man who had complained of chronic pain in his knee. He was taken into hospital, given the full knee replacement, and the subsequent follow-up physio etc. However, all the man wanted was a handle on his back step to lean on when he chatted to his neighbour, which was the only part of his life that was adversely affected by his knee pain. The moral of the story being that instead of undergoing an invasive, and expensive, treatment, we could have simply had a handrail fitted, to everyone’s benefit.

The idea, as simple and common sensical as it sounds, wasn’t universally loved.

Anecdotally, there have been senior clinicians who were a wee bit affronted at the idea that they didn’t already practice this, that they treated their patients in a way that was against their wishes or worse, against their best interests. Realistic medicine was, to some, a fancy new name for one of the most basic pillars of medical care; treating your patient as well as possible.

It would also be naive to think that the idea wasn’t – in part at least – influenced by the well-known sustainability problems facing NHSScotland. A system that is straining under the weight of its own success at treating people was effectively trying to row back a wee bit, and introduce the concept that treating people with every available option regardless of their personal circumstances, and regardless of the cost, is perhaps not in our collective best interests.

Despite any misgivings some may have had (and the misgivings seem to focus more on the packaging of the idea, as opposed to the idea itself), it was the beginning of a grown-up conversation about what we can and should expect from our NHS, a conversation that while people find easy to have in the abstract, is much more difficult when it is about one of their loved ones; but necessary as it surely must be at least part of the solution to our sustainability problem.

It is ironic then that the crisis that will bring about the most high-profile and stark example of realistic medicine, would also be the crisis that brought about the downfall of its chief proponent. For as Catherine Calderwood’s medico-political career was ended by Covid-19, the idea may have just come of age.

“We are going to be deciding on a ceiling of care very quickly” healthandcare.scot was recently told by Dr David Chung, the Vice President of the Royal College of Emergency Medicine. He used the vexed issue of ventilators to illustrate his point, asking the difficult question of who will be put on a ventilator if say only 20% of people who need them can get them? An elderly patient with multiple co-morbidities and who has a much lower chance of successfully coming though the treatment, or a younger person with a much higher chance of success?

“The CMO’s realistic medicine is going to be thrown into sharp focus here and I think it’s appropriate because we are going to be dealing with a lot of people who are very elderly. This isn’t really a change in practice but it’s going to be more noticeable because there will be a lot of them.

The ethical, practical and even moral ramifications of these types of decisions are enormous, and deserve to be considered carefully; and the middle of the worst pandemic in living memory is, by definition, a very extreme set of circumstances in which to do that. But the same questions  posed by Dr Chung about ventilators above could just as easily be asked of an elderly patient with any number of other illnesses, the treatment for which is invasive and expensive with little chance of success.

Critics will always say that every person should be treated to the highest clinical standard possible, and that we as country don’t, nor should we, discriminate based on age.

But our NHS is a rationed system, and any system with such insatiable demand and such limited resources will always have to make these kinds of hard decisions. Dr Calderwood’s innovation was to take the decisions out of an NHS accountant’s office and bring them into the clinical decision-making process between patient, family and clinician.

The merits of realistic medicine will continue to be debated as they should be, but just at the point where we are starting to move towards the kind of mature and difficult conversations that our NHS needs us all to have, it is important that we continue to debate the message, and not the messenger. 

 

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