Individual doctors do their best not to

Doctors used to be criticised for talking about “the appendix in bed 1.” The criticism was of the reduction of a human being to a single symptom or condition. Yet at a time when the NHS is talking ever more about “patient centredness”¹ it adopts payments systems that reduce patients who have many problems and illnesses to “the patient with a right shoulder problem.” It leads to the absurdity in hospital clinics well captured by Anwar et al.² In primary care it leads to referrals that go, “Thanks for dealing with his left knee. Please will you next sort his right knee out.”

The attempt by health economists and management to reduce medical care of human beings to bite sized chunks that be can be completed, counted, and billed will lead to some odd consequences. At a time when doctors are moving away from seeing all illness as acute finite problems, and towards the appreciation of complexity,³ continuity, and comorbidity⁴ of patients we have a management system laid across us that goes back to the old model of fixed, finite events in otherwise normal people.