Medicine has been described as the second oldest profession: from caring to curing and prevention, doctors and medicine have played a major role in the lives of nations. But it is clear that in many countries, including the richest country on the planet, healthcare systems appear to be struggling.
Covid-19 has been creating havoc around the globe and different national governments have responded in different ways . However, the mantra in the UK “Stay at home-Save the NHS and Save lives” is of interest. Saving the NHS is primary to saving lives. Every Thursday evening people show their appreciation by clapping for two minutes exactly at 8 pm. NHS is seemingly back in fashion but how long will it last we do not know — both Covid-19 and the NHS!
History of establishing National Health Service is well known so will not repeat it. Suffice it to say that as a result of war, deprivation and poverty, it was the step that contributed to people living longer and it is not unfair to say that it has been a victim of its own success. NHS has carried on in almost the same way over the past 72 years in spite of societal changes, although structural reforms from both sides of the political divide have been a regular occurrence. Some of these reforms have been successful whereas others have decimated morale.
So, what lessons can Covid-19 teach us? Were we to start from scratch and were establishing NHS today, will we do it the same way?
There is no doubt that NHS is a success story and envy of the world, and we can learn and convey about primary and secondary care — but social care and public health need improvement. Repeated reforms and poor resources be they financial or human have led to healthcare professionals struggling to meet ever rising demands and expectations. With Covid-19 putting pressure on the NHS, is it any wonder that mantra from the government is to save the NHS.
In recent times repeated studies have shown that the morale among NHS staff has been low which in turn has contributed to totally unacceptable levels of burnout and common mental disorders with high rates of alcohol and drug use among healthcare professionals. Disproportionate numbers of deaths of BAME doctors and nursing staff following exposure to Covid-19 adds another dimension.
Societal changes, social media, changing patient expectations mean that stakeholders need to get together to explore what the Medicine’s Social contract is: when patients demand treatments as their right, which is fair and expected, they also need to recognise their responsibilities. The Social Contract is implicit and exists between medicine and patients and public, between medicine and government, and finally between government and public including patients.
Once the Covid-19 pandemic is over, it is a critical time to explore with the stakeholders how such a contract can be reviewed and renewed by clearly exploring each group’s expectations of the others; how healthcare is funded and how it is designed, developed and delivered and then utilised. Right to free healthcare must come with responsibilities be they personal, familial or community based. Employers and regulators have a responsibility and a financial stake in ensuring that doctors are trained appropriately and keep up-to-date with advances in knowledge, new technologies and learning new skills.
The government needs to revitalize the social contract with doctors by ensuring that they are listened to when informing the government policy, which is often made without any scientific evidence as is apparent in managing the Covid-19 pandemic. Doctors lack time with their patients which means the contract between them is also at risk especially in the face of changing public expectations, and that too when patients want to be a key part of the decision making process.
There are three key inter-locking components in this social contract and each group has its own imperatives and expectations from each other. These three groups are: the government, represented by the employers, regulators and health care managers; patients, their families, their informal carers and the public; and finally the medical profession and its professional bodies as well as formal carers.
This tri-partite contract is implicit but it needs periodic discussion and re-evaluation from time to time especially as society, societal expectations and more have changed over the past few decades.
Social contract between medicine and society is of critical importance for a number of reasons. Doctors need to know what is expected of them by the patients and the government who are acting on behalf of the population. Patients need to know their responsibilities as well as their rights. And the government needs to be honest in helping identify what is needed to deliver what services.
The role of the doctor in social contract: The key role of the doctor is to improve the health of individuals, extend life and improve the health of the community through a number of resources which need appropriate and adequate funding. If Covid-19 has shown us something it is that the tripartite relationship is the key to managing pandemics. The idea of doctors as healers has been lost possibly (hopefully temporarily) due to rapid advancements of science and technological innovations in medicine but also an increase in professional regulation and poor managerialism.
The social determinants of health have as great an impact on health and healthcare as medical interventions do. Thus, doctors need to advocate more and speak on behalf of their patients. They need respect and suitable renumeration and acknowledgement.
The role of the government: A major element of government’s responsibility under the social contract is to ensure adequate funding and resources for health services, so patients get the care they need when they need it, and doctors can do their jobs properly. The government has a responsibility to improve the health and wellbeing of the nation by using a number of means. This is the key component of the contract where a major role of the government is to ensure that population are looked after as is evident from the current state of affairs with Covid-19.
The role of the patients: In the social contract patients too have a major role to play. Their expectations need to be manged but with their expectations come responsibilities in ensuring their wellbeing. Accessibility and availability of services require clear need not demand so their expectations of doctors and of the government need to be identified and managed carefully. A full, frank and transparent discussion and agreement is needed about what doctors and the NHS can and cannot provide. A major aspect has to be about funding-how it is provided and who provides it.
Looking to the future
1. There has to be openness and clarity about what the NHS, and doctors, can and cannot deliver, and what patients and doctors expect of each other. Digital and e-health need to be assessed carefully to ensure that they are being used appropriately with clear ethical and moral imperatives. The government needs to move away from short-term objectives and take a more evidence-based approach to public policy.
2. The public should influence the government so that it upholds its part of the contract with adequate funding and resources, but there has to be honest debate about costs and actual resources rather than opaque hints. There needs to be an equity between physical and mental health and to look after the health and wellbeing of doctors and medical students among other health professionals so that they can look after the patients.
3. The medical students in these extraordinary circumstances have been thrown into the frontline and need a public acknowledgement and within any social contract, student healthcare professionals need to be looked after and their views into training and education taken into account by the government who need to prioritise the health and wellbeing of doctors.
If you would like to read more about social contract you may find the following texts of interest:
Williams DL(2014):Rousseau’s Social Contract: an introduction. Cambridge: CUP
Bhugra (2013): Psychiatry’s Social contract. London: Mental Health Foundation
Bhugra D, Malik A, Ikkos G (2011): Psychiatry’s contract with society, Oxford: OUP
BMA(2019): Medicine’s Social Contract: report. London: BMA