Andrew Rix is an independent research and evaluation consultant, and Honorary Researcher at Swansea University School of Medicine.

At the end of the recent Rethinking Medicine webinar, I felt uneasy. At one level the 'movement' is repositioning medicine in the broader context of the socioeconomic determinants of health and wellbeing, but in practice what is happening on the ground is the development of a whole range of changes to service delivery, concerning both the 'what' and the 'how'.  
 
New ways of thinking are leading to new ways of working, changed relationships and, most importantly, a reappraisal of the position of evidence-based medicine and the role of the patient. 

​We heard of a 'narrative' to plot progress, but it seemed to be mainly a retrospective account of initiatives that been tried and have attracted support.

Michael Bosch is a GP in East Surrey​.

The central tenet of managing healthcare (at least publicly funded healthcare) is reducing unplanned hospital attendances.

A patient who attends hospital in an 'unplanned' way is seen as a potential failure of the system. The system should have looked after the patient better outside the hospital since once in the hospital, everyone could pay a high price for this failure: the public purse pays over the odds for quite possibly unnecessary care, and even iatrogenic damage to the patient.

The trouble is that despite all the attempts to keep patients away from hospitals when their problem shouldn't really 'need' hospital care, their numbers keep going up and up.

I was recently on the 'other' side of receiving care, as a relative of a patient. I had the opportunity to have a front row seat in viewing the exchange of communication between different healthcare professionals and said patient. Or should I say, the lack of communication.

In urgent care, the triage nurse tutted and sighed when we asked how long it was going to be until my relative was seen….to point out, this was after four hours of waiting without any form of communication. After waiting close to five hours, we received the required referral to the surgical team.

I was prompted recently to return to the perennial question, 'what is good care?', as part of a qualitative study of cardiovascular disease prevention in general practice.

This question became prominent during the study because patients' understandings of 'care' often seemed at odds with those of healthcare professionals. What particularly puzzled me was that healthcare professionals often espoused concepts of good care such as 'shared decision-making', while patients found that the interactions involved did not meet their needs.

While healthcare professionals thought they were 'sharing decisions' or 'involving' patients, patients could simultaneously feel that they were struggling to 'get a conversation' with the doctor or nurse. 

I was shocked to learn at a recent meeting that some clinical geneticists think it's OK to screen patients for underlying cancer risk without discussing the options with them and without seeking their informed consent.

Up to then I'd believed that the clinical genetics specialty was ahead of the game when it came to sharing decisions with patients, so this was depressing news.

So, what is Rethinking Medicine and exactly what needs to be re-thought? Medicine is constantly changing – so, what has happened that requires us to rethink the process and perhaps bring it back into line?
 
Medical training and care provision have developed throughout the centuries to recognise the current knowledge as well as reflecting disease profiles and social mores. It is imperative that medical training and on-going professional development are based on the needs of individual patients and the population who will benefit from the resultant knowledge and skills. 

Rethinking - interesting choice of word. Not review or assessment - more radical. Rethinking is a form of investigation not bound by the past, nor by a process and not constrained by the ecology of the future. Unlike the other option, a review, it is born of inquisitiveness, nourished by anarchy and unpredictable in its outcomes.

I cannot help but think that the group has given itself the harder of the two options. ​ 

Change takes time. We need to prepare for the future not just firefight the present. It's a popular time to wheel out some of health policy's favourite clichés. But how do you define long term? And how does knowing a realistic end point affect what you do now?
 
Let's start with what you're trying to achieve. You need to consider the scale of change needed, but also quite how embedded the status quo is. Trying to reverse decades of hospital dominance sounds like a task for at least a decade. Balancing the attention given to physical and mental health is likely to be even longer.

The NHS Long Term Plan sets out a vision for the future of the NHS that begins to rebalance the way the NHS will care for the population for the next 10 years.

It focusses on care in the community, prevention, and addressing the biggest health challenges of our time. It is difficult, however, to change the culture of an organisation, but this is a good start. The difficulty will be in turning plans into reality. 

​It’s December 1995. A chubby four-year-old boy in a Thomas the Tank Engine woolly hat is crying.

He’s suffering from a very common ear infection that almost all children have experienced, ‘otitis media’. He’s crying because it’s painful.