The role of the ‘specialist' in healthcare

Abstract

Clinical Medicine 2011, Vol 11, No 4: 329–31 The role of the specialist in healthcare has never been in doubt and its prominence is increasing. In this article, I’m going to argue that specialisation is needed to improve our national competitiveness, ability to innovate, extend life and explore the frontier of science and knowledge. I’m also going to argue that, if left unfettered and not harnessed to the role of the generalist in healthcare, we can look forward to painful debates about rationing, professional ‘turf-war’ and suboptimal patient care. I conclude that better teamwork between the generalist and specialist has never been more important for the NHS and doctors should get together to form ‘integrated care chambers’ to better serve their patients and the population at large, thus changing the pattern of healthcare that has built up over centuries. In his documentary Civilisation, Professor Niall Ferguson argues that the West became the dominant global powerhouse from the 16th century because of the simultaneous combination of six ‘killer applications’ ‐ competition, science, democracy, medicine, consumerism and the work ethic. Given current political debate about NHS privatisation, it is interesting to note that medicine and science have always helped British competitiveness and capitalism. Throughout the 16th century, it would have been impossible for the West to assert its growing economic supremacy without a strong medical and scientific base. The pursuit of knowledge in these fields has acted as a powerful economic spur and this is reflected in the UK’s 21st century desire to lead on innovation and promote our science and academic medical base throughout the world. The West has dominated global development for the past five centuries and will need to use innovation in science and medicine to a much greater degree if it is to maintain its international competiveness. Specialisation provides both the impetus and spur to maintain this dynamic force. Indeed, it was Henry VIII in the 16th century that began the modernisation and specialisation of healthcare in England. Poor relief was becoming increasingly problematic during the early part of the century due to a rising population (from two million in 1485 to nearly three million by 1509), and the dissolution of the monasteries from 1537 effectively closed the majority of hospitals that were run by monks and considered to be special types of religious houses that were ‘more concerned with saving souls than lives’. Ironically therefore, the dissolution of the monasteries paved the way for the workhouse (where the generalists started) and stimulated the introduction of hospitals which were, over time, associated with specialist care. It is no coincidence that the rise of the royal college movement started in this century, so the origins of specialisation have long historical and cultural roots. Specialisation is a trend that cannot be stopped. The average GP will receive about 15 kg of new clinical guidelines each year, while the number of articles captured and indexed annually by the electronic MEDLINE database stands at around 900,000. 1 The number of identifiable diseases and their related treatments have increased manifold ‐ the current World Health Organization International Classification of Diseases (ICD-10) currently stands at 155,000 codes. It is not humanly possible for individuals to master all this knowledge and information and, therefore, a degree of specialisation is both important and inevitable. Even a recent House of Lords Science and Technology Committee report 2 found that healthcare professionals are currently not well equipped to use genomic tests effectively and interpret them accurately, indicating an urgent need for much wider education of healthcare professionals and the public in genomic medicine. That is before the generalist is required to master the implications of nanotechnology, pharmaceuticals and new biochemical pathways! There are, of course, good clinical arguments for specialisation which we should acknowledge. Firstly, procedures have