Innovative consultation time as a common European currency

Abstract

All European care systems are converging toward a single rationalised model, in which community generalists become distinct from hospital-based specialists, linked by clearly defined referral and exchange of information both ways. This model evolved by cooperative public service rather than by competing entrepreneurs, is now being subordinated everywhere to market competition under corporate rather than professional control, on the assumption that cost efficiency must thereby increase. This industrialised model of care measures efficiency by equating episodic clinical interventions with health outputs, and dividing these by input costs, of which the largest is labour time. Though competitive production of any commodity generally leads to a fall in price, it also leads to promotion of the product. Managed competition will constrain the price and increase speed of production of medical interventions, but will also increase their volume and promote consumption. Assumptions that raised output and consumption of clinical interventions must lead to raised output of social health are unsupported by experience or evidence. Primary care teams have a common interest in reasserting the primacy of labour-intensive continuing care as a necessary basis for rational use of episodic technology-intensive body repair. In terms of health output, the chief rate-limiting factor both for quality and efficiency of primary care is the extent to which our patients become able to share complex decisions with their health professionals, as active coproducers of health, rather than passive consumers of medical care. Before patients can begin this transition to a producer role, their minimal expectations as consumers must be met. The common currency of primary care is therefore the additional consultation time, beyond the minimum required to meet traditional expectations, to allow this necessary development (of health professionals as well as patients) to begin: innovative consultation time.