The Deep NeoLiberal State

July, 19, 2021 | 14 Comments

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  1. The Deep – FDA State …

    FDA chief Janet Woodcock acknowledges agency may have misstepped in process leading up to Alzheimer’s drug approval 

    https://www.statnews.com/2021/07/14/woodcock-fda-may-have-misstepped-process-alzheimers-drug-approval/?utm_source=STAT+Newsletters&utm_campaign=64b63792bb-Pharmalot&utm_medium=email&utm_term=0_8cab1d7961-64b63792bb-149674737

    “The accelerated approval was based on very solid grounds,” she said. “I do believe that will play out over time, as people see that was a very appropriate use of that authority and the right thing to do for patients.”

    Too close for comfort: FDA shouldn’t loosen conflict rules for its expert panels

    https://www.statnews.com/2021/07/19/fda-biogen-alzheimer-conflicts/?utm_source=STAT+Newsletters&utm_campaign=36a57c3460-Pharmalot&utm_medium=email&utm_term=0_8cab1d7961-36a57c3460-149674737

    But the advisory committee made it difficult for the agency. Last November, the panel voted nearly unanimously not to recommend the drug for approval, citing uncertainty about the trial data and patient benefits. But after the FDA issued approval anyway, three panel members resigned and one slammed the agency in a letter that was distributed to the media.

    http://freepdfhosting.com/87e1640526.pdf

    Unfortunately, making concessions to the pharmaceutical industry by loosening the rules has a notable downside — it might make it more likely that dissent is curbed or eliminated, and could also cheapen the quality of scientific dialogue. And that wouldn’t help anyone.

    right now, the FDA should be all about raising standards.

    • ‘When Memory Fades’: Misinformation about Alzheimer’s disease and Aduhelm must be limited

      https://www.statnews.com/2021/07/21/when-memory-fades-misinformation-about-alzheimers-disease-and-aduhelm-must-be-limited/?utm_source=STAT+Newsletters&utm_campaign=43c0dd9bce-Pharmalot&utm_medium=email&utm_term=0_8cab1d7961-43c0dd9bce-149674737

      “When Memory Fades” is a well-planned, direct-to-consumer marketing campaign that seeks to greatly expand the target population of people that are candidates for Aduhelm, a drug that has yet to demonstrate a clear clinical benefit in patients with mild cognitive impairment or Alzheimer’s disease.

      I worry about unchecked advertising like the “When Memory Fades” campaign. Clinicians like me need to mount a conscientious and concerted effort to push back against this misinformation and educate our patients. We must ensure that their desperation is not monetized, and their hopes are not held hostage to profit.

      As the surgeon general eloquently put it, “Limiting the spread of health misinformation is a moral and civic imperative that will require a whole-of-society effort.”

      States reach $26 billion deal with three wholesalers and J&J to end opioid lawsuits

      https://www.statnews.com/pharmalot/2021/07/21/opioid-settlement-johnson-and-johnson-mckesson/?utm_source=STAT+Newsletters&utm_campaign=43c0dd9bce-Pharmalot&utm_medium=email&utm_term=0_8cab1d7961-43c0dd9bce-149674737

      Roughly 3,000 lawsuits filed by states, counties, cities, and tribes claimed the wholesalers failed to monitor suspicious shipments. Drug makers were accused of downplaying the risk of addiction to opioid painkillers while simultaneously encouraging doctors to overprescribe the medicines.

      “This epidemic was created by an army of pharmaceutical executives, who decided they wanted to put their profits above the health and well-being” of the public,” said Pennsylvania Attorney General Josh Shapiro during a media briefing announcing the settlement. The agreement does not make any mention of criminal charges, though, and New York Attorney General Letitia James declined to comment when asked if any charges might be filed at a later date.

      Meanwhile, Purdue Pharma, which marketed OxyContin, is awaiting an Aug. 9 hearing on its bankruptcy proposal. Under its plan, some members of the Sackler family who own the drug maker would contribute more than $4.3 billion to compensate people and local governments that were harmed by its opioid painkiller.

      In addition, Purdue will be wound down or sold by 2024, the Sacklers will be banned from the opioid business, and they must relinquish control of family foundations to an independent trustee. In exchange, the Sackler family members will receive immunity from further lawsuits. The proposal has sparked backlash among some state attorneys general, who argue Sackler family members are walking away with considerable wealth.

      “Limiting the spread of health misinformation is a moral and civic imperative that will require a whole-of-society effort.”

      ‘Jane and Jim’, straight out of the Paxil-Songbook…

  2. When populations are compelled to live or lose their living (eg ‘care workers’)like cogs in a machine run by people who design its parts to benefit themselves and their weirdly inhuman values . the society they try to impose on us can produce a state almost like an underground movement needing constant vigilance. There are probably more groups ;organisations and watch dogs now than ever before as well as citizen activists small groups of people goinng their own way or acting like ninjas splashing graffiti messages around But it’s taking so long for any real accountability for the deaths and misery caused by a small group eg the message was being made clear verly early on in the pandemic tht elderly people were being sacrificed to Johnson and co’s fixation with economics. It’s said that the 3 wise men and a few women who held the nonsense of daily briefings were opposed to policies but none of them spoke out Dominic Cummins whether some revenge is the cause of not is coming out with truths revealing the contempt B J and co hold for lives and democracy.
    First they came for the elderly and wiped out thousands of the dispensable (‘they’ include medics who were the ones who signed discharge papers for vulnerable people into ‘homes’ ) Now they’re coming for our children with coercive pressure to take vaccines which has no evidence of being safe and will alter their bodies -to become a medically controlled state owned ‘citizen’ Just as the medical world has assigned millions to this category or that – here comes another one with the partnership of medico – politics and all the control and difficulty they will encounter if they resist. Strangely like coercive medical practices have developed.

  3. You write that “the personal touch has generally been thought to be more likely in a private enterprise than a public one.” I’d say it’s time to wake up and smell the coffee. That sure ain’t true of nursing-home “care” in the USA. Almost all long-term care is private, and a large majority of facilities are for-profit. Poor and marginalized patients are many times MORE likely to end up in a private for-profit home than those with a bit of money. The “quality” nursing homes to which middle-class families aspire (and where a bit of personal attention might come your way) are private, it’s true. But oddly enough, they are almost all nonprofit. The for-profit outfits are staffed so thin, it’s a miracle if you get a bedpan.

    Care homes in Canada and the UK are headed the same way. This does not mean the private and public sectors are separate worlds that “operate the same way even if it is for different reasons.” You may blame poor conditions in UK care homes on government bureaucrats and the Deep State all you like. But the care-home sector is hands-down the most heavily privatized part of the English NHS, and this has a lot to do with why the crisis of care is especially bad there. The same thing seems to be taking shape in Canada.

    There is less and less of a public sector at all. Instead, there’s a rapacious private sector that is paid from the public treasury, much like in the US. Meanwhile your public treasury, like ours, gets skinnier by the day (except for the military budget of course). Why? It’s not because of disembodied “rationalization” by faceless “bureaucrats.” It’s because the people who own the for-profit sector now hoard exponentially more wealth than they ever dreamed of doing in Eisenhower’s day. They do so by squeezing the public sector to the bone—and privatizing its operations to channel even more wealth into private hands.

    Once the cuts have been made, the “government bureaucrat” may be left behind to implement them (and for us to take our frustrations on). But do not let that blind you to who is actually swinging the hatchet.

    In all three countries, the private “care” industry plays a shell game in which an “operating company” officially run the home while other entities, owned by the same people, feed off it. There’s a “property co” that owns the building, a “management co” that oversees the finances, and for-profit pharmacies, staffing firms, medical-supply vendors, etc. that sell goods and services. The owners may report a razor-thin margin for the home itself. But that’s because they are paying exorbitant rents and fees – to themselves. They are also robbing public health-care payors blind, often for services the residents don’t need and/or never receive, while refusing them things like baths.

    The shift towards hedge-fund ownership of large nursing-home chains is making things rapidly worse. These are the risk-taking entrepreneurs par excellence – the guys who like to Move Fast and Break Things. Trouble is, their “risk-taking” consists of loading up on debt to acquire existing businesses, then tearing them apart to pay back the loans and extract value for shareholders. My local area has seen three “safety-net” hospitals closed down in the past six years by these shenanigans.

    This is why, as you noted a few weeks ago, the amount spent on a day’s food for Grandpa is less than the cost of a nice cup of coffee. It’s not due to some abstract standardization or “operationalism.” It’s because every nickel not spent on Grandpa goes into the pockets of the owners and their lenders (even if the “public sector” hands them the money).

    If we don’t understand this we will end up loving our jailers, and hating anyone who suggests we bust loose. Sad to say, most of my fellow Americans already do. (We also tend to confuse the Democrats, Kennedy, Carter et al with the “Left” or the “party of the workers.”) Don’t join us, OK?

    • Jo

      You’re missing a trick here – what gets called private here is no longer private as in private bed and breakfasts – its now corporate chains. I agree corporate chains do not have a private touch any more – its corporate and factory. The problem we have is that even voluntary sector stuff – as in residential schools for indigenous people – now play by the same corporate factory rules making them also less human than they once were.

      In medicine if you want to get personal care now, you have to go boutique and if you want your medication burden reduced you have to go to someone with a sign on their door that says open to reducing medication burdens. Public medical systems like Canada or Britain are now engines that will increase your medication load. The idea that the State has less money and so would give you less meds even if its doctors were trying to put you on the latest stuff is a twentieth century idea.

      D

      • I remain to be convinced that even Bernie Sanders sees the problem. Jeremy Corbyn etc didn’t. When it comes to Health, this is now where religion used to be and between Gyms and Meds everyone – especially Greta Thunberg’s generation – are becoming Daily Communicants rather have having contact with organized religion when necessary.

        D

        • Some of the major campaigns in UK are now run to highlight the scandalous way both private and publicly funded ‘care homes’ are run .It is difficult to tell where the voluntary sector begins to be state funded and controlled or privately run but part paid by the state.’ Many people have been alerted this year by the publicity afforded by covid and its impact on the ‘care industry; Particularly against the way health and social care are separated in UK when obviously the two blend together. The well being of people is being sacrificed decade after decade because of power struggles between health and social servises , Orgnisations have been set up specifically to help people negotiate funding assessments to get ‘care’ in local authority settings. Health needs are supposed to be provided free whilst social needs are assessed separately Residents are allowed to keep just over £24 ‘for personal needs’ The assessments are finally made by a decision making tool which makes errors and is being challenged eg illegal. https://caretobedifferent.co.uk/who-completes-decision-support-tool-nhs-continuing-healthcare/
          From what I have seen for individuals it is not as ‘easy’ as public good private bad ,most of us would prefer the extra comfort, privacy, nicer surroundings of the private sector but if money is taken out of the equation those who actually run the homes and work in them can set a standard of values which attracts the sort of care for residents , making what can more be more honestly called a ‘home’ .

        • Can’t argue with you there. Bernie Sanders knows Americans pay criminally high prices for “lifesaving drugs.” (True, of course.) He probably doesn’t “get” that we pay the same high prices for life-saving drugs, possibly-useful drugs and crappy, dangerous drugs. Or that the medical care we DO get is largely a corporate product – and so is the “science” behind it. He sees medical care as basically an unqualified good, that’s controlled by greedy people in a greedy system. We need to make it a right! (Also true, even if there’s much more to the story.)

          And it’s not just Bernie Sanders who sees it that way. It’s also 99% of grassroots union-consumer-civil-rights-etc activists and ordinary working-thinking people we might ever want to talk to.

          Frankly, I would be amazed if they DID “get it.” Why on earth should they? Most never hear any other viewpoint. To the extent they do, it often comes wrapped in alt-medicine woo-woo, fundamentalist religion, hard-right conspiracy theory or other content that makes it easy to dismiss. At best, Joe Mercola and Peter Breggin; at worst, Q-Anon and InfoWars. Meanwhile, they live in a country where strong, happy young people drop dead because they can’t afford their insulin.

          Hell, it took ME well over twenty years to “get it.” And I was old enough to remember the days before Chemical Imbalance doctrine held sway – and had “lived experience” of how badly it could fail us! Still, I finally did wake up, mainly thanks to this one guy who kept writing books and trying to reach people like me. I think his name was Healy.

          Voices like yours are a small minority in the UK. In the USA, they’re microscopic. We need to keep fighting for every fragment of truth we can bring to light and every half-dozen people we can win over. Including the ones who failed to take us seriously five years ago. Some politicians, of course, are never going to listen; they know PhRMA has feet of clay, but they also know money and clout when they see it. But the rest of us are worth fighting for, especially the younger generation. When they finally do “get it,” the explosion will be something to see.

      • “Private” to me (as to most people I think) means “privately owned” as opposed to publicly owned. Privatization means selling off the provision of public services (whether care homes, prisons, schools or highways) to private for-profit corporations. Naturally they are usually large corporate chains, almost never small businesses. But they are definitely private and for-profit.

        That’s why we call it Privatization. It means handing over the public budget and the decision making power to a for-profit corporation whose first priority is its own profit (not taking care of you and me, or getting a job done efficiently). That profit is generally made by cutting services. They will tell you they will only cut the “waste, fraud and abuse,” thus giving you even better services. About 95.7% of the time they are lying, of course. Don’t be fooled.

        As for indigenous schools, they were certainly never “humane” places that later got corrupted by faceless corporate-type managers! You gotta realize they were Step Three of a process. Step One was depriving people of their lands with cannons and bayonets (Trail of Tears, Wounded Knee, etc). Step Two was treaties imposed by trickery and force. Step Three (boarding schools) was an effort to gradually wipe out the remaining communities (and grab their lands) through forced assimilation.

        That’s why the founders called it “killing the Indian to save the man” — and why it was seen as OK if a certain number of children died in the process of being “saved.” Extinguishing Native culture was a more politically acceptable solution than simply bayoneting the children — but the main goal was always to erase the First Nations, not to save or improve the children. That is why, although today’s politicians make pious noises about the virtues of indigenous cultures, they are still trying to snatch their lands for the fossil fuel industry — just about the ultimate act of blasphemy against that culture. Again, don’t be fooled.

        • Jo

          I think you are missing a trick in trying to get the people who aren’t currently on your side onside. Its this – companies became corporations in the 1950s and 1960s run by bureaucrats – managers – and the Deep State folk see these corporations as just as socialist as government.

          The private corporations then had a further transition in 1976 when the idea of following a metric – a set of figures – in this case shareholder value, which wasn’t around before 1976 – came into being. Its this following the metric as the only rational course of action that completely transformed companies from entities that of course were there to produce a profit into entities that produced a profit for a sole and only purpose and were increasingly unproductive.

          No-one can see a rational alternative to this – any more than they can see a rational alternative to treating a modest rise in blood pressure or even having a vaccine. This rational cage is what we need to extricate ourselves from and whichever side of the fence you are on the guys on the other side may be able to help.

          Allied to this the working men in unions you alluded to – as in American Steel – managed to conspire with management to feather the nests of their members (white men) to the detriment of women and anyone of color.

          There are no workers any more. They have vanished with the peasants and the Peasant Party. We have servicers into which health and education have been sucked with no party to represent them. This is most clearly visible in health. This is the whole point behind the Policy of Care Forum – there is no party that represents the interests of most us. They all support being evidence based. If you can find me a party or even 10 politicians able to take on the Evidence – ranting about pharmaceutical company profits or drug prices is not taking on the Evidence – then I will start praying to God to save Sodom and Gomorrah

          D

  4. Frankly the underbelly of british society stinks while those who are creating it can hide behind their perfumed handkerchiefs and get away with so much

    Presently inhumane and contemptuous methods have already been secretly set up using algorithms – drawn up and authorised by – who knows who – it’s so disgusting ‘they’ hide behind titles and organisations while the result includes a huge number of suicides , a modern form of starvation and the attempted humiliation of thousands of citizens-

    This would shock most people including huge numbers of people having to claim disability or housing benefits;- It’s stuff we should all know about
    1
    About Big Brother WatchBig Brother Watch .carlo@bigbrotherwatch.org.ukJake HurfurtHead of InvestigationsEmail: j With thanks to Esme Harrington and Max Katz for their vital contributions to the research in this report, from Freedom of Information requests to trawling corporate sites. Thanks also to fellow researchers and reporters for sharing advice and information that helped develop this report.
    Poverty Panopticon: the hidden algorithms shaping Britain’s welfare statePublished: 20th July 202120211ContentsChapter 1: ………………………………………………………………………………..Contribution from Christiaan van Veen, Director of the Digital Welfare State Project and Adjunct Professor of Law at NYU Law..esRSSTranslate
    View this email in your browser
    Dear friends,
    Our explosive report published today blows the lid off the shady algorithms local councils have been using to screen benefit applicants, often without their knowledge or their consent.
    Our 9-month investigation has found that councils are conducting mass profiling and citizen scoring of welfare and social care recipients to predict fraud, rent non-payments and major life events. (This includes even the ppossibility of things like child or domestic abuse indicated by the algorhythm)

    Today we can reveal to you that:
    • 540,000 benefits applicants are secretly assigned fraud risk scores by councils’ algorithms before they can access housing benefit or council tax support.
    • 250,000+ people’s data is processed by a range of secretive automated tools to predict the likelihood they’ll be abused, become homeless or out of work.
    • Amazon Echo Dot listening devices are being put in thousands of older people’s homes across the country without any additional data protection, meaning that Alexa is sending huge amounts of data about these people to the shopping giant.

    “Poverty Panopticon: the hidden algorithms shaping Britain’s welfare state” can be read by clicking here or on the image below.

    …chief executive of Xantura, who admitted that they use claimant’s ages, which are a protected characteristic under the Equality Act 2010, to decide on their future. Serious questions are now being raised about whether this system breaks anti-discrimination laws.

    Sounds familiar? same thing benefits claimants go through –
    “I’ve noticed the amount of evidence I’ve been asked for has changed over the years, which makes it really stressful. I’ve been made to go through all my bank statements line by line with an assessor, which made me feel like a criminal. Now I wonder if it’s because a machine decided, for reasons unknown, I could be a fraudster.”

    If you share your response with us, we will treat it confidentially and help you understand what it means. Get in touch at info@bigbrotherwatch.org.uk

  5. From the Marmot Report (yet another one)
    Our main recommendation is to the Prime Minister – to initiate an ambitious and world-leading health inequalities strategy and lead a Cabinet-level cross-departmental committee charged with its development and implementation. We suggest that the new strategy is highly visible to the public and that clear targets are set.

    For years the idea of taking politics OUT of care has been flagged up but party politics get in the way It may be too optimistic to hope that a merger between health and social care may actually come about as a result of scandals during the pandemic But even that proposal needs to be widened to include all with new ideas, expertise and knowledge from all disciplines not usually seen as health and including seriously the experience of people in campaigning groups who have been doing the work governments should have been doing = real lives lived in the real world – there are many with expertise which should be included in any network

  6. The head of the RCGP’s Martin….was making the same point. Here’s an opportunity to give feed back via Richard Hurley (below) tThey are obviously trying to tackle the negative feedback and poor publicity GPs have been getting around the UK ,there seems to be a project if not campaign going as the topic has been on radio as well -they need to be honest – the problem has been there before covid. We can only hope they will ‘listen ‘to feedback and act on it

    Covid-19 makes it harder for GPs to offer the quiet listening that made all the difference to me
    BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1757 (Published 22 July 2021)

    Anonymous
    An anonymous patient explains how her GP used shared decision making to help her manage her distress. Quiet listening can empower patients to lead conversations about their own care, she says, but is threatened by the effects of covid-19, including more triage, remote care, and burnout among GPs

    How are the kids doing? Did they go to school today? These were among the first things she asked me. This was the beginning of sustained, personalised care from a general practitioner whose talents were asking the right questions and quiet listening.

    My husband was in an operating theatre, my head was spinning, and I hadn’t slept in days. He needed a biopsy of lymph nodes close to his aorta. We knew that he was really sick. We didn’t know what kind of cancer he had. I was terrified that he was dying (he was) and that there would be no cure (there wasn’t).

    Hanging on to my mental health
    I didn’t have flattened affect: I could still see joy and laugh. But I cried at night, as my husband groaned, sweating, startling, and waking with the pain that followed him everywhere. For months, I was hanging on to my mental health by a thread.

    Discussing this with my GP was difficult. Her quiet listening was crucial. What followed was not a prescription for antidepressant drugs or an inpatient admission to a psychiatric ward, though both were very possible outcomes.

    Instead, with my GP, I made a plan. You could call it a care plan, but it was instigated by the patient, not the health professional. A key feature was the joint decision to demedicalise my experience of distress. Together we agreed that I wouldn’t start taking antidepressants: I chose to live with the distress and to find resilience. These discussions were very personal and practical and included where to get advice on managing financial pressures, balancing the demands of work and being a carer, and psychological support.

    If things got really bad, I’d avoid going to the emergency department: she suggested other options for an acute mental health crisis that in her experience tended to work out better for patients, such as attending the charity Mind’s sanctuary service. Avoiding unnecessary treatment saved the NHS money. My GP probably also helped me to avoid a psychiatric admission to hospital. None of this would have been possible without a GP who knew, and practised, the art of quiet listening.

    No algorithmically programmed chatbot could do what she did in conveying humanity and allowing me to lead a clinical conversation. Entering “thoughts of suicide and self-harm” into an online triage tool or virtual symptom checker could not have produced the same outcome as I experienced through face-to-face care, or the same efficiency and value for the NHS.

    Truly personalised and demedicalised care
    Our conversation was about tailoring care to the individual: finding the right solution for me. This was personalised care in action. It speaks to the sharp end of conversations about the limits of the biomedical and clinical sciences to medical practice.1

    The BMJ’s Too Much Medicine campaign has focused on changing clinicians’ behaviour by identifying diagnostic practice and treatments that are unlikely to benefit most patients (www.bmj.com/too-much-medicine). What may be missing is a concurrent emphasis on empowering patients. How can clinical practice develop to enable patients jointly with clinicians to hold risk and manage uncertainty? How can practice develop to allow patients to lead conversations in which they can demedicalise their experiences of living with poor health or of dying?

    I saw my GP a couple of times each month. The care I received was a masterclass in the highly skilled work of managing uncertainty and holding clinical risk in the community rather than referring to others. This helps create positive patient outcomes that avoid the harms of over-investigation and over-treatment, and it manages demand for health services. This is primary care’s hugely valuable but often under-recognised contribution to the efficiency of the whole system.

    How to practise quiet listening
    My GP’s willingness to play a supporting role was key. She elected that we jointly manage risk. By listening, rather than leading the conversation, she allowed me to make choices that were empowering while enabling me to demedicalise my experience of distress. She took her lead from me. I opened the conversation about whether I was depressed. I gave her my view of the evidence; I asked for her view. After a careful pause, she said, “I think you are not depressed.”

    We took it together from there. We talked about treatment options. Cognitive behavioural therapy works best when reframing can help adjust a patient’s perspective on a problem. My GP and I agreed that this was not the right approach for my situation, where the problem itself was causing distress. Instead, we brainstormed together about who might locally offer psychological support based around acceptance and commitment therapy. The cancer charity Maggie’s, as it turns out.

    My GP’s approach fits with newer thinking, exemplified in the SHERPA (sharing evidence routine for a person-centred plan for action) framework,2 for example, which values practical conversations that start by co-constructing with patients the nature of the problem. The focus is on simpler, more natural conversations about care that are appropriate for, and agreed with, individual patients.

    Creating quiet spaces
    How might quiet listening fit with active listening, often taught to students in medical school? Instead of an emphasis on listening with fascination, quiet listening is more about empathy in practice, about quiet spaces in conversations.

    With an emphasis on patient activation, which focuses on what you can do, it can be hard to find space for conversations about what you can’t do. Quiet listening makes space to speak about worrying you can’t feed your children properly, not being able to buy their shoes, not having money to pay for a funeral. These are some of the things that distressed me the most. The Dutch anthropologist Annemarie Mol points out that care “makes space for what is not possible.”3 Quiet listening is an important part of this.

    Continuity of care
    A doctor who I trust and who knows me well is crucial in enabling quiet listening and to leading conversations about my own care. Seeing the same doctor over time also means that I don’t have to repeat my story to multiple different doctors. Once is enough: some things are not fun to talk about. Seeing the same GP over time has a survival advantage similar to many drugs and complex interventions, evidence shows.4 High relational continuity is associated with lower mortality, better self-management of long term conditions, and fewer admissions to hospital.5

    The same GP can notice changes that would not be obvious to a doctor who doesn’t know me. I’m prone to ironic humour and making inappropriate jokes, for example, even about what was happening to me then. If I stop doing this, I’m in trouble. Losing my sense of humour indicates seriously deteriorating mental health. A GP who didn’t know me well couldn’t read that.

    Since the pandemic, quiet listening and relationship based care have arguably become even more important,

    Remote care and the future of quiet listening
    At the same time, covid-19 could have long term effects on the ability of GPs to offer quiet listening and face-to-face care to patients.

    With so much recent concern about rising numbers of appointments and demand on general practices,10 have we thought carefully enough about the risk of telephone triage adding to clinicians’ workload through duplication, for which there is good evidence?11

    We cannot assume remote care is the best option for most patients in the long term.12 Early evaluation of “remote by default” care finds over-protocolised general practice can come with risk.13 Case based judgment is needed to decide if remote consultation is best for a particular patient at a particular time. Complexity in primary care consultations include, for example, “doorknob disclosures,” when patients mention something crucial as they are leaving, and early detection of cancer through clinical intuition and timely investigation. In lung cancer,14 for example, clinicians believe face-to-face appointments are the best option for most purposes, especially breaking bad news.

    Positioning remote care as the norm from which the traditional face-to-face consultation would deviate sits uncomfortably.13 Decisions should be guided by evidence on the benefits as well as possible unintended harms.

    Alongside this, we should be careful not to take for granted the benefits of care that might be deemed “old fashioned” by some. I never set out to find a GP whose talent was quiet listening and relationship based care. I didn’t know I’d need her. It was pure luck that, when I needed a GP who offered this kind of care, I had one. In an age of machine learning and techno-optimism, the artful skill of quiet listening can easily be undervalued. But it makes a crucial difference to the quality of patient care and to value for the NHS.

    The challenge ahead for general practice
    General practice is now at a crossroads.15 Demand for appointments is rising, as is concern about the harms to GPs through the “moral injury” that comes from being unable to provide the kind of care they believe that patients need.10

    We previously sought to find practical ways to provide continuity alongside better access to primary care.16 Now we need thinking that allows general practice to harness the benefits of remote consultations while holding on to the value to patients and to clinicians inherent in relationship based care and quiet listening. One starting point may be the realisation of National Voices’ vision for inclusive and personalised care.17

    To send a message to the author, please contact the commissioning editor, Richard Hurley, rhurley@bmj.com

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