Dr Simon Clarke – The Compulsion to Repeat and Health Commissioning

“Insanity is the doing the same things over and over again but expecting different results”

               – Alcoholics Anonymous

I was at an NHS meeting the other day amid a heated discussion about the importance of integrating healthcare needs across the physical/mental health divide. After I made a point about the importance of centring health strategy on the basis of clinical need (i.e. on the needs and priorities of those who actually use the service), one person commented that “business decisions and clinical decisions are not always compatible” and that “health commissioners tell us they don’t want a Rolls Royce service but are quite happy with a Mini”.

Reflecting on this, I was struck by a quite fundamental question: are clinical and business outcomes really that incompatible? And can we really polarise the options in terms of either/or extremes? Last week on the IMH blog Sam Watson posted about the moral costs of doing nothing in healthcare, and the author made some cogent arguments for finding a “quantifiable way of measuring the benefit from all government spending and then choosing the health care budget based on this”. Whilst we are a long way from achieving this in practice, there is a clear recognition that clinical needs and business needs are, indeed, inseparable.

In my own field of clinical health psychology, one of the central issues at the moment is the cost to the health care system in terms of what have been called “Medically Unexplained Symptoms” (a horrible term by the way, but that’s for another post!). These are people who experience considerable physical disability and pain, but often without any identifiable organic (medical) basis. They are usually very distressed individuals, often for good reason; not only are they seen by some medical professionals as malingers and time wasters, they are rarely given a convincing explanation for their symptoms which truly does justice to the manifold complexity of the relationship between body and brain. Pain is very rarely “in your head” but neither can it ever be “just” physical.

Furthermore, and perhaps even more confusing for these clients, it is often entirely arbitrary whether they end up in a mental health service, or in a physical health psychology speciality like mine. Sometimes they will present at both, alongside frequent attendance at hospital and GP surgeries. Ultimately, this costs more in terms of duplication of services, not to mention the cost of specialist medical assessment and expertise. Much of this can be avoided by timely, and coordinated, interventions at an early stage in the process. As we all know, this costs money; but can it really be argued that this is money badly invested?

In thinking about all of this further I realised that I wouldn’t pay for either a Rolls Royce or a Mini. I want what I suspect most people want when they buy a car: something that will not cost too much money up front, but will also not cost a small fortune in the long run. After all, you a can pick up a Rover 400 pretty cheap at the moment; but let’s be honest here, who among us are likely to invest in a car that will probably result in expensive and frequent trips to the garage, not to mention the stress and hassle that goes with it?

I’m guessing that health commissioners, being human after all, are probably not that different either. But being human implies a certain temptation to plumb for the cheap option in the hope that this time, maybe, perhaps, things will be different. With the massive changes sweeping the NHS at the moment, I hope we don’t lose sight of this simple truth: things are usually cheap for a reason, and will probably cost us more in the long-term. There really are no short-cuts here; complex needs cost.

Posted by:
Dr Simon Clarke
Clinical Research Psychologist (Physical Health Speciality)
University Of Nottingham and Nottinghamshire Healthcare NHS Trust



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4 responses to “Dr Simon Clarke – The Compulsion to Repeat and Health Commissioning

  1. Brilliant! You are absolutely correct and I think analogy is spot on. I would love to post this or at least link it to my site fndhope.org. Where can I send e-mail to ask for permission?

  2. Thank you for the interest and glad you liked it! I’ve checked with Simon Clarke and he’s very happy to have you repost it and/or provide a link to the post on your site.


  4. fndhope

    Thank you I have posted this to fndhope.org and have also linked it back so readers can read more posts if they would like. I have to ask if this post is in reference to anything specific. I have read the “Stepped care for functional neurological symptoms: report and recommendations for Scotland” and was amazed at the focus and reference to cost. Don’t get me wrong I too understand that everything comes with a cost, but if “business decisions and clinical decisions are not always compatible” who is making certain they are at least comparable? I would assume the government would aim for balance, but I guess if they pay the bill it becomes a business decision. Then, surely the clinical decision would be the focus of the physicians right? Wrong, if you note that the Step Care was written by medical Consultants.
    Who is looking after the patients???

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