Medical specialisation and its consequences for England's NHS.

AuthorIliffe, Steve

In an earlier analysis of the NHS as a 'stalled bureaucracy' we identified four policy problems that Labour needs to find ways to solve:

* how to shift resource allocation in favour of community-based health services;

* how to tackle the fragmenting effect of specialisation and super-specialisation;

* how to clarify what parity of esteem between physical and mental health services actually means;

* how to begin to realise the idea of a public 'fully engaged' with the NHS. (1)

This article explores the second of these problems, medical specialisation-which we described as a key reason for the NHS's shortcomings-and discusses policy options for Labour to consider, in Opposition or in Government. (2) Specialisation of physicians follows a different path from those in nursing and the allied health professions, which will be explored in a separate article.

The drivers of specialisation

Historically, medical specialisation has emerged in response to three trends. The first was conceptual evolution in medical theory, particularly paradigm shifts such as the change in thinking that led from the notion of disturbances of 'humours' to an understanding of blood circulation. In the eighteenth century, Western views of disease changed from seeing illness as an imbalance of these humours, to focus instead on localised anatomical lesions which manifested as symptoms and physical signs. This conceptual change encouraged the compartmentalisation of medical knowledge and the concomitant development of the specialised research, instruments, and professional structures that typify a modern health service. (3)

The second was a broad set of demographic, economic and social factors associated with the growth of urban centres where medical specialisms could create and occupy niche markets, particularly during the nineteenth century.

The third factor was advances in medical practice triggered by innovations in technology and therapeutics during the twentieth century (examples are X-Rays and antibiotics, but there are many more in use or in the development pipeline). (4)

Proliferation

The process of medical specialisation is driven primarily by the splitting of prior specialities, rather than through the creation of entirely novel ones. Once a specialty is split, the prior specialty usually remains, and the split produces a more narrowly focused specialism. And if that narrower specialty is itself split, an even narrower specialty is produced. It can be helpful for policy-makers to distinguish between degrees of specialisation:

* A 'specialist' is a practitioner (in the UK usually based in a hospital) who has a broad interest in either Big Picture disciplines like acute care medicine, geriatrics or general practice, or in narrower focused disciplines like surgery, obstetrics or one of the investigative fields such as imaging.

* A 'sub-specialist' is a specialist who tends to focus on a specific field within a specialty. Examples would be an orthopaedic surgeon or a cardiologist.

* A 'super-specialist' is a sub-specialist who works in an even narrower field. Examples would be an orthopaedic surgeon who only operates on knee disorders or a cardiologist who only treats disturbances of heart rhythm (cardiac arrhythmias). (5)

Specialisation is driven by evolving medical science but it is fuelled by a culture of prizes. Specialists and super-specialists can occupy lucrative niches in the private practice market, receive financial rewards from the NHS (Clinical Excellence Awards, once called 'Merit Awards'), and develop portfolios of specialist research funded by the NHS and Big Pharma.

Strengths and weaknesses of specialisation

We have all benefitted from the wave of medical specialisation which arose soon after the Second World War. The formation of the NHS was in large part about opening up free access to specialist care for the whole population. Specialisation has benefits for both patients and practitioners. An economics evaluation published in 2013, based on a complete set of national data from 169 NHS hospitals, suggested that specialist hospitals with high levels of sub- and super-specialisation have higher patient satisfaction and better financial performance than those with less specialisation. (6) Specialisation is a feature of medicine and is bound to stay so. This does not mean that specialisation and sub-specialisation are not problems for a health service. The New Labour administrations clashed with the medical profession over specialisation and its consequences (as we show below), and the problems it attempted to solve persist.

In a world of expanding knowledge, the disconnect between specialisms is so great that clinicians forego familiarity both with other colleagues and with their areas of knowledge. (7) Specialisation is a form of cautious obedience to a limited set of rules and an...

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