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Dr Finlay is dead

The NHS, nearing its 60th birthday, is in need of some radical treatment. The prescription? A new relationship with patients

Ben Bradshaw invokes the views of the public to justify extending GP access. Telling us what we want and providing it is the oldest trick in the book. When asked what we want, we of course say that we want to be able to see whoever, whenever. But government should instead be asking what doctors, patients and the NHS need. The NHS is nearing its 60th birthday, and is in need of some pretty radical treatment.

Both Bradshaw and George Monbiot, to whom he is responding, are missing a much more important debate. While government moves the machinery of healthcare around and stuffs doctors' mouths with gold, the relationships at the heart of the NHS are at breaking point.

According to our research, patients still say that they trust their GPs, but doctors feel that they are propping up an increasingly untrustworthy system. Government policies, based around the self-evident benefits of "choice", ignore the vital need for what Annemarie Mol has called a "logic of care".

Back in 2002, Derek Wanless told Gordon Brown that unless the NHS fundamentally rethinks the way it relates to people, it will be bankrupted by growing demand and growing dependency. Treating the spread of chronic illness such as diabetes will cost the NHS billions unless patients are able to manage it themselves. Patients, according to Wanless, need to become "fully-engaged" in their care.

Last year, Wanless pointed out that not much had changed. The government still imagines patients as nothing more than consumers while professionals retreat to targets and financial contracts. As the medical profession now realises, the time is right to rethink its social contract.

Over the next 60 years, the NHS needs to get much better at helping people to take care of themselves. Doctors need to recognise that patients are often experts and that, as they gain access to new sorts of information, they are able to ask new questions. A few years, ago, patients with internet access would have been derided as "cyberchondriacs". Increasingly, doctors realise that these new questions need to be encouraged. Following a breakdown in the systems that train and recruit doctors in 2007, a new debate has opened up over what the doctors of the future should look like. The Tooke report (pdf) into the system failure found a mass of contradictions and tensions. Doctors are being pulled in countless different directions and patients no longer know what is expected of them.

With Ara Darzi's review of the NHS, the government is again looking at the healthcare machine from the top down. Darzi's recommendations are likely to focus on improving access and reorganising groups of professionals. The real changes that need to take place will be ignored. These need to happen from the bottom up. Doctors and patients need to be given the space to have real conversations that are open and transparent. Chronically ill patients will soon be given personal budgets. But they need to be given the opportunity of choosing from off the menu. They need to be able to join together to build new services and create care plans that work for them. All patients will soon be able to see their records electronically, online. We argue that patient records are one way of getting a head start on healthy conversations. People should be able to write on as well as read their records.

These changes mean getting rid of some old assumptions. Doctors are getting beyond paternalism - "Dr Finlay is dead", they now tell us. But government seems determined to continually exert parental control over all parts of the NHS, which doesn't bode well for our long term health.

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