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Why healthcare outcomes are resistant to policy change

13799802965_b07db37bf2_zAfter every match, the cricket coach gives feedback about how the match was won or lost. Whenever the team wins it’s usually because of high scoring batting, or a great performance by the bowlers. However, when they lose there’s almost always one reason—poor fielding, dropped catches, easily conceded single runs and inaccurate throws.

In medicine surgeons are the batsmen, in most games they are seldom in play for very long. When the surgeon gets involved the crowd holds its breath for something magical to happen and when it does they celebrate with ‘Mexican wave’. Physicians are akin to bowlers, trying different deliveries, aiming to make it difficult to concede runs, patiently waiting for an unforced error. Occasionally screaming at the umpire for a decision in their favour. In the limelight an over at a time.

General practitioners are the fielders, rarely flamboyant and hard to tell apart. Constantly moving across the field, often to simply return the ball back into play. Standing for hours in the hot sun, occasionally chasing a ball to the boundary. Always trying to limit the damage. No matter how good the batting or the bowling is, if those in the field are not fully engaged, or solving problems creatively, if they are not intuitive, or working for the common good, without waiting for instruction after every ball is delivered then the game is lost.

As a primary care practitioner I am aware that most of the patients I see won’t have life-threatening pathology, but occasionally I’ll get a chance to make a game-changing difference, and on other days, my patients feel safer knowing that I am there. I don’t need to make any fancy moves, most of the time what I do is simply ensure that I nip things in the bud.

In medicine, most people consult a general practitioner and not a surgeon. That’s where innovation has the scope to make a difference to most people. Without reference to the practitioners who work at the coalface no amount of policy change is likely to make a difference to outcomes. That’s because fielders can’t do their job with one hand tied behind their back or by ignoring the evidence of their own eyes, or by focusing other than on the ball. According to the experts good fielders:

  1. Don’t move. When the captain puts them somewhere they stay there until they are moved again.
  2.  Show confidence. Looking confident in the field can save many runs.
  3.  Will throw at the stumps whenever there is a chance.
  4. Back up.
  5. Want to get every ball.
  6. Are close enough. If they are on the boundary their job is to save fours so they stay as deep as possible without giving away two runs if they can.
  7. Know themselves. If they have a setback in the field, they are aware of how they will react to it.

These simple rules tell us that it is imperative to work with the fielders if the team is to win the match. Failing to do so, like failing to work with the doctors most likely to come into contact with patients leads to frustration. The emotion that most funders experience perhaps because they do not understand the business of doctoring. We need to reframe problems in healthcare as a failure to engage with front line staff.

Picture by Lawrence OP

What factors trigger an urgent and appropriate medical consultation?


There are circumstances in which it is critical for a patient to consult a doctor sooner rather than later. Imagine someone with symptoms of a stroke or a myocardial infarction ( heart attack), or with a breast lump.

In these circumstances timely intervention may be life saving. These circumstances are often the subject of public health campaigns and perhaps one of the most popular attempts to improve health care outcomes or reduce costs. Predictably such attempts are not universally successful. That may be because the issues are rarely considered from the patients’ perspective, because a solution is imposed from what seems to help ‘some people’, possibly those who might have consulted a doctor anyway.

Our help seeking behaviours are subject to the same three factors that Fogg speaks of in his behaviour model. Motivation is contingent on the person’s understanding of his or her risk to adverse outcomes. Ability is the person’s perception of access to treatment that may be life saving and finally, and crucially, triggers are factors that compel the person to make the effort to consult a doctor when they have the most to gain.

Therefore there are four possible scenarios:

High motivation and high ability to access health care.

This is ideal. In these circumstances a ‘signal’ trigger will suffice. Think ‘red traffic light’ .  Therefore someone who is bleeding or  experiences crushing central chest pain or develops sudden onset weakness on one side of their body, will quickly act to do what is necessary. Alternatively they might do the needful, as in the picture, when they are prompted by a relative or friend. Unfortunately it cannot be assumed, as it often is, that everyone is in this boat.

A health promotion campaign might be considered successful if five percent of the target audience make long–term changes in overt health behaviour. Rogers and Storey

There are three other less ‘easily’ remedied situations.

High motivation but poor access.

For these people ‘red lights’ will do nothing but cause frustration. What is needed is well publicised improved access to skilled care providers. For many people in specific areas of many countries access to health care is poor and it is reflected in inequity of outcomes for what is, anywhere else in the country, a preventable cause of morbidity and premature mortality. There is real scope to innovate here, perhaps the most promising avenue is online  or telephone access to care providers or innovations that better integrate care providers at the point of presenting symptoms especially within primary care.

Low motivation and easy access.

On the face of it this might be easily fixed simply by ‘educating’ people. However the empirical evidence is that such campaigns have limited ( as opposed to ‘no’)  effectiveness. Often the causes of low motivation are  many and varied. What speaks to one community or individual may not resonate with others and the scope for frustration or patchy results are very high. If this were not the case our jails would not have quite so many inhabitants. Law breaking like poor health is a complex issue and no solution including the death penalty will promote the most desirable behaviour. People don’t always respond to dire warnings. One strategy is to make the alternative action ( i.e. non consulting) less desirable than consulting. However such solutions fly in the face of patient autonomy.

 Low motivation and poor access.

Bad news. These individuals are unlikely to respond to anything. Changing attitudes is unlikely to follow ‘educational’ campaigns unless and until the issue of access to health care is sorted out. There are many individuals who have poor access to health care. The reasons for this are far too diverse for any strategy to be universally successful. If there were a simple way to do both then any of the triggers in the other of these four quadrants  might suffice. Fortunately only a minority of people are in this category but there are enough here to ensure that the idea of universally good outcomes for everybody is a utopian dream. Innovation, however well meaning, is set to fail some individuals most of the time.

Picture by amy_kearns

What’s needed to get doctors online?


Anyone who doubts that doctors will consult patients on line hasn’t heard of the hugely successful Sherpaa. It’s happening already in the US and in some other parts of the world. Elsewhere doctors will soon consult via the internet. It is only a question of how the service will be configured.

In a previous post I offered a way to consider what motivates doctors, what determines their ability to do things and what might trigger that action. The key questions in relation to video consults is how doctors might respond when faced with the variety of clinical problems that could possibly present on line. Also what that might tell us about the implementation of such technology.  We set out to explore these questions recently. You can read our paper and watch videos of how patients might present on line here.


A: Rewards for action

Funding restrictions were a major factor in deterring doctors from consulting on line. Unless governments subsidise the consultation it is unlikely to happen for people relying on government funded schemes. Where it is happening, private providers are stepping in to offer the service to paying customers.

T: Time

In a previous study we demonstrated that telephone consultations significantly reduced consultation time relative to face to face meetings. There is no reason to suppose that video consults would be any different.

R: Risk

This was perhaps the greatest factor moderating the motivation for video consults. Some scenarios were regarded as extremely high risk for adverse events and for litigation. Patients presenting with symptoms of an acute life threatening condition were considered the least suitable for a video consultation. Some scenarios were deemed too difficult to manage without a physical examination. Others were considered suitable if there was scope to see the patient in person in the near future. A literature search also raised concerns about potential breaches of patient confidentiality when consults are conducted via video technologies.


C: Cost

The issue of cost was not explored in our study. However this may be related to the lack of remuneration for video consults. No payment would result in a significant opportunity cost.

E: Effort

Some scenarios were considered too difficult to manage without a physical examination. Indeed the need for physical examination to establish a diagnosis was a common concern. Unexplained abdominal pain and upper respiratory tract infections were of particular concern. In other cases the scope to establish a rapport was considered insufficient, for example in the case of the patient with substance abuse:

…the use of an online consultation in this case inhibits developing rapport particularly with a patient whom I have only seen occasionally.

We also recorded a significant difference in attitudes to video consults based on the demographic profile of respondents to our study. Participants who had been practicing as GPs for longer, GPs in training, those who worked in remote practice, and those from larger group practices were most enthusiastic about video consultations.


R: Recognising the suitable patient

Our data indicate that access to video consultations will need to focus on patients with on-going medical illness, where the purpose of the consultation is to offer support. Medical practitioners appear confident about their ability to conduct video consultations however in the context in which we explored this question it is not yet routine practice.

K:Knowing what is available

Doctors in our study were unequivocal in asserting that the video consult option was not available to them at this point in time. In a previous review we explored the possibility that internet speeds and access to the relevant hardware and software may be a rate limiting step in the adoption of video technologies.


Video consults will become routine practice in most countries when they are supported with the infra structure to make is easy for doctors to make the choice to offer the service to their patients. In many scenarios motivation and ability appear to be high.  The majority of doctors in our study would either conduct video consults or consider doing so. The service is most likely to be offered to patients who either will be seen in person in the near future or seeking support for an established condition.

Picture by Matthew Hall

Convenient trumps promising

3099081998_bc5c57dd86_zThe innovator dreams of conditions that are common and for which there are untested treatments. There are many conditions that present in primary care that might fit the bill. Conditions that improve in time regardless of what is done for them. Here are a few examples from a very long list:

  • Common Cold
  • Plantar Warts
  • Molluscum contagiosum
  • Ankle Sprain

Yet there are a number of apparently effective treatments for some of these that have been known for decades. However few have been tested formally in randomised clinical trials. Our team recently attempted to test a traditional remedy in an RCT. Without that evidence the treatment cannot be recommended, even though the ‘gold standard’ can hardly be said to be effective. Ethics committees require patients who are offered participation in a trial to give informed consent. That’s as it should be. There are documents to read, special appointments to make, then follow up for a number of weeks to determine if the treatment is working and then yet more form filling to assess the impact of the treatment. Our team is good at this sort of thing. We design documents that are easy to read and procedures that are simple to follow.

So Jean turns up with 12 year old Megan after school  because has been told by the teacher that Megan can’t go swimming until she has had her warts treated, or Megan has been complaining that the warts are bothering her. Mum knows, or has heard from the woman next door that the doctor can ‘burn’ them off. Not that in many cases the treatment has to be repeated and that mostly it doesn’t work.  And then she is told- ‘ Well there is this trial we are doing…….. blah, blah.’

Never mind that just burn them off doc.

Cryotherapy stings as Megan will discover. The trial treatment is virtually cost free and painless and if it doesn’t work then you still have the cryo option. However mum has been persuaded that cryo works and isn’t interested in anything else- especially something that involves form filling. The woman next door says it worked for her little Freddie. Doctor may not have time to debate the case for testing an alternative in a busy clinic- so the idea is jettisoned and Megan is ushered into the treatment room for cryotherapy.

Here lies a major challenge in testing treatments for which an immediate commercial return is not on the cards. Pharmaceutical companies may not want to put effort into testing something that is unlikely to generate profits and what’s worse is that practitioners may not be willing to invest time promoting research that the patient deems inconvenient. It cannot be assumed that the beneficiary of innovation will participate in a trial if the established treatment is moderately effective and at that point in time convenient.

Picture by Mirko Fontemaggi

Care is not delivered in a vacuum

3798267293_030d8688bd_zGeneral practitioners (GPs) are the most used health service providers in Australia. In 2010–11, an estimated 14.5 million people aged 15 years and over (82%) had seen a GP at least once in the previous year, with 11.8 million seeing a GP more than once.  At that time in 2011 that there were 43,400 general practitioners in Australia, 43% were women and they worked an average of 42 hours. An earlier census reported that the average age of a GP was 49.3 years with almost one in three older than 55 years. Yet studies seldom report the impact of this demography on the professional advice offered in practice. If it is relevant to tailor health care advice to the ideas and expectation of the patient or client than by corollary it is relevant to consider the personal experiences of the healthcare professional who offers a service. We know for example that lectures, guidelines and protocols aimed at doctors may have less influence on whether a patient receives evidence based care than staff room conversations, peer pressure, the views of opinion leaders or the impact of personal experience within an individuals circle of influence. In research on innovations delivered in the consultation, the clinician is a significant confounding variable. A fact that is rarely mentioned in the limitations of the study.

Primary care clinicians work in “communities of practice,” combining information from a wide range of sources into “mindlines” (internalised, collectively reinforced tacit guidelines), which they use to inform their practice. Gabbay and le May.

Consider for example a recent report that the diagnosis and treatment of malaria by doctors was derailed by the influences described above. What is also recognised is that when doctors become sick or treat their own families they don’t necessarily follow clinical guidelines. What then might make it more likely that doctors provide evidence based care for chronic and complex conditions? With one in three doctors over the age of 55 it is likely that many general practitioners, their partners, families and friends will experience the onset of chronic illness- diabetes, low back pain, depression, cancer etc. They are also going to be invited for screening- colorectal and breast cancer. Their attitudes and experiences may well predict how their patients will be treated. For example in a study in which doctors were asked their views on screening their patients for alcohol abuse, the authors, Anders Beich and colleagues did not report on the alcohol consumption of the participating doctors or their experience of alcoholism in their close family or friends. One participating practitioner was quoted as having said:

To me, just asking everybody about their drinking habits is in part comparable to if I had to do a rectal examination on all patients that came to see me.

Therefore the doctor is a key stakeholder in the process of health care not just by virtue of a professional role but also with respect to his or her personal history and prejudices. This has implications for diagnosis but also for treatment. Patients need to be seen and heard. When the doctors senses are impaired by personal history it is possible that their assessment of needs,  symptom severity or risk may be limited.  What may help innovators is empirical evidence that addressing this question in a defined setting may help deliver better outcomes for patients.

Picture by ReSurge International

Innovating without inventing something new

9562611683_cd9584baca_zI’m a pathologist, which means that I run the lab, and I’m continually shocked by all the unnecessary lab work that comes my way. Doctors have to find something wrong with you, because preventative measures aren’t sexy. They know that you’re more likely to appreciate them if they tell you something’s wrong, than if they tell you to stop drinking 40 oz sodas. Humans of New York

This week a report was released that documents changes in Australian GPs’ ordering of X-rays and scans in the decade 2002- 2012. The report includes an evaluation of the quality of GP test ordering against available guidelines. The team compared two periods: Apr 2002- March 2005 inclusive (Period 1) and April 2009 to March 2012 inclusive (Period 2). Three factors were found to be relevant:

  • The number of encounters between doctors and patients
  • The number of problems managed at encounters
  • The rate of ordering tests in the management of problems encountered

It was not surprising that people are attending doctors more often and that they are presenting more problems than before. However the rate of imaging tests ordered significantly increased from 8.7 per 100 encounters in Period 1, to 10.2 per 100 in Period 2. Extrapolation of this result suggests an average 8.45 million imaging tests ordered by GPs per year in Period 1 and 12.23 million per year in Period 2, an increase of 44.7%, equating to approximately 3.78 million more orders per year over the 3 years in Period 2 than in the years of Period 1. With respect to the guidelines current ordering behaviour for new back problems, shoulder sprains/strains, knee problems, and knee sprains/strains, has room for improvement, according to the researchers.  The results were not entirely unexpected. There has long been a concern about unnecessary test ordering. In a paper published in 2008 unnecessary laboratory tests may be defined as those that have a ‘vanishingly small’ chance of:

  • revealing any unexpected pathological process.
  • contributing to the diagnosis of the cause of a patient’s presenting symptoms.
  • assisting in the monitoring of the progress of a known pathological process.
  • helping to assess the management of a known disease process.

An interesting insight is offered:

The millions of dollars spent on unnecessary tests are, in [doctors’] minds, balanced against the tens of millions involved in adverse court judgments.

In this context I recently asked colleagues what test they would perform on me if I presented as ‘tired all the time’, adding that I had no physical signs, was not depressed and was not taking anything (prescribed or otherwise) that would account for my fatigue. The answer was unanimous-‘Thyroid function test’. This was based on published advice on the approach to such patients:

However, even though laboratory evaluations rarely play a crucial role, they should be used to exclude underlying organic illness.

So, I asked my colleagues how they would interpret the findings if my results were found to be just over the limit of normal. What, in their view was the probability that I have hypothyroidism? ‘High’ came the answer. ‘We would put you on thyroxine.’ The published data suggests that the positive predictive value of tests on people in this context is  less than 12%. Which means it is highly unlikely that I have anything physical wrong with me, much less that I need to take thyroxine. At a time when there is an increasing demand for GP services, it is going to be helpful for colleagues to be aware of the positive predictive value of the tests they order and to share that information with patients before recommending tests. The article listing laboratory tests to screen for a host of highly unlikely conditions assumes that the doctor has spoken to and examined the patient and that the indications for the tests are based on specific clinical findings.  In most cases the patient who has a life limiting pathology does not look or feel well. However every patient needs to know what the test results mean- they are often meaningless and place the patient in harms way. The approach in the Dutch paper to postpone tests for 4 weeks resulted in benefit to people with unexplained fatigue who may otherwise have been harmed by further investigation of equivocal test results. The study is testimony to what  can be achieved by practitioners sharing information with patients while harnessing the power of observation, applying a little bit of science and dispensing a tincture of common sense.

Picture by Send me adrift.

Health Innovation: lessons from the past

What lessons can innovators learn from the experience of a medical practitioner born in 1749? Here is a summary of what happened:

  • He was a curious and prodigious innovator who based his ideas on his observations.
  • He built and twice launched his own hydrogen balloon.
  • He published the observation that it is the cuckoo hatchling that evicts the eggs and chicks of the foster parents from the nest. Something that many naturalists in England dismissed as pure nonsense until it was proven beyond doubt in 1921.
  • He devised an improved method for preparing a medicine known as tartar emetic (potassium antimony tartrate).
  • He worked as a doctor and noted that dairymaids were protected from smallpox naturally after having suffered from cowpox.
  • In 1797, he sent a case report to the Royal Society describing how a boy who had been inoculated with cox pox subsequently became immune to small pox. The paper was rejected.
  • Many years later he published another paper outlining his hypothesis. The publication of the Inquiry was met with a mixed reaction in the medical community.
  • In the course of his life he not only received honors but also found himself subjected to attacks and ridicule.

In summary 80% of people exposed to small pox contracted the disease. Almost 1-7 died. Many thought it was innate to humans. Others thought it was an infection attributed to menstrual blood or something caused by the putrefaction of the umbilical cord. A host of remedies were proposed at the time, including special diets and enemas.  There is a remarkable parallel between the variety of proposed “cures” for smallpox and the treatments for many modern maladies foisted on a long suffering public by those looking to make a profit. The discovery of the small pox vaccine by Edward Jenner was arguably one of the greatest leaps in medical science. It was made by someone who observed the effect of the innovation at first hand. His ideas were rejected and ridiculed by many but recognised by those with sufficient insight to ensure that humankind would benefit for generations to come. How do we recognise those most likely to offer a genuine step forward in our search for a better way?

Health innovations are not always intuitive, but rather are made by innovative thinkers who are brave enough to try something new and think outside the box. Colin Farrelly

My colleague Ori Gudes drew my attention to this post by Chris Dixon. Chris brings the Jenner experience into the 21st Century. His post outlines three key features of those with a winning idea:

  1. Know the tools better than anyone else
  2. Know the problems better than anyone else
  3. Draw from unique life experience

However, having said that he points out that these characteristics are not immediately successful in getting their innovations to market because:

  • Powerful people dismiss them as toys
  • They unbundle functions done by others.
  • They often start off as hobbies.
  • They often challenge social norms.

So how do you spot a good idea? Pose one question: Does the founder have technical expertise, problem/domain expertise or experience? My colleague Oksana Burford and I observed the reaction of young women who were shown photoaged images of their wrinkled faces after a lifetime of smoking. What we observed persuaded us that this reaction would trigger determined attempts to stop smoking. Despite numerous applications Oksana couldn’t get her project funded. Potential funders couldn’t see what we had witnessed in the consulting room. So she committed to it as a self funded PhD. Oksana delivered the intervention as part of brief professional smoking cessation advice in a randomised controlled trial. As per the published results we observed 1 in 7 successful quit attempts, which is better than most other interventions. Oksana will soon be working with colleagues targeting Parisian smokers. Meanwhile Gemma Ossolinski and I are using a similar intervention in obesity– the preliminary results are also very encouraging.

Testing assumptions before innovating

Successful innovations are based on addressing ‘real’ problems. They are not founded on assumptions that haven’t been tested. All too often we are presented with ideas that don’t really address the problem from the perspective of the end user. Usually these innovations are designed to solve someone else’s problem and then foisted on an unsuspecting end user. The result is the creation of yet another problem and worse of all wasted resources at a time when economies are under strain.  There is another way. In a very generous contribution with a more sensible approach Julius Parrisius offers this brilliant slide deck. It involves actually finding out what the ‘client’ aka end user needs from you to get through their day, what they find challenging about the problem in question and what’s on their wish list.

The issue in healthcare is that many value propositions are hard to pin down, either because the circumstance are relatively uncommon or because people don’t want to talk about them. They include people presenting/ experiencing:

  • Cancer symptoms- especially the kind that involve embarrassing symptoms- diarrhoea or offensive discharging from unmentionable orifices.
  • Psychosexual problems
  • Sexually transmitted disease
  • Substance abuse
  • Death and dying

Sure you can organise focus groups with a handful of ‘representative stakeholders’ but are you really going to get to the truth? The whole truth? There isn’t really a better way then observing the interaction between practitioner and patient. The challenge is that no one wants you or your video camera in the room while they confess their problem and the care professional doesn’t care for this either. Ethics committees tend to agree. What’s more this preliminary, hypotheses generating research is seldom funded by anyone and sounds daunting- much more so than calling up a friendly ‘stakeholder’ from your list and taking it for granted that they know what they are talking about. So you enlist the ‘support’ of your token end user on one of your ‘project steering groups’ and then hope and pray that they haven’t misled you. Unfortunately it can persuade grant committees that you have done your homework. They won’t find out until they read the press following a launch of your baby and discover that other end users don’t agree. Then you…start again, if anyone still trusts you.

The other issue is that you may also uncover evidence that could land the professional end user into some difficulty-failure to provide evidence based practice with actual patients cannot be overlooked if it is likely to put people at risk in the future. You have a responsibility to protect people- notwithstanding your role as innovator. So, where to from here? How do you get behind closed doors without interrupting the business at hand and while also allowing the practitioner to demonstrate their ‘pain’ with this problem/ issue? Our team has done well deploying simulations. It has allows us to generate and even test hypotheses in an environment in which people have not been put at risk and also relatively quickly allowed us to duck blind alleys before we were committed to them. The key is to accept that the rubber always hit the road when the person with the problem seeks help- in our setting that is usually when they present to a general practitioner /primary care physician/ family doctor and therefore the stage, the props and the actors are already defined- all we have to do is produce enough of the script to let the cast develop the plot- the rest is done by the participants and the truth will out.

Putting the patient first is not just good medicine, it’s good business

Primary healthcare is mostly organised as if all patients had the same needs. Patients who have a chronic illness who are repeat visitors and those with significant risk factors for future disease, are expected to fit into a system that is designed to meet the needs of someone with urgent and temporary illness. The current system is designed as if it doesn’t really matter which doctor consults them or what is known about their needs.

These are the facts:

1. Each week, there are 1,700 new cases of dementia in Australia; approx. one person every 6 minutes.

2. Cardiovascular disease affects one in six Australians

3. In 2011/12,4.6 million Australians(32%)aged 18years and over had high blood pressure (systolic or diastolic blood pressure is ≥140/90 mmHg or taking medication). Of these, more than two thirds (68%) had uncontrolled or unmanaged high blood pressure (not taking medication), representing 3.1 million adult Australians.

4. 1 in 2 Australian men and 1 in 3 Australian women will be diagnosed with cancer by the age of 85.

In some cases patients are expected to make appointments at a time and place that suits the practitioner. They might be seen for as little as 10 minutes and can feel that their questions and concerns have been addressed. The consequence is that both the doctor and the patient become frustrated.

The clinician complains about workload while the patient seeks alternative ways to meet their needs. There is published evidence that patients with chronic illnesses have significant unmet needs that impact on their quality of life.

The lean innovator knows that the future success of healthcare depends on serving the needs of those who are likely to need to consult a doctor many times in coming years. These patients need to live life despite pathology and to care for others even when they are not feeling their best. The person with enduring health problems also needs to believe that their doctor knows them, understands their perspective and has their best interests at heart.

In the business world such a loyal customer is prized. The business strives to make them feel valued. Great businesses constantly reinvent themselves and look for new ways to ensure that the customer is happy with the service on offer. It takes relatively little to satisfy the patient in a primary healthcare setting. We know, but sometimes forget, that what the patient craves most of all is their doctor’s undivided attention. Like a customer in any other business our patients want to feel that they matter.

We don’t need a department or a huge budget to innovate, because as both business owners and doctors we have the authority and insight to redesign how the patient feels from the moment they walk through the door and at every stage before and after their appointment.

If research has taught us anything it is that the fundamental need in healthcare is for their doctor to have good communication skills. Without that foundation nothing that technology can do for the patient will ever be good enough. Every touchpoint of the system needs to reflect the experience in the consulting room and should say to the patient—we know and care about you.

What is the most important thing you do for the people you serve? Do they get a sense of that from the moment they look for your help?

Why the future of health lies in thinking small

General Practice in Australia is a private business. There are 7200 GP businesses in Australia, with a revenue of $10bn per annum. Each practitioner is estimated to earn $200,000 on average. 95% of the income for these businesses is derived from government rebates, mostly from 10 to 15 minute consultations. The concerns of the practitioners in this context are said to be:

1. Threat of litigation

2. Too much work to do in a limited time

3. Earning enough money

4. Patients who are difficult to manage

5. Paperwork

6. Intrusion of work on family life

7. The cost of practice overheads

8. Time pressure to see patients

9. Unrealistic community expectations

10. Negative media comments

Increases in the Medicare rebate have failed to keep pace with the rise in the costs of running a GP service with increased patient throughput often used to make up the shortfall. Where this and other barriers exist, it may not be feasible for patients to be offered additional advice or services beyond their original reason for presentation unless a strategy is negotiated and agreed between the relevant players.

We know that the healthcare needs of patients are set to change in three important ways:

1. The population is aging.

2. There are more effective, albeit ever more expensive treatments available.

3. Poor lifestyle choices, linked to obesity will generate greater demand for medical appointments.

We are therefore relying on private businesses to respond to growing need in the knowledge that they are already working to capacity.

Under the central set of assumptions used in this study, total health and residential aged care expenditure is projected to increase by 189% in the period 2003 to 2033 from $85 billion to $246 billion—an increase of $161 billion….This is an increase from 9.3% of gross domestic product (GDP) in 2002–03 to 12.4% in 2032–33. Increases in volume of services per treated case are projected to account for half of this increase (50%). Projection of Australian health care expenditure by disease, 2003 to 2033

Another unique aspect of the business of medicine is that despite its technical and scientific basis, medicine is most effective when the human interaction between practitioner and patient is at its heart. Efforts to interfere in the process through the revision of payment schedules are only partially successful if not actually harmful.

The commercial reality is that without innovation, primary care as a business will not keep up with demand. To date evidence in practice is that researchers in primary care often fail to engage with clinical partners and innovation is stymied. Government investment in innovation in primary care is on the one hand conservative and limited. Ninety percent of government funded healthcare is delivered by small businesses and yet over 90% of government investment in research and innovation is targeted elsewhere. What little is funded is usually awarded to competing tertiary institutions whose performance is measured on academic outputs rather than impact on practice.

These are the foundations for a lean, agile, creative, approach to innovation  based on commercial reality and factoring in three key elements:

1. The most expensive component of innovation is establishing the problem and creating a value proposition that  factors in the perspective of end users.

2. Innovation only ever works when it is driven by a champion willing and able to re-engineer multiple prototypes to solve the problem.

3. There are opportunities for commercial partnerships if the key performance is reframed in the metrics of sales.

The conditions already exist for this approach to innovation in the business of primary care. Primary care in many countries, like Australia, is led by highly creative, intuitive problem solvers, many invest their insights and energy on small projects that have the scope for substantial commercial returns but more importantly to deal with the coming tsunami of health related problems. The final word is to Paul Graham:

People are bad at looking at seeds and guessing what size tree will grow out of them. The way you’ll get big ideas in, say, health care is by starting out with small ideas. If you try to do some big thing, you don’t just need it to be big; you need it to be good. And it’s really hard to do big and good simultaneously. So, what that means is you can either do something small and good and then gradually make it bigger, or do something big and bad and gradually make it better. And you know what? Empirically, starting big just does not work. That’s the way the government does things. They do something really big that’s really bad, and they think, Well, we’ll make it better, and then it never gets better.