Integrating primary care providers

People can, and do, consult other than doctors when they are unwell or perceive that there is something the matter with them. The list is large but includes:

  • Pharmacists
  • Nurses
  • Podiotrists
  • Dentists
  • Physiotherapists
  • Opticians

These care providers offer  a specific skill set but this does not include the ability to deal with undifferentiated conditions or to make a definitive diagnosis of a condition outside their scope of practice. However research suggests that such primary care professionals are often among the first to treat someone with depression, cancer, atheromatous vascular disease, hypertension and or dementia. Early diagnosis and treatment of any of these conditions would result in a much better outcome for patients. That does not mean that these health care professionals could or should be a substitute for medical practitioners. For one thing their business model does not allow them to spend time on dealing with the complexities that are inherent in establishing a diagnosis of such conditions, or to deal with the many others that need to be ruled out in the differential diagnosis. Nor are they equipped to coordinate the care of people with such conditions.

Cheap intuitive and creative solutions include ways to signpost people who present with such problems to the care professional best placed to coordinate their care. Research suggests that when someone is offered a note to present to a medical practitioner suggesting investigations for significant pathology, people will follow up with an appointment and benefit. The components of such an innovation include a way to screen people for risk of significant pathology- the person with persistent diarrhoea seeking advice from a pharmacist, the person with unrelenting back pain who might be clinically depressed, the person with undiagnosed diabetes presenting with visual problems. All these people need to consult a medical practitioner. However they are not always recognised and here lies the scope for relatively cheap innovation to integrate care providers without interfering in the way care providers function within their own domain of expertise.

Managing demand for primary care

Why do people consult doctors? At first glance because they feel unwell. However research suggests that the reasons are far more complex than that. Innovators also know that the answer to this question is vital for those seeking an agile, intuitive, creative and cheap solution to the demand for their services. Theories predict the consultation habits of many patients. I especially like this summary:

The overall prevalence of symptoms in the community is not closely related to general practice consultation rates, and the consulting population is a selected population of those who are in need of medical care. The literature reviewed suggests that poor health status, social disadvantage poor social support and inadequate coping strategies are associated with higher consultation rates. Some populations subgroups may experience particular barriers to seeking care. Campbell and Roland

Innovators might also ask why are those patients sitting in my waiting room? I remember a hoary old tale of a doctor who was feeling especially grumpy one day and stormed through the waiting room announcing that anyone who thought they had a ‘real’ problem should stay everyone else should go home- half the waiting room emptied.

It seems quite a few people who go to doctors will have symptoms- however a proportion will be back there by invitation. How big a proportion and why have they been invited back? There are many reasons to schedule a repeat appointment. It conveys the notion that the patient will be harmed if they don’t see a doctor on a given day for one or more of these reasons:

1. Their response to treatment is unpredictable and the dose or drug may need to be revised

2. They have a condition that can’t be diagnosed or may progress or need additional measures by a specified date

However other reasons for requesting a review include:

1. The doctor isn’t confident that the diagnosis is correct and wants a chance to review the advice issued.

2. The patient is required by someone (e.g. an employer) to produce evidence of a visit to a doctor

3. A full waiting room ensures the doctor looks busy for whatever other reason.

4. The doctor needs to reinforce the impression that the condition has been taken seriously.

The time cost for doing everything that could possibly be recommended for patients with chronic conditions  has been shown to be untenable. Either the guidelines are wrong or a different solution needs to be found for at least some of these people. What is the evidence for asking a patient to return within a week or two with a specific new condition and within a month with a longstanding condition?

There is a need to be proactive in some cases. However is it possible that we encourage people to attend for review appointments when there is a low probability that they will benefit? Are there other reasons to fill the waiting room?

The most successful health innovation ever

What medical innovation is:

1. Available worldwide
2. More likely to yield a diagnosis than an X-ray
3. Cheaper than the cheapest stethoscope
4. Requires less training to operate than a tendon hammer?

Answer: A tongue depressor

Why? Because when deployed within the context of a medical consultation- when the practitioner gives the patient their undivided attention, the tongue depressor forges a relationship that may lead the patient to express their deepest concerns. In what other social context can you shove a piece of wood into someones open mouth and get them to say ahhh? A few years ago I consulted a fifty year old mother of five, working as a supermarket check out assistant complaining of a sore throat. We talked about how awful she felt and how she was struggling to cope with her job, how she gets frequent bouts of tonsillitis and how she was afraid her boss would sack her. She had a mildly red throat and I thought I could feel a couple of tender lymphnodes in her neck but her temperature was normal and I remember thinking I’d seen worse earlier that day. Then as I turned around to write a prescription she burst into tears and said-

‘There’s something else I need to tell you doctor. I’m now working as a prostitute because for the first time in ten years I haven’t been able to afford my kids school books.’

That was not what I expected to hear, or anything they told me at medical school could result from examining a throat. That consultation took a very different direction, she was screened for other infections and was fortunately negative. We then talked about her dilemma and she decided there may be better ways to furnish her kids with what they needed for school.

There is very little evidence that the appearance of the throat aids the diagnosis in most cases- even a viral sore throat can mimic a bacterial infection. In any case in developed economies penicillin does not help the patients recover much quicker. However, anyone with a sore throat who consults a doctor expects to be examined. Besides why do people seek medical advice about pharyngitis? It is common knowledge that in most cases a couple of paracetamol, fluids and rest is the only effective treatment. In many cases people are expressing concern about some other aspect of their life when they present with minor self limiting illness. What people say, if you are receptive is

‘I’m unhappy, I’m worried, I’m bored, I’m feeling guilty, I’m tired or I’m not coping and this discomfort is the last straw.’

That’s one of the myriad of reasons that general practice is the most challenging medical specialty, nothing is necessarily what it seems at first glance.

Innovations don’t need to be high tech or expensive- a tongue depressor costs 13 cents. That doesn’t mean that in the right hands such simple equipment is not extraordinarily powerful. There are tools we seldom do without- a stethoscope is vital and not only because of what we can hear when we put it to the chest.

The secret to lean health innovation is harnessing the truth

In the later 1990s when I was practicing in a 7,000 patient practice in England we had a system of five minute appointments. Five minute appointments that were really ten minute appointments. In most cases a doctor can’t achieve anything useful during a five minute appointment. Some doctors would argue that ten or even fifteen minutes is scarcely enough. However this was how it had ‘always been done’ so the new doctors to the practice adopted the system that was in place. By the time you got to the last patient in every surgey you were running at least half an hour late. We were kidding ourselves—nobody ever finished by 11am. We were still consulting at midday and then rushing off to do home visits stuffing a sandwich in as we drove from patient to patient. We were back at the surgery by 2pm ready to start the whole thing again—intending to finish at 5, but in reality turning off the lights after everyone had gone at 6.30pm.

The data was right under our noses. Some doctors were known to ‘always run late’, others became adept at pushing patients in an out quickly with a prescription in their hand and instructions to return next week. Patients learned to choose the doctor they thought was best for them, whether that was one who would ‘get to the bottom of it’ or give you a prescription and a sick note but couldn’t be relied on to know when you had cancer.

Consulting style does impact a patient’s choice of doctor. and doctors and patients don’t always share the same view on their consultations.

Meanwhile back at the practice resentments festered because some doctors were having coffee in the staff room at 11 while their colleagues were still working through the list until nearly midday. There were suspicions that the early finishers were seeing fewer patients and never around when the emergency walk-in turned up at 11.45. Stressed doctors couldn’t see what was already evident to everyone else in the practice—we needed to redesign our appointment system and tackle issues engendered by our own delusions. In the end, as a practice, we needed to look at how each practitioner was consulting and how this was reflecting the practices’ values to its patients.

Something had to either change or give and we decided that if it wasn’t going to be us or the patients, then it had to be our system. We had to face the truth that the numbers of patient appointments we scheduled during the day was greater than our capacity to treat them properly in the time we allocated.

Our colleagues in other surgeries thought we were ‘brave’ to move to ten minute appointments. There were implications for radical changes to our appointment system. But the first thing we needed to recognise was that our schedule must treat our patients as if their time mattered at least as much as ours. It was, and is, unacceptable to keep patients waiting because we don’t want to accept reality. This denial leads to patients failing to keep their appointments, choosing to go elsewhere and it ultimately leads to doctors burning out.

We didn’t need a big R&D department to tell us what our staff and patients would say if we bothered to ask. I now work in Australia and still see the same patterns here. My friends tell me you can count on this doctor to prescribe antibiotics no matter what is wrong with you, and that one always gets to the bottom of things but prepare a packed lunch when you make an appointment with him.

Our time is not more important just because we are doctors. Innovation sometimes involves taking responsibility not investing in a new computer program or running a focus group.

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.

The lean innovators’ insight

Simple access to medical records is a strategy for failure. Generate value to patients…people… then medical information and tools. Please do not reverse. Grant Taylor

When it comes to defining the value proposition lean innovators have a substantial advantage. They know that some innovations won’t work because:

1. They take up time that should be spent listening to the patient.

2. They require the practitioner to learn a new skill.

3. They are good for the patient but add an administrative load.

4. They assume the patient will invest time and effort on collecting information that has no apparent benefit to them.

5. They obviate the need for physical contact with the patient.

6.  They demand time and energy without solving any immediate problem.

Lean innovators- clinicians who practice their art-know this because they’ve been in the moment with those intended to benefit. They’ve sat opposite the person in crisis , the person who struggles to function or has to redesign their life and revise their dreams because of some all too inconvenient health problem. To that person it isn’t about the latest gadget or gizmo, they do not care if it helps the system to collect data. They want tangible benefit, they want human contact for which no device is a substitute and the lack of which reduces the potential for recovery and regeneration. For the practitioner an invention should fit seamlessly into their way of working and earning a living. The innovator knows that if an innovation is resented as an intrusion in practice, that end users will actively search for reasons that it ‘doesn’t fulfill its promise to patients’. Result: another promising idea shelved, another innovator frustrated.

Funding creativity

The organisations or institutions most able to fund and promote creative solutions have the resources but it is unusual for them to embrace novel ideas. Perhaps because they are accountable to stakeholders, risk averse and have rigid governance structures enforced by people with no stake in the outcome, rewarded instead for enforcing process. Decisions taken by such organisations are vulnerable to influence. Here are ten ways competitors stem funding for novel ideas:

1. Nominate: Get nominated as a grant reviewer on a funding committee on the basis of ‘expertise’ in their field.
2. Spook: Express concern that the applicants don’t seem to be aware of other funded projects on the same topic. Committees are easily spooked by the idea that applicants might be generating ideas that compete with something that has already been funded. The details don’t matter as long as whatever the committee ‘expert’ cites sounds like it might be relevant.
3. Foster doubt: Express concern that in their ‘expert’ opinion the project won’t succeed especially if the applicant could be accused of being unfamiliar with the context in which they intend to operate. Committees will be relying on their member’s special ‘expertise’ and are unlikely to disagree.
4. Cast aspersions: Note that the applicants don’t have the relevant expertise. It needs some imagination but always possible. No one is accomplished in every facet.
5. Magnify: Make much of reports that the pilot studies were inconclusive and by corollary risky. Novel ideas usually are. If the pilot studies showed promising results they make the remark that further research of this untested, risky idea is therefore probably unnecessary.
6. Argue: Present arguments why the budget requested is too high- in the current economic climate there is always room for economy. If the grant is approved having the budget slashed should slow competitors down.
7. Impugn: Comment that the chief investigator doesn’t have a strong enough track record to deliver on this project. Innovators doing something new are unlikely to have done anything exactly like this before. It spooks committees who might worry about any possibility that the money will be wasted. Sexism and racism, when it is subtle makes this easier.
8. Choose: Find another project on the list, led by someone who isn’t a threat, that is ‘so much better’ and of course less risky and would make a ‘big’ difference in practice. Committees would be happy to hear that the subject expert thinks they’d be funding something that would be so much more likely to meet a need.
9. Gossip: Express concern that even though they don’t ‘know’ the applicants personally, they’ve heard rumours that the applicants don’t produce good work. The doubts should generate enough anxiety to make some reviewers rethink their enthusiasm for a project.
10. Ambush: If such attempts at heading off the applicants at the pass fails and the committee funds the project- there’s always a chance for a competitor to stop them publishing their results later on. There’s lots of scope to recommend rejection of any paper- inadequate literature reviews, debated methodology, concerns about sample size, participant attrition, conflicting ideas about analysis of the data, failure to acknowledge the limitations of the methods. If all else fails someone can always find typographical and formatting errors that cast doubt on the whole manuscript- after all there is ‘lots of competition for space’ and the best journals receive ‘so many more papers than they can publish’.

On the other side of the fence if you are a determined innovator there is an opportunity buried here. On whom does your future depend if not on yourself? How do you innovate in a world that is viewed by some as being so small that if you have even a little then they don’t have enough? How are you being so resourceful that this doesn’t matter? A lean medicine approach is not about big projects nor reliant on big grants. Lean medicine is fuelled by the imagination and resourcefulness of champions.

Where do innovators start?

Lean innovators can’t help themselves. They see ideas every where. Inspiration is to be found where ever there is a problem and healthcare is full of problems. I’m going to mention three problems:

1. Health care is rationed. Even in countries where it appears to be on tap- it is rationed. For example when it was launched by Britain’s then minister of health, Aneurin Bevan, on July 5 1948, the national health service was based on three core principles:

That it meet the needs of everyone
that it be free at the point of delivery
that it be based on clinical need, not ability to pay

No one believes this is true and the experience of many is that even if it is ‘free’ you may still have to wait for it even if your need is great- simply because the ‘gatekeeper‘ doesn’t recognise the urgency of your need. Here is scope to innovate.
2. Health care is organised around the needs of the provider. In many countries you have to make an appointment at a time, and a place that suits the practitioner. This might mean taking a day off work, traveling a long distance, sometimes, as in my country several hundred kilometers to consult the expert. It is possible that you don’t fit the mould designed for the ‘patient’ in that system. Your culture may clash with the provider- so that you struggle to be understood, cause or take offense and generally find that things are lost in the translation. Consequently inequity characterizes most if not all health care systems. Another prime opportunity to innovate.
3. Health care can harm you. It is possible, some would say probable that at some point in your life the drugs or procedures designed to relieve your suffering may actually harm you or at best do nothing for you.

Simply being a patient in an acute care hospital in Australia carries, on average, a 40-fold greater risk of dying from the care process than from being in traffic, and a 400-fold greater risk than working in the chemical industry.  Australian Patient Safety Foundation

Further honing the indications for tests, prescriptions and procedures may do much to improve outcomes for most of us. For example it has been shown that the participants in trials of most drugs bear little resemblance to those for whom those drugs are prescribed in practice.

Although 61% of new cases of cancer occur among the elderly…..studies indicate that the elderly comprise only 25% of participants in cancer clinical trials.  J Clin Oncol.2003 Apr 1;21(7):1383-9.

Similarly potentially harmful tests are performed unnecessarily and many invasive procedures are carried out for dubious reasons. Finding ways to reduce the scope for harm is therefore a priority.

Why innovators should learn to embrace feedback

Lean innovators often work in isolation and not surprisingly the innovator is emotionally invested in her idea. She has conceived the idea, developed it, spent time and resources on bringing the idea to life. This makes criticism of her brain-child very hard to bear.

The temptation is to be defensive. To shout down the critic. To take the view that the person offering an opinion hasn’t understood the brilliance of what has been brought to the world. The cure for this sort of pain is to begin with the end in mind.
Consider who is this innovation is for? Who needs to cooperate to make it available to the end user? Who will pay for it, either with hard cash or with their time and effort?

Another way to get a better understanding of the real problem you’re trying to solve is to write a short letter to the person you want to solve the problem for. A crucial part of innovating is to tell the story of the invention effectively, to make the people who need to care in that moment, care. It’s worth investing the time to get your story right and to seek out people you trust to give you honest feedback before you have to tell the story for real.

Agile, Intuitive, Creative, Cost Effective Healthcare solutions