Tag Archives: patient advocacy

The bean counters of BoGIn

5085594028_fc5d378a40_zThe bean counters at BoGIn (Bank of Good Intentions) noticed that some people came to the bank to get mortgage advice and others for personal loans. In fact there was a lot of money to be made by persuading people to borrow money. So they decided to make some reforms. A memo was circulated informing staff that customers will only be able to deposit money in the afternoons- it was to be called the ‘deposition clinic’. Similarly customers would only be able to make withdrawals on Wednesday mornings. Additionally this service would be manned by the most junior clerks who must have all their work checked by the bank manager who would also spend the day at meetings reporting his branch’s performance on key performance indicators.

Customers who withdraw their money are not good for business.

Bank tellers were ordered to ask every customer to fill out a form documenting how much they owe other banks. Customers must always do this before tellers can attend to any other reason the customer came to the bank. Forms must be completed with a black pen and the signatures witnessed by two independent adults. Bank tellers would earn a bonus every time a customer takes out a loan and would accrue points towards promotion if the customer takes out a mortgage at 5% above the cheapest rate on the market.

The bank managers and their staff were shocked. How was this to be achieved? However the bean counters pointed out that the shareholders required the staff to be accountable and there was a need to increase profits by at least 25% this year. A percentage agreed by the committee of bean counters advising the shareholders.

But we are doing so well. The bank makes a hefty profit and our customers are among the most satisfied in any industry. We offer a service. We listen to our customers. We try to help our customers achieve great things that keep our economy afloat.

The bean counters were not impressed and threatened to force managers to be recertified every year or lose their right to bonus payments. Many managers have since found alternative employment. Recently the CEO of BoGIn attended her branch to deposit a cheque. She queued for hours before she was first asked to complete a form documenting her debts and given a brochure on mortgages. Then she was informed she could only make deposits in the afternoon so she had to return the next day. The bean counters have been sacked and were last seen at the department of health next door.

Picture by DaMong Man

What do you want from your doctor?


Finding a good doctor is like finding a good lover: there are lots of anecdotes but no data Richard Smith

Our family has moved to an new city and we are looking for a family doctor. What would you look for if you knew a little about evidence based medicine? Would you want your doctor to have read the latest medical journals and could quote research evidence for every decision they make? New premises? New furniture? Free wifi? Short waiting times? A coffee machine? Text messaging? Internet booking? A PhD?

How do you choose a new dentist? A new hairdresser? Do you just walk in to the nearest premises and hope for the best? Do you ask your neighbours for a recommendation? Do you google the names you see in the phone book? The chances are you spend more time choosing a restaurant then you do choosing your doctor. And yet there is far more at stake other than a good meal or a hair cut.

For us in selecting a doctor nothing matters as much as the doctor’s interest in our family. Our new doctor may not have read this week’s medical journal but he or she will be curious about our family because they will want to understand the context of any symptoms . That isn’t simply limited to our medical history, allergies or genetic predisposition. It also means the fact that we have moved interstate, we have new jobs, renting for the first time in years and experiencing a number of other life events. They will take into account any support we might be receiving from friends or family and our satisfaction or otherwise with our decision to relocate.

If you feel the same way then you might agree that doctors, especially family physicians aka general practitioners, provide a relationship and not just a service. This is what we seek when we consult a doctor:

Their willingness to make eye contact, to listen actively, to pick up verbal and non-verbal cues, to be respectful  and unwavering in the opinion that our perspective on our bodies and its functioning is what matters the most. To our new doctor we will be free to make choices. They will see their role as adviser and advocate rather than enforcer of what’s best for us as determined by somebody else. The best doctors understand that they may not have all the information on which we make decisions but faithfully realise that we also want what they want i.e. what’s in our best interests.

I love this quote from Anatole Broyard:

What do I want in a doctor? I would say that I want one who is a close reader of illness and a good critic of medicine…I see no reason or need for my doctor to love me, nor would I expect him to suffer with me. I wouldn’t demand a lot of my doctor’s time, I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.

We will choose our next doctor based on how we feel not what we think. Is that a good thing? It’s not logical, but it’s the only basis on which humans make the most important decisions in life.

Picture by frances1972

Willingness to pay


Often what we need from health care providers isn’t a specific product or service but to be signposted to the best that’s available even if that isn’t something they are able to provide on the premises.  That was the conclusion to a paper just published in which the researchers asked West Australians whether they would pay to be better advised about their symptoms at a community pharmacy. The majority said they would even though the advise they would receive was to go and see their general practitioner. What’s remarkable about these data is that people are already able to get ‘free’ advice from their local pharmacy. What would make them reach for their wallets is if that advice was delivered systematically, in private and with reference to an evidence based protocol. What’s more the enhanced service included a written referral to a general practitioner, something tangible, something that might be helpful when negotiating an appointment at the clinic.

In the published study people were shown a brief video of what they already experience followed by a video of what a ‘quality enhanced’ service would look like. They were then invited to vote. The results were clear they don’t value what is but they already like what could be. What might drive such innovation is the notion that the public will pay out of pocket for something that is perceived as offering better quality.

Better quality does not mean making a diagnosis if that is not a reasonable expectation. However it is about making the most of what is possible so that the patient’s need is met in this case to have their concerns validated. You don’t need to radically redesign for a  quality service, above all it means making sure you ‘see’ the person who has chosen to seek your help. In what circumstances are you unable to offer what’s ultimately needed but are able to facilitate access to it? For that you will be rewarded, because your customers will want you to thrive. Find that opportunity and either re-engineer or rehearse your response.

Picture by Dwayne Madden

Prepare to avert a drama in a crisis

128886598_e895d6d0a0_zWe were dismayed that there were no seat back screens for our five hour flight back to Perth and there was a feeling of foreboding as we took our allocated seats on what was clearly an aged plane. As we were taxiing onto the runway the pilot made the fateful announcement:

I’m sorry to report that a warning light has flashed in the cockpit and I must return to the terminal for engineers to investigate. We regret the inconvenience caused.

When we pulled back into the gate the pilot turned off the engine and engineers boarded the plane. 45 minutes later the pilot was heard to say:

Ladies and gentlemen I have good news and bad news. The good news is the copilot has just become an uncle (applause rippled through the cabin). The bad news is that we have discovered another fault on this aircraft and we will be off loading you until safety checks are completed.

We gathered our belongings and when the seat belt signs were turned off we filed back back into the terminal. Everyone headed to the desk where the ground staff were busy apparently seeking telephone advice from supervisors. They seemed oblivious to the many anxious faces queuing for information. Ominously the crew wheeled their luggage past and headed off down the corridor. Some of the 400 passengers pushed their way to the front of the queue and demanded information. These eventually passed on the news that the flight was cancelled. Some people walked away muttering that they had given up on the airline and would stay the night. The rest of us waited for a couple of hours returning to the desk every few minutes, still ignored by the staff until eventually one said that frequent flyers would be boarding the later flight to Perth the rest would have to take their chances with other airlines or stay the night. Surely that was always the plan from the moment we were off loaded?

In such a situation the behaviours the airline would wish to see are:

  1. Staff know what to do and are instantly at action stations, reassuring, advising, assisting and redirecting. Effectively minimising the damage to reputation.
  2. Passengers queue in an orderly fashion, remain calm and reassured that the airline has a plan B. Making it less likely to make a drama out of a crisis.

The pilot could not be faulted he knew exactly what to do in the event of a potential emergency. However ground staff struggled to be polite much less organise themselves to inform all the passengers what contingencies were in place when one of their aging fleet of planes was unexpectedly deemed unfit to fly. Consequence- very unhappy customers who will blog about their experience and write complaints.

This happens in medicine all the time. The surgery is cancelled, the medication isn’t in stock, the patient has a cardiac arrest, the transplant organ is rejected, there is a flu epidemic. What makes a difference is anticipating such a crisis. Medicine too often gets this aspect wrong. Surgeons, like pilots, usually do exactly the right thing- abort the procedure, delay the treatment or place the patient in intensive care. However that isn’t the end of story. If we claim, as medicine does that we aim to support the patient through the crisis, disruption, shortage or adverse event then we need to do more than simply hope they don’t turn up at reception to ask the difficult questions. Flights are cancelled on a regular basis as is surgery. This is a set play just as everyone is shown the brace position on boarding the aircraft and as the safety announcement states:

You must know this instantly in the event that there is an emergency

However ’emergency’ isn’t just a threat to life and limb. Emergency is also a situation where there is a substantial and immediate risk to the brand. The staff behaviour did not trigger the desired behaviour from the customers. And as anyone who has done an Advanced Trauma Life Support course knows the noisiest patient isn’t the one whose life is at greatest risk. Find the one who really is going to die without a timely intervention. It seems the airline policy was to attend to those customers who were most vociferous. Many of us deemed it rude to push our way to the front of the queue. But those who had no such compunctions were rewarded with boarding passes to the few flights leaving the city that evening. We can all learn from these experiences. Health innovators have something to offer the airline industry. An industry that remains the leader in safety but not in customer service.

Picture by Alex Avriette

Prepare to say no


For 10 years I have ridden my 50cc scooter on the streets of Perth, Western Australia. I now want to take my scooter to other parts of Australia- but alas the laws in some states won’t allow it. In WA you can ride a scooter on a WA car license, elsewhere, mostly you need to do a motorcycle test.  Nonetheless I decided to speak to the people at the licensing offices. May be someone would find a way around this. Several people in officialdom seemed irritated that I was making life difficult on the 2nd of January with an office packed full of teenagers doing their test. They vaguely looked at their computer and told me to speak to the licensing offices in the other states. I already had. No one had a definitive answer. Eventually I was ushered in to do a theory test- despite the fact that I had a valid license that allows me to ride my scooter in this state. Having passed the test in about 5 minutes I was ushered to counter 18 to speak with Jayne ( not her real name). She said what I was thinking:

This is ridiculous. Did anyone speak to a supervisor?

I didn’t think so. I didn’t want a motorcycle license. I just want to ride my Vespa moped in other places in the country. My existing license needs to indicate the inclusion of the class ‘RN’. A class that is already incorporated in my ‘LR’ designated license. She looked concerned:

If I can sort this out today, I will refund the money you have just paid for that test.

She spoke to her supervisor, I saw it happen. Then she went to the ‘big boss’ in the office next door. Through the glass window I saw her pleading my case. She eventually told me what I had already guessed- I would need to do the test although I was apparently already qualified. The authorities could then indicate that I had formally been tested and could add ‘RN’ to my license. I’m dubious but that’s the best that was on offer.  Throughout her dealings with me Jayne was empathic and supportive.

If you have any problems on the day of your practical test please don’t hesitate to ask for me at this office.

This was an object lesson in how to enforce the rules even when saying no. We decline requests in healthcare often:

Patients often arrived at the office armed with complex and marginal information from the Internet that was inconsistent with standards of care. Sometimes, if the patient’s spouse was enrolled in a separate insurance plan, the patient moved to a second “primary” provider through that plan to obtain the desired referral. Even if I work with a different kind of patient population in my new practice, I would like to know how to handle patients who insist on having unnecessary and expensive diagnostic studies performed or request treatments of dubious benefit. Victoria Maizes

We need Jayne’s skill in handling these situations. In soccer terms this is a set piece play.

Be Prepared: know exactly WHAT your responsibility is;
Be Organized: know exactly WHERE on the pitch you should be;
Be Aware: know exactly WHO is where at all times;
Be Active: know WHEN to move and HOW to get where you need to go — Get to the ball!

Circumstances in which we have to say ‘No’, are easy enough to predict in health care. Not all of them are curved balls. Our team needs to be prepared for a situation when the ball is kicked out of play. Jayne was motivated to give me what I wanted but because she was not able to, my request did not trigger the response I desired. She took longer to deal with my problem than she needed to. She demonstrated that she was indeed not able. I was in the office at least 90 minutes. She asked me to wait while she investigated and dealt with other customers.  She went above and beyond the call of duty. She offered to reimburse me if the rules were wrong. She made eye contact. She smiled. She showed empathy. In the end I will do that test and whatever the outcome I will write to the licensing office in praise of Jayne. Her job is to apply the rules, not write them. She need never see her customers again and can remain yet another faceless person there to enforce the rules even when they are daft.  In health care where continuity of care matters, we cannot simply vanish into the ether like yet another public official. Denying someone something that they feel might help them, or that they are entitled to may have greater consequences than the right to have a toy on the street. On the occasion when the patient is unable to trigger the response they wish from us their relationship with us is strained. We need to be prepared to say no but to retain their trust.

Picture by Carlos Fronseca

Personal choice versus social responsibility- compassion before all.

9363012140_4304b8498b_zAt 52 years of age Suzy knows better. She is unemployed and divorced, again. She takes her antihypertensive only very occasionally. She is obese. Often sleeps rough, drinks far too much especially when flush with social security payments and is frequently at the emergency department with injures following a binge drink or a fight. Her destiny is to become a statistic.

Nothing is more evident in the statistics of public health than the role played by individual health behavior in contributing to accidents, illness and disease. Daniel Callahan

In a now classic series of studies Lester Breslow and his associates revealed that men who successfully adopted seven good personal health habits had lower morbidity and mortality rates than those who followed six; those who followed six of the habits had better health and mortality outcomes than those who followed five; and so forth. Kayman, Bruvold, and Stern demonstrated that individuals who develop their own diet and exercise plans are more successful at achieving and maintaining weight loss that those who play a more passive role. Each year, millions of smokers successfully quit the habit (albeit usually after several attempts), and most who do quit do so on their own.  Individuals have a fundamental right, based on the principle of autonomy, to choose health-related behaviors. Yet, with this right, so it is argued, comes a responsibility to make wise choices. Herein lie the strongest case for innovations targeted at the individual.

It is often supposed that given information people will make the right choices. Suzy knows that when intoxicated she is likely to injure herself, she has been advised that she is at significant risk of cardiovascular disease and is aware that her junk food diet is likely to maintain her BMI at 35. She has had bariatric surgery but she had the surgery reversed. Knowing is not enough. So one point of view says:

Being ill is redefined as being guilty. MH Becker

At the same time epidemiologists such as S. Leonard Syme have pointed out that people at progressively lower socioeconomic status (SES) levels have correspondingly less opportunity to control the circumstances and events that affect their lives. Conversely, for individuals at higher levels, factors like higher income and greater discretion, latitude, and control over their lives may contribute to a more generalized sense of “control over destiny, ”which, in turn, may translate into enhanced health behaviours and health outcomes. Suzy  could be, and is, stigmatised. Conservative governments have used the rhetoric of personal responsibility for health to justify cutbacks in needed health and social programs. Only this week the Australian Government was urged to consider a proposal in which

about 2.5 million welfare ­recipients on “working-age ­payments”, including disability support pensioners and carers, would be forced into a cashless world where 100 per cent of their payments were income-managed and they were banned from purchasing “prohibited” goods. The Australian.

Meanwhile concerted efforts have been made to support Suzy to lose weight, drink less and take more exercise. Clearly none have succeeded so far. Suzy may turn things around despite previous failures. On the other hand if she is forced to use her social welfare payments for food she may trade food for alcohol, and it’s unlikely to be a fair trade. Suzy’s response to life, may be a factor of the attitudes she comes across on the street. How do you innovate against disdain?

There is no question that her poor choices have landed Suzy in trouble. But no one who takes the time to listen could possibly believe she doesn’t want better. One day we might find the trigger for a radical change. In the meantime what Suzy needs most is someone on her side. She needs continuity of care, someone who understands the complexities of her deeply troubled life, someone who knows the actors and can interpret her cries for help, often couched in somatic terms. As her clinician she deserves my undivided attention anything that comes between us would detract from the chance that she will one day reinvent herself. ‘Suzy’, as described, doesn’t exist- but the elements of her story are true for many who seek help from their general practitioner.

Picture by Kat N.L.M.

How to make data more valuable

The 1st of July 2014 will be forever etched in my memory. On that date I woke up and peered across the bed to the window. Realising by the half light it was just past dawn I wondered why there was another body in the bed. It should have been at the gym. So I turned over and put my arm around her. I registered she was looking straight at me. She then uttered the words no man wants to hear who hasn’t planned for it. ‘Happy anniversary darling’. In the micro seconds it took my male brain to weigh up a response, her female intuition had already worked out my dilemma and laid the charge. ‘You’ve forgotten haven’t you?’  Guilty. I had forgotten. The rest of the day was spent demonstrating that 1. I loved her and 2. regretted forgetting our special (and easily remembered) date. It would have been so much easier to focus on one rather than both. A stitch in time and all that.

Later in the week I received what looked like a court summons with an official looking government stamp on the envelop. The letter inside read:

Dear (first name, last name),

Did you know that around 80 Australians die each week from bowel cancer? ..blah, blah , blah,…inviting people turning 50….blah, blah,.. faecal occult blood test kit with instructions…sent to you in the next few weeks…blah blah. If you are already being treated for bowel cancer contact….during business hours.

Yours sincerely,

Scanned signature

Chief Medical Officer.

Not ‘Happy birthday this is a big one mate!’ Not ‘We want you to stay healthy and happy’. No connection with me. Just a cold request to take a government funded test now that I have reached an age when my bowels are more likely to turn on me. Were they concerned about me or the statistics? This lack of connection may be part of the reason most people fail to participate in what is a life saving program.

Still later in the week my reception staff told me that a patient had left something for me in the staff room. Also being an Indian he anticipated my penchant for curries and had prepared a small feast as a thank you. Instant connection. I felt appreciated. I pulled out my pen and drafted him a note. The government invitation on the other hand, though it may save my life didn’t have the same impact. Sure I’ll take the test but only because I know it’s a good idea.

People who chose to share intimacies with us want to know that we really see them and that they matter. Medical practitioners and general practitioners in particular document all sorts of information about their patients; height, weight, gender, waist circumference, family history, alcohol and tobacco consumption, sexual orientation, menstrual history, temperature, blood pressure, pulse, heart sounds, medications, allergies, etc. How about their date of birth? Anniversaries of births, deaths and marriage? Why don’t we collect and use this information to make a connection? What I would have appreciated from my doctor in April this year was a hand written card that said something like:

Happy Birthday Moyez! Thank you for letting us be part of your life. We wish you health and happiness always. Don’t forget your wedding anniversary 01/07/2014! This year you can help keep yourself in good shape by taking the bowel cancer test, someone will write to you about that soon. To mark the very special occasion of your 50th birthday we have donated $20 to Medecins sans frontieres  Australia (http://www.msf.org.au/). Please stay in touch and call us if we can do anything to help you stay in good shape this year.

If a practice manager at an average Australian general practice searches their database for every 49 year old who visits the practice, I guess the list would contain a 100 souls at most. A 50th birthday card would cost the practice less than $25 including the donation. The goodwill that would generate would be priceless and make all of our lives better. As experts have noted:

GPs who initiate discussions about screening with underserved population segments in particular (e.g., those aged between 50 and 55, men, and people from a non-English speaking background) are in a unique position to decrease inequity in health outcomes and improve morbidity and mortality from bowel cancer. Carlene Wilson


Innovation doesn’t always have to mean new

In a world of new gadgets and gizmos we have lost sight of the fact that medicine is a social construct and that there have been some extraordinarily successful doctors who never ordered an X-ray or prescribed penicillin. That does not mean to say that X-rays or antibiotics don’t make us better healers but if we lose sight of the reasons why people have always needed doctors then we face a very uncertain future. In the world of business it is recognised that people buy ( i.e. make decisions or commitments) based on how they feel about something, not just, and sometimes in spite of , the information available. Heart always trumps mind. How else do you explain so many of our questionable decisions in life? By corollary we need to invest in the experience we offer as health care providers, perhaps more than the devices we chose to purchase that keep us at arms length from the patient.

What that means for innovators is that we occasionally have to rediscover the ‘innovations’ that are already in our offices. Possibly the most celebrated research I led was a study that demonstrated that people trust you more when you are seen wearing a stethoscope. It followed on from research that confirmed other things we have ‘always known’- what you wear matters, how you greet your patients/ clients matters and if you seem distracted in the consultation then it detracts from the patient’s experience.

At medical school one of our tutors offered this advice:

Always stand to greet the patient, never sit down before the patient and always find a reason to touch the patient even if it is only to take their pulse.

Simple advice that speaks to the art of healing- because in the end that is what gives medicine its mandate to be involved with people in distress. We were reminded that for some of our patients, perhaps those who need us the most, the unemployed, the marginalised, the unfortunate  the doctor may be the only person in any authority who will greet them with respect that day. Therefore innovation begins and ends with a review of the basics- What is it like for your patients or clients? How are they welcomed to the service? Is your telephone message welcoming? Are your reception staff professional? Do you offer privacy at all times? Do you seem interested or concerned? Would you trust someone who presented themselves the way you do?  Would you feel better after a visit to your clinic? Do your staff need a new machine more than a better way to make people feel they care?

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?

Innovating at the interface between service providers

At least one in a hundred patients seen in general practice are referred to hospital.

In many countries the referral process hasn’t changed in decades. It’s still done with pen and paper and even in 2013 in some developed countries it still involves a fax machine. What’s interesting about the process is that once the letter is received at the hospital, it is read and then triaged by someone to determine when the patient should be offered an appointment. The decision is made in less than a minute. Everything, perhaps even life or death situations. hinges on the impression created by the writer of that letter.

In a government subsidised system, where there is a need to ration appointments, a patient might be seen next week, next month or six months from now. The reality is that in some cases a patient might wait longer than is ideal and the outcome for them may be compromised, because of what was in the referral letter and how that was interpreted. Who then is to blame, the doctor who was consulted first, or the hospital that arranged a deferred appointment? How can innovation help in this situation?

I’ve been involved on teams that have studied this problem from many different angles culminating in a randomised trial of an innovation in 2012. We came to a number of conclusions. Firstly involving people in innovation when they don’t believe they have a problem is frustrating. Many doctors think their letters are just fine, or that the recipient hardly reads them. Its difficult to innovate in a busy clinic where doctors are working flat out, and the truth is that if the innovation doesn’t make life easier for the doctor as well as the patient then it’s going to be hard to implement.

Secondly colleagues are reticent to demand change from one another, especially when they work in different parts of the system. So, as a hospital specialist I might not feel I have any mandate to require that referral letters contain the details that I like to have. It’s even worse when the paymasters across the sectors are different. In Australia hospitals are funded by State governments, whereas primary care is funded by the Federal government. What’s more primary care providers work to a ‘pay for service’ model. Which effectively means that primary care survives on profits.

Thirdly, it is unsafe to assume that all colleagues apply the same criteria about what clinical scenarios should be allocated an urgent specialist opinion, even within the same specialty, in the same healthcare system, and with reference to nationally accepted guidelines. That was unexpected!

Some problems require a whole systems approach. A problem that has seemingly obvious roots, with a strong(ish) evidence base can be difficult to crack with a lean medicine approach. Where multiple individuals are involved across health sectors, it is absolutely necessary that innovations make everyone’s life easier. Requiring letters to be written a certain way, and demanding that the process is enforced by the recipients, when there isn’t local consensus on what is an urgent case, is not going to work without something else to make it worthwhile for all concerned. What this problem calls for is more innovation when it comes to making the decision to refer. Perhaps more sensitive near-patient tests, which are better able to predict who is most likely to benefit from limited national resources.

What are your ideas for improvement that don’t require people to donate time and effort for no personal gain? Pushing out innovation is not enough, if there isn’t a pull from those at the coalface to adopt those ideas. It isn’t safe, even in medicine, to assume that people will do it, use it or promote it simply because they recognise that patients will benefit.