Tag Archives: primary care

The case for shared care

People are uncomfortable, if not alarmed, when the behaviour of someone they live with suddenly becomes ‘deviant’, ‘offensive’ or embarrassing; Grandfather becomes disinhibited, son becomes violent, wife starts shoplifting, daughter steals money from home. The unfamiliar moves us out of our comfort zone and we start to question the future, often catastrophising. Many chronic medical conditions result in behavioural changes. People hope that there is something that can be done to remedy the situation quickly so one of the first steps is to seek medical advice. It may be that the person has one of a host of acute or chronic conditions including life limiting pathology; Depression,  psychosis, dementia, substance abuse or cancer. The reaction to the behaviour may also result from misinterpretation or the complainant may be the one with the problem or feel stigmatised by the experience. Once an explanation is found it is often the case that medicine could make things worse- prescriptions, hospitalisation and tests may be harmful. There is also a risk of medicalising the problem as noted by Dworkin.

In the past, medical science cared for the mentally ill, while everyday unhappiness was left to the religious spiritual or other cultural guides. Now, medical science is moving beyond its traditional border to help people who are bored, sad or experiencing low self esteem- in other words people who are suffering from nothing more than life.

Nonetheless people seek help from doctors and there is great scope to assist by sharing care with others who may be able to help with a problem for which there is no pill and people have to revise their ideas, concerns and expectations. It may be that doctors are reluctant to engage people in these circumstances because they do not perceive that they have the resources or expertise to assist with what they consider outside their sphere of influence. Nonetheless people will continue to expect assistance. Epidemiology records that the rates of chronic and complex conditions are set to rise almost exponentially as the population ages and suffers the pathological consequences of poor life style choices. At the same time the cost of healthcare is increasing to the extent that services may be rationed. Already in Australia, even with a relatively healthy economy, the government is proposing cuts to healthcare expenditure. Meanwhile the number of people living with a family member who has a condition where behavioural changes are possible, if not likely, will increase. For instance the prevalence of dementia in Australia will increase from 332,00 to just under a million by 2050. The proportion of people with behavioural changes in the context of  this diagnosis is the majority of patients with an average duration of about 8 months during the illness. Such behaviours may have a profound impact on the emotional well being of the caregiver. It is  acknowledged that some caregivers do not easily adapt to the stresses of caregiving and are at risk in terms of their ability to continue in their role. A failure to maintain this unpaid caring role would have a significant impact on the cost of caring for the patient who may have to be institutionalised sooner rather than later. The conclusion of a study from Sweden was that:

Informal care, measured as hours spent caring, was about 8.5 times greater than formal services (299 and 35 h per month, respectively). Approximately 50% of the total informal care consisted of time spent on surveillance (day and night).

Therefore innovations that allow the medical practitioner to quickly incorporate assistance from organisations that specialise in supporting caregivers will enhance the prospects of sustaining an effective health service for all. The services of organsiations such as Alzheimers’ Australia may be underutilised because of a failure to respond to calls of help from stressed carers. Similar observations can be made about other chronic illnesses including substance abuse, cancer and palliative care where changes in behaviour may be common and medication has a limited role.


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.

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.

Symptom or disease? The four circle rule.

Four Circles for innovators in Lean Medicine
Four Circles for innovators in Lean Medicine
Most people with symptoms don’t seek medical advice. Those who choose to make an appointment with a doctor are more likely to have a disease and those who are referred to a hospital specialist are even more likely to have pathology. Lean medicine takes account of Bayes’ theorem that demonstrates this simple truth mathematically.

I like to think of it as ‘the four circles rule’.
This schematic tells us that many people with pathology do not seek medical advice and some don’t even have symptoms. It also tells us that doctors have to find those with pathology from among the many who do seek their advice. Often patients present with a host of problems, so that the four circles become 8, 12, 16 or even 20 different circles, one set for each condition.

My team have applied this principle to study people with bowel symptoms. It is a fact that most people with bowel symptoms do not have pathology, or at least not cancer. Epidemiologists have identified groups of symptoms which when they occur together are most likely to signify pathology. This isn’t always reliable and there are lots of false positives, leading to anxiety among the worried well. On the other hand it is also true that people with pathology may or may not seek medical advice. The latter is especially true of men who find discussing their bowels embarrassing. Sometimes so much so that they don’t mention the diarrhoea or rectal bleeding to anyone, least of all their doctor. The consequences are that in some cases they delay seeking help for potentially life limiting disease until it is too late for curative treatment.

We also know that colorectal cancer is diagnosed in most cases only after the patient has developed symptoms and sought medical advice. Only a minority of cases are diagnosed from among those with no symptoms who have been screened for the disease. Whatever the case the sooner a diagnosis is made the better the chances of successful treatment. Because the symptoms can be so embarrassing and to some extent because some men procrastinate with seeking advice colorectal cancer has a worse prognosis in men.

It’s in situations like these that innovations which are low cost, personalised and offer creative solutions to healthcare problems come into their own. The focus could be to provide opportunities for as many people as possible to get convenient, reliable, personalised information in privacy without necessarily going to a doctor. What’s more such an innovation needs to make life easier for the practitioner and the patient.