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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

Innovating in the too-hard box

Approximately one in a hundred people who consult a general practitioner is referred to a specialist. There isn’t an exact number because some GPs will refer more often, either because they have more patients who need referral or because they need the additional support themselves. Whatever the reasons the demand for specialist appointments is increasing; more people are diagnosed with cancer, dementia, diabetes and depression.  More people are surviving life limiting illnesses and joining long queues in outpatient clinics. At the same time there is enormous pressure to contain healthcare costs. So in the name of ‘safety, quality or efficiency’ healthcare providers are reigning in expensive healthcare interventions and access to specialists is on the list. That means there is a growing incentive to ‘prioritise’ those who are most likely to benefit from attending specialist clinics- those who are at highest risk of having a life threatening illness and especially those who are most likely to benefit from earlier treatment. There is pressure to ensure specialists are employed to serve new patients with serious illness and spending less time on matters that can be delegated to someone else.

In this context it is a feature of many healthcare systems that the specialist is requested to assist via a letter from his or her colleague in general practice. The GP is in fact the ‘gatekeeper’ to those services, this is especially true of those services that are subsidised or wholly funded by the tax payer. So what that letter says determines how quickly the patient will be seen because someone, often the specialist will schedule an appointment based on the contents of that letter. Of course it is still possible that a the doctor in the community might pick up the phone and call his specialist colleague if he was concerned that the patient needed urgent attention. Nobody really knows how often that happens. It is also possible that the patient may opt to see the specialist at a private clinic and, as would be the case in my country, be seen within a week.

In any case the ‘referral letter’ is an important element of the patient’s trajectory through the system and here are some inconvenient truths:

  • Doctors are not formally taught how to write referral letters and there is evidence that such letters can be improved.
  • The letter may be ‘triaged’ by a specialist, a nurse or a clerk.
  • Doctors don’t generally think there is anything wrong with their letters, or that their colleagues read those letters and everyone has a different idea about what they should contain.
  • We know specialist often say that GPs don’t write enough detail in their letters.
  • We also know that some people don’t think it’s worth spending time and effort focusing on referral letters because one day the process will be superceded by technology- it hasn’t happened yet and doesn’t look like it will happen soon.

Exploring, let alone improving referral letters is fraught with challenges:

  • GPs are not paid to do research and therefore are loath to spend precious consultation time recruiting and consenting patients for access to their records at a time when the patient might be facing bad news.
  • GPs are ambivalent about testing tools to improve their letter writing skills unless those tools are incorporated into their existing clinical software system.
  • Software developers won’t ‘waste’ time incorporating such innovations until they have proven value.
  • Doctors also argue that there is nothing wrong with their letters and that they record a lot of the relevant clinical details in their records. In fact, they don’t.
  • Specialists may be reticent to be involved in the research in case it sullies relationships.

Twelve years and several small or unfunded studies and some false starts later we are able to report on what we believe is the first randomised controlled trial examining the impact of GP referral letters on potential outcomes for patients. We were surprised by the results. The paper is in press and I look forward to sharing it with you soon. Suffice it to say that we still think it is an important issue, especially because most cancers are now diagnosed from people with symptoms who consult a generalist and because there are more, not less people in need of urgent specialist care. What’s more we have developed an innovation that just might work.