The future of healthcareLearn More

What’s the shortest route to where you want to go?

As the conference season begins we note that response rates in the order of 10-20% are not unusual in primary care research. Hardly generalisable. And yet we need sustainable and workable solutions that will promote health and well being in an ageing demography with increasing multimorbidity. Researchers take note the traditional gatekeeper in primary care, the general practitioner is occupied just keeping up with demand. There is no time to recruit, to seek informed consent or to deliver interventions that are being tested in a traditional randomised trial. At one time membership of networks with ‘committed’, well meaning practitioners were considered essential to successful research. In 2017 relying on anyone or any organisation that purports to guarantee recruitment rates or ‘collaboration’ seems at best naive and at worst risky.

Health requires people to make different choices. Eat better, drink less, take more exercise, jettison bad habits, consider when and where to seek medical advice. The traditional model of healthcare is evolving. The evolution is driven by technology that has fundamentally changed our experience of many if not all things. People consider themselves more time poor than they ever were.

The ability to satisfy desires instantly also breeds impatience, fuelled by a nagging sense that one could be doing so much else. People visit websites less often if they are more than 250 milliseconds slower than a close competitor, according to research from Google. More than a fifth of internet users will abandon an online video if it takes longer than five seconds to load. When experiences can be calculated according to the utility of a millisecond, all seconds are more anxiously judged for their utility. The Economist

The lesson for those hunting for better ways to reach people is to consider the least that can be done to get there. The answer may be waiting in all of our pockets.

Picture by Toshihiro Gamo

Denying people the feeling that someone cares

The conversation I overheard in my practice many years ago went something like this:

Jean, I’m sorry there are no appointments available until Friday. Has he got a fever? Try him with some paracetamol today and I’ll book him in for Friday afternoon. There’s a lot of this flu like thing going around school. Ok, see you Friday.

A receptionist was triaging my patients! Medical qualifications = nil. She looked up with a pained expression, she was carrying more responsibility than I paid her for. And yet it has long been recognised that:

Little difference was observed between the symptoms reported by patients to the physicians as compared to those received by the receptionist staff. Physicians are more likely to use the telephone contact to treat the patient’s complaint with home care advice or a prescription. Receptionists are more likely to use the telephone contact for scheduling an office visit. Fischer and Smith.

What we also don’t acknowledge is that receptionists take calls from their friends, neighbours and relatives. The callers may be worried, unwell, confused, frustrated, angry, grieving, embarrassed, lonely, sad, suicidal, dying or just simply unable to cope. We place them in a front line role in a system that is often over subscribed, under staffed and the first port of call for anyone who thinks they need medical attention. Sometimes receptionists undertake tasks that should be the preserve of someone with other qualifications! We expect the receptionist to be polite, courteous, discrete, sensitive, thoughtful, obliging and intuitive. If she, and it’s usually a she, gets it wrong the practice faces complaint or litigation and a very bad press. Employers have recognised the challenge inherent in the role, but in many parts of the world those who under take this work have no formal qualifications or appropriate training. This issue has received research attention but there are challenges to developing innovations to help reception staff to prioritise patients.

Where contamination of the study population is an early complication, no current gold standard exists to define safe triaging, contextual differences between practices lead to inter-practice variation, and proxy outcomes (improvement in receptionist response to written scenarios of varying urgency) are used. Hall et al
Can we really guide someone who isn’t a doctor, or have any medical qualification, to make appropriate decisions based on a telephone conversation about potential medical emergencies?  There was a recent report of a disastrous failure to appropriately sign post the parents of a very sick child which involved ‘suitably qualified’ people working to nationally accredited algorithms. The issue at heart is that there is a greater demand for access to medical practitioners than supply. In response to demand policy makers have promoted ways to limit or control access to that expertise. The temptation is to innovate for alternatives that don’t involve the doctor. Those who advocate for this approach may be failing to recognise that people in distress aren’t simply disordered machinery in need of a technical fix. They can’t be rescheduled like a car service. That doesn’t mean they need to see the doctor straight away but they do need to feel they have had that experience sooner rather later. People are hard wired to feel better after contact with a doctor- it’s fundamental to how medicine works. That was what we decided back then so we relieved our reception staff from having to determine who was ‘not urgent for today’ when our schedules were full- instead we, the doctors, spoke to the patient by telephone and if we were not absolutely sure we had enough information we saw the patient and we still reduced our workload by 40%. Innovating to ration access to the healer is a bad idea if only because we are deny people the feeling that someone cares. The cost of that loss of connection is a failure to fulfill our purpose in people’s lives.

 

See demand in context and respond creatively

9645066390_babd98c3f1_zHello Jill, Oh, I’m sorry I have no appointments to offer you today. the doctors are all fully booked. If your son has a fever try him with some paracetamol and call back on Friday when I might be able to squeeze him in with Dr. Jones. Ok, bye.

Many years ago I overheard this conversation in my reception. Our receptionist giving medical advice without any qualifications. The surgery was over booked. She was harassed, doctors were grumpy and the patients were being turned away without being assessed by anyone.

We noticed that there was a seasonal pattern to this demand for appointments. Most doctors were aware of this trend because there were specific weeks of the year when they avoided taking holidays. Our reception staff kept meticulous colour coded records of such ‘same day’ appointments. When we entered this data on a statistical database there could be no doubt of a seasonal pattern with definite peaks and troughs. What’s more, we could predict the demand for ‘same day urgent appointments’ with reasonable confidence. At this point, it may be important to stress that doctors in the UK are paid a ‘capitation fee’ for serving patients. That means they are paid an annual fee no matter how many times they see the patient.

Understanding that people have a fundamental desire to talk to the decision maker, we settled on the notion of putting the doctor in charge of making the appointment. Patients who requested a ‘same day’ appointment were offered a telephone consultation with a general practitioner initially. Not with a nurse, as happened in some practices, but with their doctor. We believed patients wanted to speak with a medical practitioner, not because the advice they received was necessarily better than that given by another member of the team, but because people in distress want a doctor. Whatever the reason it worked. Important policy makers noticed. Doctors could deal with most requests within a couple of minutes, offer a ‘same day’ slot or something else without the need for a face-to-face appointment. We calculated a 40% reduction in demand for such appointments. Patients loved it, reception staff loved it too (no more arguments about lack of appointments with irate patients) and doctors found themselves in control of their workload. What’s more, we could prove that this simple intervention worked from the impact on longitudinal seasonal trend.

By allowing patients to speak to their doctor when they felt they couldn’t wait our practice chose to treat this small minority of patients differently to those who were happy to make a routine appointment. We acknowledged that these patients had a need that warranted a creative solution. Perhaps you have a group of patients who would benefit from being treated differently too? What is the context in which they seek help? The tired mother with a fevered child does not have the same needs as the young professional who requires a convenient appointment to obtain a prescription for the contraceptive pill. Both might seek an urgent appointment.

Picture by Marjan Lazerveski