Chapter 2 The Challenges of Personalising Realistic Medicine
For most health and social care professionals, the major barriers to delivering Realistic Medicine are not ideological. In fact, 95% of those who responded to our survey felt that the principles of Realistic Medicine fully or somewhat matched their own personal beliefs and values about how healthcare should be practised. The greater challenge is how to practise Realistic Medicine in our current healthcare landscape.
Engaging our patients
If we are to realise the vision that everyone will be practising Realistic Medicine by 2025, we need to engage more effectively with our patients. This means shifting the culture of communication away from the traditional paternalism of ‘doctor knows best’, and toward a collaborative partnership of shared decision-making between professional and patient. Professionals must endeavour to build trusting relationships and maintain a dialogue of openness and honesty. People must truly feel comfortable asking questions about their care and they must be reassured that their beliefs, choices and preferences will not diminish the quality of care that they receive. Similarly, professionals must feel able and willing to ask the right questions and give clear, honest and realistic answers.
Engaging the public is more complex. There are an array of different approaches and which works best depends partly on the nature of the conversation and the subject matter. For example, surveys work well with topics which people may already be quite knowledgeable about, or have had the opportunity to develop an opinion on, but do not work as well if people are less familiar with the topic. Another consideration is that there is rarely, if ever, a single public view on anything. In fact, taking this further, some have argued that ‘the public’ does not actually exist. Real people have real lives, real stories, real problems and real priorities and, therefore, no person is a ‘typical’ member of the public. So, when engaging with the public, one tends to encounter a diversity of views, sometimes with only subtle yet important differences. Capturing such views can be more of an art than a science.
We must also remember that ‘how’ we engage constructs the public we engage with. If we engage with them as thoughtful and reflective citizens, we encounter a different public to the one we encounter through surveys or the media. This is the reason why deliberative methods of public engagement, such as Citizens’ Juries, are increasingly being used to understand what citizens think about particular topics. This is why I considered it appropriate to use a Citizens’ Jury to ask members of the public for their thoughts on shared decision-making. And so, last year, Scotland held its first ever Citizens’ Jury on a health topic.
The Jury has been a fascinating and most valuable exercise that has given us the opportunity to reflect on how we can get better at shared decision-making. Box 4 describes the process and the recommendations that the Jury has made. I am aware that some have expressed concerns around whether the public are willing to be engaged on Realistic Medicine and even whether the public can be ‘realistic’. I do not believe that either concern is founded and this process has provided further evidence that, when provided with the information they need, the public can make practical and very sensible recommendations about how to provide better value care. Having sent 3000 letters of invitation, 269 applications were received, an overwhelming response rate for this process. All Jury members attended all three sessions (all on different Saturdays throughout October and November 2018). This is rare for Juries, because size almost inevitably shrinks over time, and it demonstrates this Jury’s commitment to supporting our understanding of shared decision-making. All participants engaged actively and enthusiastically at each session. Throughout, the Jury was empathetic to the challenges and pressures that healthcare professionals face on a daily basis. Their recommendations reflect their compassionate, pragmatic and reasoned participation.
Box 4 – Our Voice Citizens’ Jury on Shared Decision-Making
Erica Reid is Associate Director of Nursing and Allied Health Professionals in NHS Borders and Chair of the Citizens’ Jury Oversight Panel
The purpose of the Our Voice programme is to engage the people of Scotland to improve health and social care. The Scottish Health Council was commissioned by the Chief Medical Officer to hold a Citizens’ Jury on shared decision-making.
An Oversight Panel was formed to ensure a fair and rigorous process, agree questions, identify commentators and witnesses, monitor the process and advise on the Jury’s findings. The Panel included representation from the public, clinicians, social work, an academic expert in public participation, Health and Social Care Alliance Scotland and the Royal Colleges of General Practitioners and Physicians.
The Citizens’ Jury members were a stratified sample of the population, chosen by a ‘near random’ selection process to achieve as close to a representative sample of the Scottish population as possible. Over three sessions, the Jury deliberated the question: ‘What should shared decision-making look like and what needs to be done for this to happen?’ Commentators, ranging from healthcare professionals to those who had experienced care, were selected to bring a range of perspectives to share with the Jury.
The Jury then developed 13 recommendations and prioritised them. The three main recommendations, as written in the Jury members’ own words, are to have:
1. A programme to inform and educate patients of their right to ask questions of health professionals and which questions are useful to ask;
2. Training for all health and social care professionals on shared decision-making;
3. The opportunity for an independent person to join conversations between medical professionals and patients.
The Chief Medical Officer met with the Jury members in February 2019 and they shared their recommendations with her. The Scottish Government has committed to carefully consider each of the Jury’s recommendations and reply to them all, either with a commitment to action or an explanation as to why that recommendation cannot be taken forward.
‘My predominant experience is that patients and indeed citizens are appreciative of the challenges facing the NHS and that their requirements and hopes for the service are, in most cases, entirely reasonable. The vast majority are very understanding of the constraints and very grateful for the service that they have received. So it’s an important and rewarding exercise to listen systematically to citizens and patients as it can provide a valuable reference point for how we can improve things’.
The value of engaging our citizens is increasingly recognised. For example, following the introduction of the new GP contract in Scotland, the Scottish Government have begun to collaborate with stakeholders, including the Royal College of General Practitioners (Scotland) and the British Medical Association, to lead a national conversation to increase the public’s understanding of the new models of primary care.
There may be no single ‘best way’ to engage with the public but we need a dialogue based on trust and mutual respect. In 2000, the House of Lords Science and Technology Committee produced a report calling for the rejection of what it termed the ‘deficit model’. This is the notion that the gap between professional experts and the public is down to an information deficit that can be filled by expertise being provided to educate the public and, with this new information, the public would then be expected to agree with the professionals. This does not deliver good engagement. Professionals frequently discount or fail to understand the social and ethical values that the public bring to the discussion. Although the ‘deficit model’ argument was made in relation to science, it holds relevance for health and social care and for Realistic Medicine. It is far more productive for us to engage in a two way dialogue, to build trust and to understand the importance of the public’s social values. The House of Lords report concluded that ‘many of the issues currently treated by decision-makers as science issues may in fact involve many other factors besides science’. In the same way, we must accept that, to deliver Realistic Medicine, we need to consider many factors besides medicine.
Finding the time
‘All interactions of care carry their own tempo and, in kind care, we give adequate time for this tempo to develop’.
Lack of time to deliver a personalised approach to care is the barrier most frequently cited by professionals. This concern has some legitimacy: our health service has never felt busier and there are certain situations, particularly in the emergency setting, where it may not be desirable or possible to give more time to provide information and reach decisions. But are there ways of making better use of the time we have? Can we change the way we practise to create time?
Evidence suggests that, while lack of time can impede shared decision-making, the primary factors are often clinician attitudes and skills. Work by Rabinowitz indicates that, on average, doctors interrupt a patient’s opening monologue after 12-18 seconds whereas, when left uninterrupted, patients typically speak for between 30 and 90 seconds, often disclosing significant concerns. Allowing these extra seconds may provide the clinician with valuable background for framing and personalising the rest of the conversation.
An initial investment of time can also save time downstream. Dr Al Mulley talks of there being two important diagnoses in a consultation – the medical diagnosis and the preference diagnosis. As a health service, we go to great lengths to avoid misdiagnosing the former and, if we do get it wrong, our response tends to be immediate and comprehensive. However, a misdiagnosis of a patient’s preference tends not to be recognised, despite it having similar consequences for the patient.
By building a personalised approach to care, we reduce the risk of making this so-called ‘silent misdiagnosis’, leading to better understanding of people’s needs, improved personal outcomes and ultimately time saved. Evidence of this can be seen by revisiting examples from Chapter 1. Two independent evaluations of the work of the Patient Experience and Anticipatory Care Plan Team (PACT) in NHS Lothian have found that PACT care plans are associated with a measurable reduction in acute hospital demand that outweighs the cost, both in time and money, of providing the service.
Likewise, in the year following the pilot of The Silver City Project in Aberdeen, emergency hospital admissions of people aged >75 (from that GP practice) fell by around 12% and outpatient referrals to Geriatric Medicine reduced from 10 to 4, allowing more effective use of Geriatrician time in contributing to Silver City multidisciplinary team (MDT) meetings.
Time can also be saved by making innovative changes to our services. This means rethinking which patients need to be seen, by when and by whom. Evidence from many specialities throughout Scotland has consistently demonstrated the benefit of promptly supplying patients with information leaflets regarding self-care, when to contact clinicians for advice and how to “opt-in” for a face-to-face review. This approach has been shown to reduce unnecessary outpatient attendances, freeing up resources for use elsewhere. Traditionally, no clinical information has been sought or provided for new outpatients until seen face-to-face, despite the accessibility of electronic patient records, laboratory results and imaging. If we can review this information at an earlier stage, certain outpatient appointments may not be necessary.
The Orthopaedic Team at Glasgow Royal Infirmary provide one such example. Traditionally, all non-operative limb fractures referred from Emergency Departments to fracture clinics were seen face-to-face within 72 hours. A new model of care was introduced, based on provision of clinical information leaflets, an “opt-in” clinical helpline for patients and a “virtual clinic” where the Orthopaedic Consultant reviewed and triaged all new referrals. Now, less than 40% of patients require a face-to-face review but the right people are being seen at the right time. An evaluation of the service shows that 79% of patients are satisfied with the pathway, outcome and clinical helpline.
Other services have “made time” to deliver more personalised care by making better use of their whole clinical team. Box 5 shares the experience of the Breast Service in NHS Lanarkshire.
Similar approaches have been successful in primary care. Inverclyde are piloting the use of an Advanced Practice Physiotherapist (APP) as an alternative first point of patient contact within three GP practices, with a total patient list of 14,000.16 Reception staff at each practice were trained to offer patients APP appointments where appropriate. To date, the APP has provided over 1000 consultations, most of which would otherwise have been GP appointments. 94% of patients were seen once and did not need a further appointment with the physiotherapist. GPs are now able to use their time more effectively by focusing on patients more in need of their expertise. In qualitative evaluation, the pilot was rated highly by GPs, practice staff and patients, with patient feedback in particular being extremely positive.
‘Of all the work that’s ever been done in GP practices, this has been the one that feels like it has truly taken work away. Patients are safer – there is quicker access to the most appropriate intervention because triage assessment conducted by the physiotherapist gets people to the right place sooner’.
The service redesign proposed in The 2018 General Medical Services Contract in Scotland reflects the ambition to ‘reduce and refocus’ GP workload and use the wider primary care MDT to create more time for GPs to spend with patients most in need.
These are all compelling examples of the unrecognised waste that exists in some of our care pathways and which consumes our time unnecessarily. Careful, thoughtful, design-led processes, such as those being undertaken through the Waiting Times Improvement Plan and by the Scottish Access Collaborative, can help us to improve how we use this most precious resource.
Box 5 – Breast Service Redesign in NHS Lanarkshire
Juliette Murray is a Consultant Breast Surgeon in NHS Lanarkshire
By 2012, there had been 4 retirements from a team of 6 Consultant Breast Surgeons working between the 3 acute hospitals in NHS Lanarkshire. In a challenging recruitment environment, we had to consider whether there were innovative ways of reconfiguring the service.
We trained a combination of sessional Specialty Doctors and Advanced Nurse Practitioners to see and assess patients. We designed a service footprint which matched capacity with demand and used team job planning with flexible sessions to promote cross-cover between colleagues, with the aim of keeping theatre sessions and clinics fully staffed and running 50 weeks per year. By having more than one subspecialty interest, staff are able to move between services based on demand. We concentrated on role extension: trained Consultant Radiographers to do most of the work of a Breast Radiologist; Surgical Care Practitioners to perform minor surgical procedures; Clinical Support Workers to become scrub practitioners.
We have worked hard to match capacity within the service to demand. We now have a 10-14 day wait for all urgent and routine referrals to the breast service across Lanarkshire and a less than 2 weeks wait for surgery. We have focused on all parts of the pathway, from working with local GPs to develop referral pathways to considering which benign surgical procedures we should perform. We have developed virtual clinics for family history patients and moved to a patient-led follow-up model for breast cancer follow-up, with a 70% reduction in patients needing to attend these clinics. This allows staff to spend more time with those patients who have more complex needs, which leads to higher patient and staff satisfaction.
Having long-term committed staff means that trainee surgeons who come to work with our team are supernumerary and their training time can be prioritised. They are able to spend 2-3 days per week in theatre and we can offer dedicated training clinics.
By creating a little flexibility in our system, we have been able to offer both surgical and radiological support to the Breast Units of neighbouring Health Boards, in Fife, Dumfries and Galloway and Forth Valley.
Processes include a systematic way of spreading enhanced practice roles when they have been shown to work elsewhere and accelerating the implementation of successful team service planning models, such as the one described in Box 5.
Supporting professionals to seek out and eliminate unwarranted variation and to practise shared decision-making will help us to tackle over-treatment. This will not only reduce harm and waste in our system but also has the potential to increase capacity by redirecting those resources currently used for interventions of limited, or no, clinical value to more appropriate care. This, in turn, will have a positive impact on waiting lists.
It is true that challenges must be overcome to deliver a more personalised approach to care. However, if we are courageous in committing to our 2025 vision, I firmly believe that Realistic Medicine will enable us to succeed. A more personalised approach towards our patients and our citizens can foster their engagement, allowing us to understand and co-create the care they really value. Giving time to patients can often save time for professionals, and the appropriate redistribution of work - using all the assets of our diverse teams - can improve patient care, rather than undermine it.