Realistic Medicine: Survey Highlights

Barriers to Practising Realistic Medicine

Respondents were asked for views on key barriers to implementing changes and improvements aligned with Realistic Medicine in their practice and service delivery. From a list of nine options, there was no limit to the number of options that respondents could select, plus a free text option was also available. On average, respondents identified nearly three (2.9) barriers each, including free text responses.

The most frequently cited barrier to practising Realistic Medicine was “insufficient staff time” (53%). Other frequently identified barriers included “lack of formal training” (50%), “lack of local leadership for Realistic Medicine” (41%) and “fear of litigation or other censure” (32%).

Lack of time

Insufficient time was the most commonly selected barrier for GPs (63%), Pharmacist / Pharmacy Technicians (63%), Resident Doctors (59%) and Consultants (53%). It was a consistently selected barrier, cited by more than four in ten respondents across each profession and those in each of the fourteen territorial Health Boards. Only respondents based in the Scottish Ambulance Service (30%) were less likely to identify insufficient time as a barrier.

Within some respondents’ comments, lack of staff time was aligned to challenges resulting from wider system pressures:

”In the current working environment and constant crisis mode, it’s hard to see how staff can be enabled to practise Realistic Medicine really and truly.”

”Overwhelming pressure on acute services.”

”Sustained NHS bed / social care crisis preventing planning or implementation of Realistic Medicine.”

Lack of formal training

Half of those who responded (50%) said that lack of formal training was a key barrier to practising Realistic Medicine. There is clear variation by profession.

Lack of formal training was the most commonly selected barrier for Dentists / SAS Doctors (66%), Nurses / Advanced Nurse Practitioners (66%), Allied Health Professionals (61%) and Managers (52%). However, GPs (36%) and consultants (33%) were much less likely to say this, despite these professions being less likely to report having completed training.

Criticism from patients and fear of litigation or other censure

Around a third of all respondents selected fear of litigation or other censure (32%) as key barriers to implementing changes and improvements aligned with Realistic Medicine. However, this was the case for nearly half of Consultants (47%) and nearly six-in-ten GPs (56%).

Similarly, while a little more than one-in-five respondents identified criticism from patients, this was also more frequently selected as a barrier by GPs (34%) and Consultants (27%).

Respondents’ comments suggest criticism can come not just from patients but also their families / representatives, and some feel this can be driven by unrealistic expectations.

”Criticism from patients’ relatives.”

”Many patients tend to want more treatment when symptoms persist despite current/previous treatment, even if there is little likelihood of benefit.”

Differences with local or national guidelines

Around a quarter of all respondents identified differences with local or national guidelines as a key barrier (26%). GPs (38%) were more likely to cite this barrier, as were respondents based in NHS Tayside (38%).

Themes from respondents’ comments suggest some feel that guidance is incompatible with the principles of Realistic Medicine.

”Local, National and SG guidance conflict with the principles of RM and focus on best evidence care with disregard for actual benefit.”

”We are being asked in guidelines to prescribe more drugs and this is at complete odds to Realistic Medicine.”

Variable implementation and unwillingness to adopt Realistic Medicine principles

A number of respondents referred to variation in interpretation or implementation of Realistic Medicine practice, across different professions or areas of the system. In some cases, it was suggested that this inconsistency was driven by limited adoption of Realistic Medicine principles, grounded in a reluctance to implement new approaches.

”It’s just not part of some senior doctors world view and not translating into their practice.”

”Organisational culture – ‘we’ve always done it that way’ and not exploring new methods/ways of working.”

”I understand strategically what the CMO is trying to do with Realistic Medicine, however I don’t feel that this is connecting with the rest of the health system- this should be driving everything that we do in NHS Scotland, but I don’t feel that it is.”

”I think the main barrier is that doctors do not feel able to make decisions in line with Realistic Medicine, because they will not be supported by management.”

Reflections

The biggest barrier to practising Realistic Medicine is lack of time (53%), which is not surprising given the pressures our system is experiencing. Lack of time has been a recurring theme in my discussions with health and care professionals over the years. Time is one of the scarcest resources in healthcare and talking about different treatment options with the people we care for, or whether it makes sense for them to have treatment at all, and then recording that discussion, all take time.

However, not taking the time to understand what matters to the people we care for can lead to both wasted resources and time wasted in providing low value, or futile care. This can lead to complaints. Many of you are also clearly concerned about receiving criticism from the people they care for, or fear litigation. However, the conversation itself, and the record that it took place, are the best protection against successful complaints action.

In this blog, Michael Stewart, Head of Central Legal Office, discusses the relationship between Realistic Medicine and consent. Michael makes clear that the best way to prevent an informed consent claim is a robust shared decision making process which:

1. puts the patient at the centre of decisions made about their care;

2. encourages healthcare professionals to find out what is important to the people we care for;

3. treats the patient as an equal partner; and

4. engages people in decisions about treatment options to make sure that they can decide what is right for them.

It’s time to fully adopt shared decision making as the way we can ensure that we provide appropriate care that people will benefit from, and value.

Lack of formal training is an additional perceived barrier. Just 13% of you said that you had completed any Realistic Medicine and/or Value Based Health and Care training. This was the case for one-in-twenty Resident Doctors (5%) and fewer than one-in-ten Consultants (7%) and GPs (9%). This is surprising given that NES has developed excellent training resources on Realistic Medicine available on TURAS and we have worked with Boards to promote these resources.

NHS Boards and HSCPs must work together to raise awareness of the excellent training available and do more to ensure that you are supported to complete it. Why? Because while only 13% of you have completed Realistic Medicine training, 76% of those who have, feel more confident in practising Realistic Medicine as a result.