Realistic Medicine: Survey Highlights

Benefits of Practising Realistic Medicine

38% of respondents said that some positive outcomes have been achieved in improving health equity, reducing harm, and/or achieving the outcomes that matter to people, as a result of practising Realistic Medicine.

A follow-up question asked respondents to specify those outcomes.^[1] A summary of the main findings follows:

Reducing Ineffective Interventions for Harm Reduction

Many respondents highlighted a reduction in ineffective interventions as a positive outcome from practising Realistic Medicine.

They noted that more appropriate use of treatments was based on a personalised approach to care which reduces avoidable harm and waste in the healthcare system.

”Reduction in number of times investigations are monitored for chronic conditions. Prevention of duplication of investigations. Focus instead on patients’ priorities.”

”Rationalising interventions which will not provide overall benefit to people.”

In relation to prescribing, many respondents indicated that polypharmacy and prescription reviews, alongside deprescribing, are improving people’s understanding of the risk-benefit ratio. They consider these medicine reviews as a positive outcome achieved because of practising Realistic Medicine.

”Some polypharmacy reviews and deprescribing, more awareness of risk vs benefits of meds in the elderly, [more] care with antibiotics…”

Some respondents noted these prescribing processes were most effectively being used with frail, elderly people and those with comorbidities and multiple conditions. A few also mentioned the reduction of prescribing of medicines of what are considered low clinical value. A small number of respondents mentioned these processes have allowed the reduction of harm and medicines waste.

”In relation to medicines use - reducing variation in prescribing and ensuring evidence based use of medicines.”

Some respondents highlighted the reduction of ineffective tests, treatments, and interventions as positive outcomes.

A few noted that a focus on appropriate care has helped minimise waste, overtreatment, and harm.

”I see some improvement in areas like surgery – avoiding surgery in situations where no overall benefit can be gained – e.g. frail and elderly patients with poor surgical outcomes. Good collaboration is developing between surgical teams and palliative care teams on this.”

A few respondents highlighted reducing hospital admissions, referrals and readmissions as a positive outcome of practising Realistic Medicine, particularly where an intervention is expected to provide minimal or no overall benefit for the people we care for.

”We now have a high-risk anaesthetic clinic to facilitate discussions about surgical interventions with patients to allow them to come to a shared decision about proceeding with treatment or not.”

Others noted the reduction of follow-up consultations and the increase in virtual consultations as effective healthcare practices.

”Increased access to community pathways to avoid unnecessary hospital attendance. Increased access to more specialist support to manage conditions at home and appropriate to the patients’ needs.”

A small number of respondents noted improvements in equitable healthcare access, while others highlighted a general increase in effective treatments.

”Reduced eye screening where risk is low, resulting in patients only been seen when required and resources freed up to see our [increasing patient] population.”

A few highlighted removing or reviewing treatments and tests, particularly those with low clinical value. Some also noted improvements in reducing the healthcare system’s environmental impact and promoting sustainability.

Shared Decision Making, Personalised and Equitable Care

Several respondents said that a key positive outcome of practising Realistic Medicine has been ensuring that people and those closest to them are actively involved in informed care decisions, including end of life discussions, treatment choices, and self- management.

”Improved care, right care, right time, right place, every time, excellent end of life care, joint decisions that are realistic with people at the centre of their care.”

A few respondents emphasised how people are actively participating in their care, particularly in self-managing chronic conditions and end of life care.

”Encouraging patients and their families/carers to undertake foot dressings thus reducing their need to attend clinical appointments.”

Many respondents highlighted the active role of people and their families in treatment and care decisions through a shared decision making approach.

A few also noted the use of tools such as ReSPECT (Recommended Summary Plan for Emergency Care and Treatment), BRAN (Benefits, Risks, Alternatives, Nothing), and TEP (Treatment Escalation Plans) as valuable in facilitating informed decision making with patients.

”People can avoid admission to hospital following a ReSPECT conversation, they can avoid unwanted treatments following a ReSPECT conversation. ReSPECT conversations include family and loved ones. ReSPECT increases patient and family satisfaction with health services. This improves experience for staff and the people we care for, including the wider community.”

Training and awareness

Many respondents mentioned that increased awareness, and better access to information and training, as a positive outcome of practising Realistic Medicine.

”Improved access to information and a change to seeing people we care for as partners in their care.”

”The multidisciplinary team uses Realistic Medicine now as a principle of decision making. Enables clearer communication with patients and families if we work in cultures that promote this approach.”

Some also highlighted the rise in training and shared decision making tools and conversations for clinical and non-clinical staff, which are helping to integrate Realistic Medicine into daily practice.

”All staff have been trained on Motivational Interviewing and supporting patient to be involved in their care. We are about to run a patient survey based on BRAN Questions and the CollaboRATE tool.”

A small number of respondents mentioned a cultural shift to a more pragmatic and personalised approach to treatment choices based on robust evidence. These efforts also include embedding a shared decision making approach to personalised care for patients.

”Awareness that the principles of Realistic Medicine support less intervention if patient values allow.”

”Started Supportive Care Renal service over past three years – realistic conversations regarding appropriateness of dialysis treatment for patients.”

Improved communication and collaboration among teams

Many respondents mentioned better communication, collaboration and governance among teams as a positive outcome resulting from practising Realistic Medicine.

Some said this has resulted in a decrease in low-value and inappropriate treatments being provided to people where the evidence suggests they are unlikely to benefit, as well as a reduction in hospital admissions and waiting times.

”Routine liaison with patients and next of kin to consider the most suitable care plan has been embedded within our team culture. Structures exist to review practice and consider whether unwarranted variation is occurring. Clinical governance structures exist and are as robust as I think plausible.”

A few respondents noted that healthcare teams are encouraging meaningful, informed discussions with the people they care for, emphasising evidence based practice and improved understanding of alternative treatments through shared decision making. Additionally, a small number of respondents highlighted that health and care professionals are now better equipped to engage in these conversations.

”Locally within my department we are much more aware of and practically doing more to consider whether certain treatments are appropriate- especially in frail patients – and we now have the tools and language to talk to our staff about it.”

Similarly, a few respondents mentioned a strong collaborative working environment characterised by enhanced communication, the exchange of ideas for improvement, the delivery of value based and realistic care, and reflective thinking.

”We have good flow through our department, we discuss ‘value’ and ‘realism’ at our daily MDT [multidisciplinary teams] board round, we have a flat hierarchy where everyone in team can challenge one another to help deliver realistic care (which might not actually be what people expect, but what is possible and realistic in relation to their circumstances).”

Improved efficiency and personalised care

Several respondents highlighted the implementation of more efficient healthcare processes, procedures or services as a positive outcome resulting from practising Realistic Medicine.

They also mentioned more effective treatment choices are being carried out based on a personalised approach to care.

”With specific regards to skin cancer, low grade skin cancers in elderly population will often outlive the patients and if asymptomatic often don’t need to be treated. We try and have a sensible approach to focus on maintaining good quality of life rather than treating a lesion because we see it!”

Similarly, some respondents highlighted the development and implementation of streamlined, evidence based care pathways across different services or specialties, as well as the use of specific protocols and improved data to support decision making.

”In my practice we’ve reduced delays to diagnosis of rheumatology conditions through working with the people we care for to develop a PIFU (Patient Initiated Follow Up) pathway that reduces waste and provides personalised care for people on PIFU and creates capacity to see new patients.”

Shift towards supporting the most appropriate location of care

Some respondents highlighted a strong focus on supporting people to receive care in the most appropriate care setting based on what matters to the people they care for as a positive outcome.

This was frequently mentioned in relation to care of older, frail people and end of life care.

”Home-first approach and when hospital care is required, people are there for the right amount of time and are supported to return home without delay ‘discharge without delay’.”

Other respondents highlighted the implementation of “hospital at home” care as a positive development that reduced inefficient long hospital stays and admissions.

”Increased access to community pathways to avoid unnecessary hospital attendance. Increased access to more specialist support to manage conditions at home and appropriate to the person’s needs.”

A small number of respondents noted that care provided in a community or home setting was often more appropriate than hospital care, which was not always the most appropriate care setting.

Better future care planning, palliative and end of life care

The increased use of future care planning tools was frequently emphasised as a positive outcome from practising Realistic Medicine.

Several respondents said that they helped to personalise care through shared decision making. The tools mentioned were advance care planning, treatment escalation plans and anticipatory care plans.

”Improved future care planning conversations capturing severely frail people’s views on treatment interventions, hospital admissions and preferred place of death has significantly improved outcomes for people approaching end of life to remain in their home or care home and prevent unnecessary admission to hospital.”

Many respondents highlighted more effective use of care planning tools that ensure appropriate treatments for palliative, elderly, frail, and end of life patients based on what matters to them. Respondents noted these care planning tools incorporate people’s preferences and prioritise quality of life over prolonging intervention or treatments. One commonly mentioned example was that care planning tools reduce inappropriate hospital admissions.

”We are seeing an increase in meeting people’s wishes to die where they choose; reduced risk aversion in support planning, and the highest level of Future Care Plans in place in NHS Greater Glasgow and Clyde.”