Thursday, 24 March 2011

The patient has gone AWOL

The UK National Health Service is based on a military model of organisation. In the 1970s Monty Python devised a sketch that parodied the hierarchical organisation and tendency to infantilise patients. I remember the key lines as: 'Me doctor, you patient. Me expert, you idiot.' This clip shows that the second line is a figment of my imagination, though the tendency to assume complete ignorance amongst patients was accurate at the time:

Writers on empowerment and culture change, such as Bowen and Lawler, tend to suggest that managers are responsible for bringing about change that benefits customers by various initiatives.

If we take a systems view of organisations, it should be possible to bring about change in the whole system by introducing a variation in one part of it, so that everything else adjusts to come back into balance.

Peter Senge focussed on a US health example in 2010 at the Systems Thinking in Action Conference:

This clip shows Russell Ackoff discussing US healthcare and the split between theory espoused and theory in practice:

In the 1990s Glaxo Wellcome made a strategic decision to shift its marketing effort away from the usual custom of giving desk ornaments, equipment and stationery to general practitioners as a way to encourage them to prescribe GW drugs. Scenario thinking indicated a growing discontent amongst some doctors at the way pharmaceutical companies operated as well as concern amongst the public at the idea of bribing doctors for profit. Impact on prescribing was declining and local coordinating bodies were considering ways of reducing costs by recommending the use of generic, cheaper alternatives to branded medicines.

Glaxo Wellcome trained practice nurses to become specialists in dealing with a small range of diseases (such as asthma and diabetes) and learn how best to monitor and adjust medication. This altered the position of nurses within primary care and was one of the catalysts for the introduction of nurse prescribers, which was useful for district nurses and others who could not rely on easy access to a doctor to issue a prescription when doing home visits. Pressure was applied to upgrade nursing training and ensure that all nurses had degrees. A split emerged, particularly in hospitals, between those who did menial tasks and hands on care work and those who sat at computers, undertook medical procedures and dispensed medicine.

Some aspects of the supply chain were challenged by new providers. Tesco started offering prescription chemists in large supermarkets, which was especially welcome to Sunday shoppers. Both opticians and dentists were challenged by large corporate chains and Vision Express and Specsavers came to dominate the optician market. This introduced more flexibility, choice and some lower prices to consumers. New models of payment and insurance further changed the market, with Denplan making waves in dentistry.

The growth of the internet and freely available information led to the arrival of the 'WikiPatient', who would turn up to a consultation carrying a thick bundle of documents printed from the net. Doctors might dismiss this as information overload, quack alternative medicine or populist misinformation and tell patients either that they risked becoming a hypochondriac or simply "Trust me, I'm a doctor". However with freely available peer reviewed scientific abstracts and full articles available through PubMed, these arguments began to seem lame.

Intelligent lay people in the US have access to medical education, which, in some cases has gone viral globally, for example Dr Robert Lustig's entertaining lecture on high fructose corn syrup:

Politicians also influenced the NHS. Margaret Thatcher was a champion of free markets and impatient with silos and closed shop agreements amongst professionals, which restricted who could do a particular job. She challenged the distinction between barristers and solicitors and allowed solicitors to represent clients in court. Doctors and consultants recognised that Thatcher had them in her sights and that they could not retain exclusive access to certain work. The new GP contract introduced by the Labour government was an attempt to gain more flexibility from doctors, but resulted in added costs for evening cover.

Subsequent governments have introduced Choose and Book which ensured that doctors and patients decided together when and where a patient would receive secondary and tertiary level treatment. Patients now have the choice of a GP centre wherever they wish, not restricted by a catchment area. Wikipatients, who discover their doctor resists entering a collaborative relationship in caring for their health, can now easily vote with their feet. They also have the right to view their notes and specify if they want to allow open access to the information on the NHS Spine or opt out of the system.

Burgeoning consumer choice and experience of rapid service from the likes of Tesco, increased pressure on doctors from patients who might, for example, demand an obscure treatment with Mongolian goat serum costing £100,000 for their rare foot disorder free on the NHS.

Diabetes care is one example where there was pressure from all sides to introduce home monitoring equipment. Inverness Medical pioneered glucose monitoring strip manufacture in the UK and now glucometers are in widespread use and can be purchased without prescription. The combination of busy lives, lack of time to go for health checks and the cost of nurses' time in doing simple tests was one driver, as well as increasing demand from patients for control over their own lives and accurate information on which to base choices. At the same time compact, portable devices for testing and treatment were developed for use by ambulance paramedics, oil rigs, armed forces and astronauts, where easy access to doctors and hospitals was limited and costs and consequences of non-treatment were great. Manufacturers have understood the trends and marketed similar devices to professionals and the lay public.

Dr Bernstein was a US engineer who took charge of his own health and reversed major side effects of his diabetes. No one would publish his results and he trained to be a doctor so that he could help other diabetics who were getting worse.

Some doctors are rebelling from within. Dr Malcolm Kendrick challenges current orthodoxy about cholesterol. This video is part of a series where he presents evidence to medical colleagues:

The work of Dr Kendrick and his international colleagues has increased the number of patients resisting routine prescription of statins because of government guidelines.

Some patients are bounding up Professor Mick Marchington's stairway of empowerment from consultation, to codetermination and towards a measure of control, whilst many are standing on the bottom two steps, satisfied with information and communication.

Doctor education now includes a significant amount of time devoted to communication skills, including an element of role play assessment, to test how trainee doctors deal with patients in a range of situations.

Not all doctors or consultants are happy with the pace and type of change. Some continue to challenge patients who show evidence of knowledge or involvement with their own healthcare. As Bowen and Lawler assert, Theory X managers find it harder than their Theory Y colleagues to adapt to the pressures applied by patients. Some find it tough to work with patients who are passive and waiting for the doctor to fix everything without their active collaboration.

The spread of ambulance chasers and recourse to the law to resolve complaints has the potential to make relationships more adversarial, though some doctors claim that the more they involve patients, the fewer complaints they receive.

Managers have played their part in empowering staff and patients, but change has been introduced into the system from other parts of the supply chain and external organisations.

Clay Christensen talks here about future opportunities for disruptive innovation and starts with healthcare:

Postscript:  Here are 2 people encouraging Wikipatients

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