Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Salami slicing of patients
- Peter G Davies (22 March 2008)
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Is this the right question?
- Niyi Awofeso (25 March 2008)
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Neglect may lead to negligence
- Peter Gooderham (25 March 2008)
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Unneccesary and morale-sapping
- David Evan Morris (28 March 2008)
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Patient presentation may be important too
- Nigel C Smeeton (29 March 2008)
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Musculo-skeletal problems in general practice
- Gabriel Symonds (9 April 2008)
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Peter G Davies, GP Principal Keighley Road Surgery, Illingworth, Halifax. HX2 9LL
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Anwar, Gogi and Anjum (1) capture a key dynamic in the current NHS. As a GP I am delighted to see them doing this, and to see hospital colleagues willing to challenge the current orthodoxy and referral politics. Doctors used to be criticised for talking about "the appendix in bed 1." The criticism was of the reduction of a human being to a single symptom or condition. Yet at a time when the NHS is talking ever more about "patient centeredness" (2) it adopts payments systems that reduce patients who have many problems and illnesses, to "the patient with a right shoulder problem" The management of Practice Based Commissioning and Payment by Results adds, "You only wanted the right shoulder looked at, that's all we'll pay for, and all you are allowed to deal with." It leads to the absurdity in hospital clinics well captured by the authors. In primary care it leads to referrals that go, “Thanks for dealing with his left knee. Please will you next sort his right knee out.” The attempt by health economists and management to reduce medical care of human beings to bite sized chunks that be can be completed, counted and billed will lead to some odd consequences. At a time when doctors are moving away from seeing all illness as acute finite problems, and towards the appreciation of complexity (3), continuity and co- morbidity (4) of patients we have a management system laid across us that goes back to the old model of fixed, finite events in otherwise normal people. To answer the authors’ question, “Do we neglect patients with multiple health problems?” the answer is that individual doctors do their best not to, but the system tries its best to deny the existence of complexity and co-morbidity. The mismatch between what payment systems provide, and what patients need, will become obvious in time. Ref 1.Rahij Anwar, Nitish Gogi, and Syed Neshat Anjum Do we neglect patients with multiple health problems? BMJ 2008; 336: 670 [Full text] 2. Davies. P (2007) Patient Centredness Journal of Epidemiology and Community Health 61:39 3 Tim Wilson, Tim Holt, and Trisha Greenhalgh Complexity science: Complexity and clinical care BMJ 2001; 323: 685-688 [Full text] 4 Wright N, Smeeth L, Heath I. Moving beyond single and dual diagnosis in general practice. BMJ 2003;326: 512-4. (8 March.)[Free Full Text] Competing interests: GP whose practice receives income via a directed enhanced service (DES) for Practice Based Commissioning.(PBC) |
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Niyi Awofeso, A/Prof. School of Public Health, University of New South Wales, Australia
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Anwar, Goji and Anjum discuss the likely adverse impact of the NHS “one way healthcare commissioning” on patients with co-morbid conditions1, but I’m not convinced they are asking the right question. “All things being equal”, it is obvious that medical professionals should not ignore patients with multiple health problems. However, all things are hardly equal. Rich patients with multiple health problems can easily access quality health care, so they should not be factored into this critique. If the NHS had limitless budgets, all patients with multiple health problems will have good prospects of receiving holistic care, but this is not the reality. Thus, the real question should be; “can health systems like the NHS afford to provide quality care for indigent patients with multiple health problems?” The answer depends on how we define affordability, quality care, and indigent patients. Co-morbid health conditions like mental illness and substance abuse tend to exert a synergistic adverse effect on patients2. Diabetes and many chronic diseases facilitate development of associated diseases which increase the cost of managing the primary conditions two-to-three-fold.3 Given finite and scarce health resources, a tension will eventually emerge between quality and coverage of health services if all patients with multiple health problems are provided with tax-payer-funded holistic care. Quality of health care may be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.4 Despite intensive human and financial resources, the desired health outcomes that is achievable from with most co-morbid conditions will still fall short of what is commonly regarded as “optimal health status”. The definition of ‘indigent patients’ relate in large part to the cost of health services required. However, there is a cohort of patients for whom enforced poverty is part of punishment – prisoners. Prisoners have disproportionate healthcare needs, most of which the state has to fund because they are, in most cases, legally poor. Experience from prison services, particularly in the United States which does not have a universal healthcare system, indicate that not only is the state unable to afford to provide free quality health care to most prisoners, access to such health services is deliberately encumbered by administrative, health system, and financial disincentives.5 As the British NHS becomes less generous due to fiscal constraints, the blank cheques for health care provision regardless of cost will gradually become a thing of the past. The medical profession needs to adapt to these fiscal realities. A greater focus on implementing effective and sustainable public health interventions will help to reduce the prevalence of multiple health conditions and minimise cost. References 1) Anwar R, Goji N, Anjum SN. Do we neglect patients with multiple health problems? BMJ 2008; 336: 670 2) ADCA. The Effective Management of People with Dual Diagnosis (Mental Health/Drug and Alcohol Problems). Alcohol and other Drugs Council of Australia, Canberra, 2000. 3) Norlund, J. Apelqvist, P.-O. Bitzén, P. Nyberg, B. Scherstén (2001) Cost of illness of adult diabetes mellitus underestimated if comorbidity is not considered. Journal of Internal Medicine 250 (1) , 57–65. 4) Mainz J. Defining and classifying clinical indicatyors for quality improvement. International journal of quality in health care, 2005; 15: 525-530. 5) Awofeso N. Prisoner healthcare co-payment policy: a cost-cutting measure that might threaten inmates’ health. Applied Health Economics and Health Policy, 2005; 4: 159-164. Competing interests: None declared |
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Peter Gooderham, Tutor Cardiff Law School
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Anwar et al are to be congratulated on highlighting a significant problem (1). It seems that the NHS is increasingly operating a policy of NOT addresssing patients' health needs. Rather it seeks to maximise income into the secondary care sector by fragmenting pathology into separate financially-based units. This should be addressed promptly by those commissioning secondary care services. One factor which may concentrate minds is that introducing extra steps into clinical management may increase the risk of error and delay. Both of these may lead to breach of a duty of care. If injury results, then the NHS will face upward pressure to its bill for clinical negligence. It is to be hoped that enlightened risk management and clinical governance policies will lead to a restoration of clinical good sense. (1)Rahij Anwar, Nitish Gogi, and Syed Neshat Anjum Do we neglect patients with multiple health problems? BMJ 2008; 336: 670 Competing interests: None declared |
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David Evan Morris, General practittioner St Mark's Dee View Surgery, Connah's Quay, Flintshire CH5 4AD
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Thank you, thank you, thank you! Anwar, Gogi and Anjum have done us all great service by drawing attention to this tiresome and tiring practice. As an NHS GP I have far too often recently had consultations just as they describe - wasteful of my time and of the patient's, simply in order to generate "a letter [from] her GP ... for a fresh referral so that this new problem could continue to be managed.." I do not wish to inconvenience my patient, and so I produce the new referral. (It is simple enough, and short enough: "Here is my request, at your request, for you to continue to treat my patient in the ways that you already know about...") But each such consultation takes time and effort that could have been used more productively (and this at a time when the english Health Minister has resorted to compulsion over access issues, on the premise of patients needing more GP consultations); and each such encounter reduces my enthusiasm, and that of my patients, for the great ideal of the NHS. (A further annoyance occurs when the letter from my hospital colleague, explaining the proposed work, takes longer to reach me than does the patient - but that's an old story, and one for a seperate article!) Yes, there was under the old system the possibility of occasional inappropriate referral onwards within secondary care. ("Dear GP, I have seen and sorted this teenager with complex cardiac problems. She also has mild acne, and so I have asked our consultant dermatologist to give her an appointment...") But this was not a large problem. May I suggest a way forward? The tension here is between the need of the bean-counters to know when a "new" matter is being dealt with, and the wish of patients and clinicians for care to be as seamless as possible. Could then the financial requirement of the Trust be met more simply than by this back-and-forth delay? I suggest that the hospital doctor in the position of Anwar et al, realising that he proposes to deal with a "new" matter, could simply flag that in the consultation. (This could be with a click of his computer, or a brief form from the paper-stock on his desk). The presumption should be that the new work is appropriate and relevant - the clinician's decision will have been made, after all, for valid and honest reasons and in the light of the specialist clinical knowledge for which the hospital doctor is employed and for which we have made the referral. The process would then be invisible to the patient, and of minimal note to both GP and hospital doctor. And the hospital administrators would still have a simple record of these "new" problems. They can adjust their contracts appropriately (for the payment which is their legitimate concern); and they can allow clinical audit to detect and deal with the small proportion of cases where the extra work may be deemed less appropriate. Problem solved? Time for the next patient, please... Competing interests: The detail of this NHS policy relates to the NHS in England; I am a GP in Wales, but one of the district general hospitals to which I refer frequently is in England, giving me experience of this |
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Nigel C Smeeton, Lecturer in medical statistics King's College London, Division of Health and Social Care Research, London SE1 3QD
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Anwar, Gogi and Anjum (1) rightly point out that weaknesses in the health care system can disadvantage the patient with multiple health problems. However, there is evidence that the way in which a patient presents might influence whether a particular problem is seen as a priority, a secondary issue or overlooked altogether. In a study of a videotaped general practice consultation of a male patient with physical, emotional and social problems 27 GPs were asked to give a diagnosis in their own words (2). The patient's medical records revealed deteriorating cardiac and pulmonary disease over the previous eight years. However, the patient presented in an angry and distressed manner. As a consequence, most of the GPs picked up on the psychological issues but many failed to note the patient's heart problems. References. 1 Anwar R, Gogi N, Anjum SN. Do we neglect patients with multiple health problems? BMJ 2008; 336: 670. 2. Jenkins R, Smeeton N, Marinker M, Shepherd M. A study of the classification of mental ill-health in general practice. Psychological Medicine 1985; 15: 403-9. Competing interests: None declared |
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Gabriel Symonds, General Practitioner Tokyo
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Perhaps the difficulty of multiple referrals to specialists would be reduced if Drs Anwar, Gogi, and Nanjum had a little more confidence in their abilities to treat shoulder problems in general practice. It seems one of the authors was able to diagnose a patient with a disorder of the rotator cuff which he reasonably treated with a local steroid injection. But why did he think that relief would only be temporary? Perhaps this reflects some diagnostic confusion since he seems to believe that, as the patient had “a rotator cuff disease”, there is more than one “disease” of the rotator cuff. And what is “rotator cuff disease”, anyway? If the patient had a disorder of the rotator cuff, why was MRI imaging “required”? And what would be the point of an MRI unless one thought the patient would be likely to need surgery for definitive treatment? Further, it seems the patient mentioned was initially referred because of a tennis elbow. Why could this also not have been treated by the general practitioner? Local steroid injections for tennis elbow and shoulder disorders are eminently suitable techniques for primary care doctors to carry out. All that is needed is to learn when and how to do them. Then, gratifying results can regularly be obtained, which is much more cost- and time- efficient than referring patients with these common disorders to specialists. Competing interests: None declared |
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