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Rapid Responses: Rapid Responses published:
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Patient-centred at a price
- Peter A West (14 February 2009)
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Really Better by Design?
- Jenny R Jessop (14 February 2009)
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A different kind of upheaval is needed
- Joe D Symonds (17 February 2009)
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Becoming patient-centred means changing our minds
- Danilo di Diodoro (24 February 2009)
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Unrealistic expectations
- Sophia C Nelson (28 February 2009)
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Ginny Jones - alternative scenarios
- G J Forbes (6 March 2009)
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Peter A West, Senior Research Associate YHEC, University of York
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The focus in this article on making patients the centre of the NHS is admirable and some of the suggestions potentially valuable. However, we should not overlook the potential cost of more rapid access to services. Queueing models show how rapidly costs rise with the shortening of the queue. To see a dermatologist in two days, probably the norm in some parts of Europe, means having a lot more dermatologists who either cost more or get paid less - either way they have to be less busy to make sure there will always be free slots at short notice. In addition, while we might all like to arrange our mortgage, open a bank account, deal with different government departments or have some work meetings in the evenings and at weekends, in the end the result of greater convenience for all would mean many more people working unsocial hours, or less convenience for many. Part of the issue here is that the patient is depicted as a high-powered executive of some kind, whose work is clearly so important that only a cancer scare can displace it! There will always be circumstances where someone cannot attend a meeting and those working in many other jobs will have colleagues around to take over the work. How many of us really begrudge our colleagues, our postman, our builder time off to go to see a doctor? This does not mean I do not see a case for more convenient appointments or a chance for a longer discussion with the doctor. But perhaps we also need to put the importance of work in proportion and consider that actually our health might just be worth taking off some time to check it, particularly if the cost of a much more accessible system will be much higher. We certainly need to know the costs of the alternatives before we vote for a system where a significant proportion of the outpatient capacity is kept free in case of a late surge in referrals (which could be a consequence of the access proposals in this article). I speak as someone who has just had three outpatient appointments, one for a diagnostic scan on a Saturday morning, all involving a 15-30 minute wait when I got there. I took a book and managed to get through! Competing interests: The author is a health economist who works on a wide range of evaluations and projects for the NHS, other public sector bodies and the private sector, including pharmaceutical companies. He is not working currently on patient pathway improvements. |
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Jenny R Jessop, Consultant in Pain Management Montagu Hospital, Mexborough, S64 0AZ
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I am absolutely committed to the concept of patient centred care, but Rogers and colleagues seem rather more committed to pared down care for middle class professionals. I was particularly upset at the idea of breaking bad news over the phone. Without being able to see the patient, how can you possibly tell how she is reacting? If she breaks down, how will you comfort her? A conversation along the lines of 'you've got cancer and here's a website' is about as low as it gets. Of course we should aim to provide flexible and prompt access to care, but do we really think that a patient who knows they have a possible malignancy will perceive a business meeting as more important than getting a diagnosis sorted out? And how does this work for the less well educated who won't know where to start with reading up on a website but won't like to say so? NHS Direct is as far down the road as we should contemplate going with Call Centre medicine. Face to face consultation is the Gold Standard for good reasons, and we should have the guts to at least continue breaking bad news face to face. Anything else is cheapskate and disproportionately disadvantages more vulnerable patients. 1. Rogers H, Maher L, Plsek P. Better by design: using simple rules to improve access to secondary care. BMJ 2008;337:a2321 Competing interests: None declared |
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Joe D Symonds, FY1 Trainee Borders General Hospital, TD69BH
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I agree with Rogers and Colleagues that the NHS badly needs to be more patient-centred. However I'm not sure that their proposed pathway, using the example of Ginny - the investment banker with a suspicious- looking mole - would tackle any of our problems. To make information and counselling on diagnosis, management and prognosis available when and where is convenient for each and every patient would mean either a)increasing the number of hours that each health professional works or b) making more health professionals party to important information about each patient's care. a) is ruled out by the European Working Time Directive, and I believe that b) would further erode continuity of care. In my experience as an FY1 I have already noted many examples where patients have suffered physically and psychologically because of a failure in continuity of care. Some may be seen by three or four different consultants within a 24 hour period, and be told contradicting information by each one. Speaking to patients I get to overwhelming impression that they would generally like to have fewer people involved in their care. And they want those who are looking after them to empathise with their concerns and belive their stories. To make the service more patient-centred an upheaveal of attitudes would be far more effective than yet another upheaval of secondary care structure. Competing interests: None declared |
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Danilo di Diodoro, chief of Knowledge Management Local Health Unit - 40124 Bologna, Italy
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This article written by Rogers and colleagues shows us the importance of changing the old-fashioned mentality of health workers and managers. It’s a very hard fight, and probably we will never accomplish it. Health services should naturally be patient-centred, but that’s not the reality. I’m convinced that’s not a matter of financial resources, but a matter of priority. It’s plain that at the moment it’s not a priority to built health services that really meet the needs of citizens and patients. If this were the priority it would be enough to switch Health Service’s investments on it. Competing interests: None declared |
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Sophia C Nelson, GP Wirral, CH60 7SG
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I read the article by Rogers et al with some interest. Whilst I am deepy committed to improving the patient journey whenever I can, I feel their proposals are unrealistic. Firstly, whilst I agree that waiting 45 minutes for an appointment is not favourable, at the end of the day, Ginny Jones is seen and treated for her malignant melanoma within 13days. The consultation style of the doctor is poor and perhaps the issues around this need to be addressed (for example why is he so stretched, does he need consultation-style training?). In the second 'improved' scenario, there are suggestions which make me feel very uncomfortable. Firstly, she is referred to dermatology clinic by a nurse, who has not seen her mole. Ginny has compared her mole to pictures on a website and described this to the practice nurse who then refers he. I fear that this kind of practice would quickly lead to the urgent cancer clinics in secondary care being swamped. Secondly, I too feel uneasy at the amount of information being given by telephone. There is certainly a place for telephone consulting in today's NHS, but surely not to tell someone they have skin cancer?! I feel the proposals are too idealistic, and while we should aim high with our efforts to make the patient journey smooth and as pleasant as possible, we also need to remain realistic. Competing interests: None declared |
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G J Forbes, Salaried GP Leadgate Surgery, Leadgate, Co. Durham, DH8 6DP
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I read Rogers et al. suggestions for changes in access to secondary care in NHS with some concern. I propose two alternative, equally plausible scenarios. Ginny Jones: a patient’s story in the traditional system On a Monday morning, Ginny Jones (age 34, separated with one child, works in London as a food handler) shows a co-worker a large mole on her hand. After hearing how her colleague’s aunt died of skin cancer, Ginny is shaken and ring the general practitioner’s surgery in her village. The receptionist is friendly and concerned, and tells Ginny that she can come in any day, but politely notes that the surgery closes at 5:30 pm Monday, Wednesday and Friday and at 7 pm Tuesday and Thursday. Ginny finds it hard to concentrate – more stories from well intentioned friends do not help. On Tuesday evening she sees her usual GP. He knows her well as he has seen her on frequent occasions in the six months since she separated from her long term partner ( the father of her 12 year old daughter, Alice). Ginny and Alice have presented frequently with minor illnesses and Alice has had a significant amount of time off school. The GP recognises the skin lesion as an entirely benign problem and reassures Ginny but seeing how anxious she appears he takes a little longer to talk to her. It transpires that she has been drinking most evenings and isn’t sleeping. She is under financial pressure and is struggling with the mortgage now that her partner has gone. She is having to take on more shifts at work. She is also worried about Alice especially the frequent bouts of abdominal pain that keep her away from school. The GP empathises with the amount of stress that she is under and they discuss the dangers of her increased alcohol consumption. He suggests she might benefit from contacting the citizen’s advice bureau to discuss her debts and to try and establish her rights with respect to maintenance payments from her partner. He offers her an appointment with the practice counsellor who would have more time to go into things in greater detail. He offers her an appointment in a few weeks to see how things are going. He asks her bring Alice to the surgery again so they can discuss her abdominal pain. The GP discusses the case with the primary health care team. None of the other members have any particular concerns about the case, in particular the school health advisor does not have any safeguarding concerns except for the frequent absences from school. Ginny sees her GP two weeks later and notes that she has been sleeping better since she reduced her alcohol consumption and the CAB were very helpful. Alice seems a little improved and whilst she is still under a lot of stress she does not wish to consider counselling at this time. Note: cycle time to diagnosis of benign skin lesion, harmful alcohol use, significant mental health problem and potential child safeguarding issue is 2 days. Ginny Jones: a patient’s story in the proposed new system On a Monday morning, Ginny Jones (age 34, separated with one child, works in London as a food handler) shows a co-worker a large mole on her hand. After hearing how her colleague’s aunt died of skin cancer, Ginny is shaken and ring the general practitioner’s surgery in her village. The receptionist is friendly and concerned, and tells Ginny that she can come in any day, but politely notes that the surgery closes at 5:30 pm Monday, Wednesday and Friday and at 7 pm Tuesday and Thursday. She also suggests that Ginny could do some self-assessment on the NHS Direct website, with assistance from one of the practice nurses if she wishes. Ginny sets up a telephone appointment with a practice nurse later that day. Ginny feels that her mole looks like some of the pictures on the website. The practice nurse is comforting and offers to book Ginny directly into the dermatology clinic. Although slots are available tomorrow, Ginny is working several extra shifts at the moment to make up the shortfall on her mortgage since her partner left, so she selects a convenient time on Thursday evening. Ginny finds it hard to concentrate – more stories from well intentioned friends do not help. She continues to look at the website and others which link her to patient experience fora where she reads stories of people dying from metastatic melanoma. Her anxiety levels rise. She has been drinking more heavily since her partner left to relax at night and now she drinks more to try and put the horrific stories she has read to the back of her mind. Ginny turns up early for her booking in the dermatology clinic, and is seen about 5 minutes after her appointment time: the nurse notes this delay and apologises. The dermatologist recognises the mole as entirely benign but seeing Ginny’s incredibly anxious state and, hearing her tell of the horrific stories she has heard on the internet, he offers to remove it. She gratefully accepts. The procedure is performed quickly and efficiently and seeing she is a food handler, the dermatologist gives Ginny a sick note for two weeks, explaining that this new system means she won’t have to go back to your GP just for a sick note. He explains that the sample will be sent for routine testing and the result should be with her in three days. He provides her with the clinic’s email address, where she can send questions when they occur to her. He clarifies that he may not always be able to personally answer all emails, but that someone from the practice team will always respond. "And, of course, there is always the old-fashioned way of ringing us up," he mentions. On Monday, the dermatologist’s secretary emails Ginny that her test results are ready. She offers Ginny the options of booking a telephone conversation with the dermatologist, coming in for a visit, or giving permission for someone from the team to call. Ginny immediately phones the clinic and asks for a telephone consultation later that morning. The doctor rings at the appointed time and explains that the microscope tests confirmed that it was a completely harmless spot and no further action is needed. Ginny is relieved for a short while but her daughter Alice is very concerned about her mother and has a flare of her abdominal pains. Ginny keeps Alice off school and finds her daughter’s presence at home reassuring. The wound on her hand heals well but the constant site of the scar reminds her of the stories and images that she found on the internet. She continues to drink more heavily and at the end of the two week period she realises she cannot go back to work. She visits her GP and obtains an extension of her sick note for a further two weeks, saying that her employers have said they do not want her back until the wound is completely healed. A fortnight later she returns to her GP and begins to discuss her anxieties. Her GP quickly discovers the extent to which alcohol is compounding her mental health problem and offers a referral to the community alcohol service and the practice counsellor. The primary health care team discuss Ginny at their weekly meeting and the issue of Alice’s non-attendance at school and abdominal pain is discussed. The school health advisors make plans to contact Alice directly where they discover Alice has taken a significant caring role, doing the household shopping and cleaning as her mother isn’t managing to do this. Ginny doesn’t return to work for over 6 months and Alice continues to have frequent school absences. Note: cycle time to diagnosis of a benign skin lesion is 4 days. Cycle time to identification of harmful alcohol use, significant mental health problem and child safeguarding issues 4-5 weeks. Competing interests: None declared |
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