New design rules for driving innovation in access to secondary care in the NHS
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2321 (Published 15 December 2008) Cite this as: BMJ 2008;337:a2321
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
Ginny Jones - alternative scenarios
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
Competing interests: No competing interests