Flipping healthcare: an essay by Maureen Bisognano and Dan SchummersBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5852 (Published 03 October 2014) Cite this as: BMJ 2014;349:g5852
All rapid responses
‘Flipping the healthcare’ article has very little to do with medicine, or with science about improving healthcare and has all to do with vacuous catchy phrases, ‘management speak’ and useless advices. It tells us a lot about the contributors, the BMJ and filling in the available space. But don’t take my word for it. Let us read the paper carefully and try and analyse it to see if any of the insights offered or any of the advice apply to the UK or to the broader international readership.
The authors mention the book ‘Best practice’ by C Kenney, who claims to have learnt from Corning (manufacturer of glass such as Pyrex), Bell Laboratories (telephony and computer technologies) and Florida Power and Light (utility company), as well as Toyota and NASA. I am not disputing that they have learnt a lot by studying the above mentioned book or that the learning quite possibly has been an enriching experience for them. Other than the personal enrichment, it has also given them the courage to dispense their insight to others, so we can also benefit from the wellspring of this insight, no matter how irrelevant this insight may be. The fact that this book was conceived in the USA in response to the failings of the USA healthcare system and very likely is of no consequence to nations that don’t spend so massively on healthcare or don’t have the same failings does not seem to have registered.
The authors recommend ‘flipping the classroom’, a recommendation based on an example of a high school just outside Detroit. It is the same Detroit of the largest municipal bankruptcy in the US history as reported by the BBC on 21/02/2014. The experiment consists of asking students to read the material at home, and then discuss it in the classroom. The New York Times reported improved graduation rates after adoption of this method.
The authors recommend ‘flipping healthcare’. They reason that doctors should know what matters to the patient and not just try to work out what (if anything) is wrong with the patient. Evidently they are not aware, for example, that the approach above is part of the GP curriculum or that though worded differently it is in the Hippocratic Oath. This re-invention of the wheel presented here as a ‘momentous discovery’, this ‘Eureka moment’ was prompted and supported by watching the video blog of one, I repeat, one, high school student. By telling us his story in detail with the solemnity of a Sunday sermon, the authors show how little they know about the everyday interactions taking place in thousands of surgeries in the UK or how little they know about the standards of care in the UK.
Then there is the example of a volunteer pastor-doctor in Memphis, Tennessee, providing counselling sessions, diet and exercise advice to parishioners.
There is an example of community nursing care; very similar to what is the current community nursing care in the UK.
In dispensing their advice the contributors are obviously oblivious to the facts. And the facts are as follows:
Healthcare spending: According to the Worldbank and WHO datasets, the USA leads the world with staggering 18% of GDP being spend on healthcare (10% in the UK)
Life expectancy: According to Worldbank and WHO datasets, the USA is rated 34th with life expectancy of 80 years (UK is 27th, with life expectancy of 81 years)
Infant mortality: USA is rated 34th again, below UK, Cuba and 31 other countries
Literacy, numeracy and science: According to PISA study 2012, the USA is 23rd, 35th, and 28th respectively, below the UK and many other countries, including Vietnam.
Reading the paper carefully the main conclusion is that it has nothing to offer the average reader and policy maker outside the USA. What has a country that spends such a great proportion of its GDP on health and yet has the same life expectancy and worse infant mortality than Cuba has to teach others? Why would any team/organisation like to hear an advice on ‘flipping healthcare’ from a team/organisation that is producing worse results that the rest of the OECD countries while spending almost twice as much on heath?
Why would any educational establishment in the UK or more broadly in the OECD need advice about ‘flipping the classroom’ based on a single experiment and from a country below in the literacy and numeracy ranking rather than from one above? Is the doctor-pastor example applicable to the UK and other countries where there are universal and comprehensive healthcare systems? Is the community nursing example applicable to countries (such as the UK) where it already exists? The authors don’t tell us what exactly was there to be learnt from Corning, Bell Labs and a utility company all these 25 years ago, and how it is applicable to healthcare in the rest of the world, but looking at the health trends in the time since, it cannot be all that much or all that important, otherwise the US would not have the results as it has, as shown above. The authors probably have no insight into the fact that their advice is of no use to anyone outside the US, otherwise they would not have offered it. Were they cognisant, they would probably seek advice.
Why would the BMJ publish such paper? The conclusion must be that it is firmly on the road of transforming itself into a medical tabloid. The paper is commissioned and not peer reviewed. It is of no value to the average British reader or I suspect to many international readers. It has catchy phrases (sage on the stage, guide on the side), predictable clichéd graphics (back flip) on the front cover and inside, it is based on no serious research, and is written in the style of the airport staples like ‘7 Habits of Highly Effective People’. And yet it occupies three pages and the front page, which is more than the three pages of space allocated to research papers. The fact that the paper ‘Flipping Healthcare’ is not just published, but is given more space than research, tells us how shallow the BMJ has become, how irrelevant are some of articles published in the BMJ, the difficulties the BMJ is experiencing in attracting serious research or review papers and how low the standard of its Editor and its Editorial Board are.
Competing interests: No competing interests
We write with reference to the well presented article Flipping healthcare: an essay by Maureen Bisognano and Dan Schummers of 03 October 2014. It is very timely and is fully supported by our experience. With the publication of the Wanless report, we too realised that the NHS was becoming more financially challenged and that a new approach was needed, given that more than 70% of the NHS budget is spent on managing long term conditions. This represented an opportunity to see whether we could use an evidence based patient centred shared decision making approach  the objectives being to enable patients to take control of their health, share decision making and improve health outcomes.
To test this, one of us (SA), being a general practitioner, implemented care planning with his practice team. Patients with one or two LTCs came to specific care planning clinics where, having had relevant clinical assessments, patients were given an open invitation to speak about the issues affecting them - including social, health and economic, and how these impacted on their lives. Patients set their goals and actions plans, guided and coached by the clinician, using a motivational interviewing approach. Patients took a print out of their care plans home. A one year before and after analysis of service utilisation (practice visits, A+E attendances and acute admissions) costs in these patients showed a 40% reduction ( 2 ,3). We now have outcome data showing improvements in weight, blood pressure, and glycosylated haemoglobin, through lifestyle changes. This early testing of the care planning approach in UK General Practice did indeed show that ‘flipping healthcare’ works and inspired us to continue on this journey.
In attempting to persuade colleagues of the merits of the approach, it became clear that the logistic and organisational challenges involved with making this change appeared to preclude its introduction at scale across primary care. Faced with this challenge, we decided to use a digital approach to incorporate the innovation into an Internet delivered service called VitruCare(4,5). This is a scalable and integrated digital health services platform that can present different services packages as suits the patient. The LTC package enables patients, including those with multi-morbidity, to take control of their health, set goals, action plans and see real time changes in their health status while remaining connected and ‘coached’ by clinician they know and trust. We believe that an approach such as this, which has at it heart personalisation and empowerment provides a route for individuals, families and communities to engage on the scale advocated by Bissognano and Schummers.
With the current users, early evidence shows that this patient centred approach benefits those with LTCs. However, we believe that by using digital health across the spectrum of wellness, through LTCs and into the End of Life period, the cultural change in approach that the NHS desperately needs will be stimulated and can thrive. We believe that patient centred care will become the norm across the health services in just the way the authors envisage, using sophisticated personalisation tools engaging and activating patients, enabling proactive management and immediacy of care support to address patients needs and deliver improved outcomes in both health and healthcare.
 Right Care Shared Decision Making Programme (2012). Measuring shared decision making: a review of research evidence. Cambridge.
 Ali SM, et al. (2010). When Care Plans come together. Health Service Journal. Dec 2010, p 20-21.
 Ali SM, Colletta J, Pope R. (2011). QIPP and care plans revisited. Health Service Journal. May 011.
 VitruCareTM’ online service. Supporting patients with long-term conditions. TRANSFORMING PARTICIPATION IN HEALTH AND CARE. SEPTEMBER 2013. Patients and Information Directorate, NHS England. Publications Gateway Reference No. 00381
 Personalised care planning approach helps to improve patient outcomes in Bradford. Case Study, NHS Commissioning Assembly. NHS England 2014.
Competing interests: Shahid Ali , Axel Schulte, Richard Pope, Douglas Muirs are all directors of Dynamic Health Systems which created and designed VitruCare based on clinical experience and patient participation.
Many of us who work in the NHS are I suspect now tired of the exhortations to innovate for the benefit of patients. The process has become political, utterly top down & driven by central initiatives embodied in the corruption of the "Quality Improvement Programmes" or QUIPs which are, we know cuts in resources masquerading as improvements in patient care. The key mechanism operating in the NHS is - Success is Failure - because you are only allowed to change anything to save money - and if you do that effectively resource is immediately removed whilst expectations are maintained or raised.
Being patient focused & flexible was easy in the NHS & it has in the past been a joy to listen to patients & put together local programmes to improve care, but this is now impossible as we are dragooned into implementing management driven saving plans masquerading as quality initiatives. I'd love to return to flipping but in the current NHS it's forbidden - just as it is in the US where the innovative authors battle to introduce an approach that was natural to the NHS until very recently.
Competing interests: No competing interests
I approached the article "Flipping Healthcare" in anticipation of a new paradigm of medical care. As I read it I found myself increasingly confused and bemused.
What, I wondered, was the big deal? I've been a GP for the past 32 years. I and my colleagues have been practising patient-centred, community-based care since we entered general practice, together with other members of our practice team and wider teams of community nurse, physiotherapists and health visitors.
In the article it mentions that "Trevor's dreams for his healthcare are to be able to maintain a strong bond with his doctor and care tram; to express concerns or ask questions and get answers and advice".
Again, what's the big deal? I've l known many of my patients for three decades. Many of them tell me that I'm like a member of the family. They're always phoning me judging by the confetti of memo notes on my desk so I seem to be pretty accessible.
And what GP doesn't take into account the wider social context of their patients, often having a good knowledge of local networks that can help our patients?
Then I twigged. The article was penned by a couple of Americans.
Someone ought to tell them that British GPs have been turning somersaults on behalf of their patients for years.
Most of us are flipping well fed up that no one seems to understand or appreciate what we do.
Competing interests: No competing interests