Hierarchy disruptors: bringing specialist knowledge from hospital to community careBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4376 (Published 28 June 2019) Cite this as: BMJ 2019;365:l4376
Imagine comprehensive community based healthcare, where more patients can receive specialist advice locally, without having to go to a hospital. Where ongoing training enables generalists to develop specialist skills. And which routinely enables hospital consultants to share their knowledge with, as well as learn from, clinicians on the ground.
Such an approach is being piloted around the world. If it works, its proponents claim it could provide a new model of care for the whole NHS. There are already 60 examples of its use in UK care, particularly in community palliative care.
The model, Project ECHO (extension for community healthcare outcomes), uses virtual meetings to share knowledge from the hospital environment with clinicians closer to patients who can’t easily reach a specialist, hopefully improving their care. Video conferencing enables training among specialist and community based clinicians who can learn from each other simultaneously.
Project ECHO was developed by the University of New Mexico Health Sciences Center, which has patented it. The non-profit venture is backed by the US government and private donors.1
So many patients, so little time
In 2003 Project ECHO’s founder, Sanjeev Arora, a hepatologist based in Albuquerque, was frustrated that he could treat so few of the 28 000 patients with hepatitis C in New Mexico. “I was seeing people dying of liver failure. People were waiting eight months for an appointment and then driving hundreds of miles each way, making 12 trips to see me,” he told The BMJ. “These were poor people. They just didn’t have the resources to make those journeys.”
He decided to share his knowledge with practitioners closer to where the need was—in the community. “I was treating just 140 people with hepatitis C a year. I needed to create new hepatologists from scratch,” he says. “I needed to teach people how to fish rather than giving them fish.”
Project ECHO has led to treatment for hepatitis C being available at several centres of excellence outside Albuquerque, and research indicates that the care is just as good as that provided by university based specialists.2 Each community site has a lead clinician (a physician, nurse practitioner, or physician assistant) and a nurse or medical assistant. Before joining the ECHO network, these sites had not treated patients with hepatitis C infection.
UK hospice movement
Online conferencing is merely a tool for what Arora describes as a “hub and spoke” approach. The hospital consultant is at the hub, connected with several locally based clinician spokes. But the learning goes both ways, he says. And patients’ voices are, to an extent, reflected in the discussions by the local clinicians who know them well, Arora says.
The model has been studied in several settings,3 and the New York Academy of Medicine has guidelines for evaluating programmes to understand how adaptations of the model affect clinician effectiveness, patient health, and healthcare use and costs.4
Funding arrangements for doctors’ time to attend ECHO sessions vary considerably, but often patients’ medical insurance is used.
When Max Watson, a palliative care specialist who works for Hospice UK, heard about Project ECHO he thought the model might meet the challenges facing the hospice movement in the UK. With people living longer, and with more complex health conditions, more care will be needed in the community, and community professionals will need more training in how to provide it, he explains.
He developed a Project ECHO programme in the hospices of Northern Ireland four years ago.5 There are now 35 Project ECHO networks in Northern Ireland and 25 more in the rest of the UK in several specialties.
In a six month pilot in a UK community palliative setting, most of 28 clinicians reported gains in learning that would have been hard to access otherwise because of geography and said that the pilot had helped them care better for patients.6
The concept interested health officials in Northern Ireland who saw it as a way to improve NHS care. One subsequent network linked 21 opticians and optometrists with a professor of ophthalmology because patients with glaucoma and macular degeneration had long waits to be seen at hospital. There are now clinics around the province.
“The big change that took place was in the professor’s mind when he realised the quality of care that was available [in the community],” says Watson. “The network has designed a better way of working, so people don’t have to travel to Belfast.”
Diverse applications worldwide
Today, more than 220 Project ECHO networks exist for more than 100 diseases in 31 countries. They are used in the care of prisoners, people with diabetes or autism, and people who take illicit drugs, for example,2 with research from many networks indicating benefit of some kind.
Clinicians’ perceptions of their skills increased after establishing an autism network in Uruguay.7 A chronic pain network in Canada may have increased clinicians’ confidence in treating patients, but downsides included the time involved and internet problems.8
Projects “needs pump priming at the beginning,” says Watson, with investment for the technology and clinicians’ time. He’s reluctant to oversell the approach and cautions that the model is not a solution in itself but about creating the right environment for solutions to emerge.
So much depends on how the people involved interact. Some networks have been more successful than others, he admits. “The first two or three meetings people often hide behind their formal titles and can be reluctant to share their knowledge. It only suits people who want to work collaboratively. But it only needs a few of such people to multiply the impact.
“For many years we have been working in silos,” he says. “Project ECHO changes the way people interact with each other. Communities of people facilitate discussion and come up with ideas no individual can.”
This could be a different way to provide an outpatient service in a community clinic or as a better way to care for a patient with dementia who is in pain, he says.
From hospitals to communities
Things are less complicated financially in a more joined up, state owned NHS. And the approach is proving attractive to overworked specialists with long waiting lists where, unlike the US, there is no potential for financial loss.
Some general practitioners in Northern Ireland are funded by the government, so they can get a locum to backfill for them while they attend an ECHO meeting, although hospital specialists do not have any such arrangement. England, Scotland, and Wales do not have backfill arrangements; attendance at an ECHO meeting is seen as part of a doctor’s education.
“It’s a revolution that we can’t stop, from hierarchies to networks of knowledge and power,” says Watson. “It’s taking place in business and parts of social care, but medicine has been slow to adopt.”
Could this approach help the NHS abolish its hierarchical structures, with hospitals being the font of all knowledge, to become shared, community based networks?
“We want to shift care into the community. We’ve had so many attempts in the NHS to do it, but they’ve all failed because the hospitals say: ‘We are not going to give up anything because we are specialists doing really valuable stuff.’
“Project ECHO provides a way where hospitals doing fantastic stuff can also help communities to do fantastic stuff, while learning about what they need to do together. All that, without throwing stones at each other, and in a safe, facilitated environment.”
How a Project ECHO conference call works
I joined a network conference in Northern Ireland discussing the problems that GPs face in diagnosing ear, nose, and throat cancers. Online were 13 doctors, from consultants with expertise in ear, nose, and throat cancers to GPs who make referrals.
After introductions, the 90 minute session began with a presentation from one of the consultants on the red flags that should prompt GPs to refer urgently. The GPs didn’t want to miss a possible cancer, but unnecessary referrals could clog up clinics and cause delays.
In a question and answer session, GPs said that often when they “fast tracked” cases to hospital, staff initially downgraded the urgency only to reverse that decision later. But the GPs weren’t told this. The consultants in the call pledged to investigate.
They discussed specific cases, and one consultant outlined the complexity of diagnosing some head and neck cancers from imaging. There was a strong sense of learning from one another, voicing concerns and listening, and finding solutions to problems in an open and collaborative way.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.