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The 10 minute consultation; the unacceptable face of general practice

May 6, 2015

Martin Marshall

Professor Martin Marshall,

Lead for Improvement Science London

 

 

 

‘Perfunctory work by perfunctory men’. That’s how an eminent physician once described general practice. ‘A ridiculous claim’ cried GPs, rising to the defence of their discipline, ‘specialists just don’t understand the nature of general practice. They don’t value our ability to make quick decisions based on a deep understanding of our patients and their context, our exceptional skill at managing risk and uncertainty, of using serial consultations to optimise the effectiveness of our diagnostic and therapeutic interventions’.

GPs went even further. Not only could they deal with the presenting problem in 10 minutes, but they could also deliver the other components of the consultation models that they learnt about in their training. Like managing on-going conditions, offering advice about prevention and health education, modifying help seeing behaviours. Was there no end to their efficiency?

But it’s time GPs stopped fooling themselves. In 2015 the 10 minute consultation is an anachronism. It is damaging to patients, damaging to clinicians and damaging to the reputation of general practice as a speciality that provides holistic and patient-centred care.

If we are honest with ourselves, perhaps the short consultation that characterises general practice in the UK and in some other European countries was never really viable; it is certainly becoming less and less so. The pressure is mounting as the complexity and intensity of the consultation increases. More patients to see, more problems presented, more information sources to search, more solutions to consider and balance, more templates and forms to complete, more ideas to discuss and negotiate. Something has to give and it shouldn’t be the quality or safety of clinical care that patients receive, or the humanity that underpins that care, or the mental health of clinicians struggling to maintain a sense of achievement that they have understood and sorted out a problem. It is the travesty of the too brief encounter that must give.

Even within the constraints of the established system and the strangely modest expectations of too many patients, clinicians, managers and policy makers, there is good research evidence that time matters. For most patient groups longer consultations are associated with greater patient satisfaction, a stronger focus on health promotion and disease prevention, increased willingness to address psychological problems and fewer prescriptions. Time is a key component of the effectiveness of the clinical encounter, rushed consultations are the enemy of high quality care.

Some years ago a GP professional leader complained to the then Secretary of State about the time constraints in general practice. ‘Show me the legislation that restricts the consultation length’ the politician retorted. Some of the solutions do lie in professional hands. Some practices already offer 15 minute appointments, actively support patients to self-care, utilise triage and make more effective use of nurses, pharmacists and healthcare assistants. All of these approaches help and should be used more intensively and in a more coordinated fashion. But the solution is also a political one; we need more GPs and an aligned set of values and incentives that encourage longer consultations.

Perfunctory work done by perfunctory people? It can’t go on.

Monkey Business

November 26, 2014
Professor Martin Marshall, Lead for Improvement Science London

Professor Martin Marshall, Lead for Improvement Science London

I recently listened to a fascinating presentation at the annual conference of the Dutch Royal College of General Practitioners. The speaker was the curator of Amsterdam Zoo and an expert in chimpanzee behaviour. She’s spent most of her career observing troops of chimps and has become fascinated by their leadership behaviours. She is convinced that doctors have much to learn from their primate cousins and with respect to my profession, I’m inclined to agree.  Chimpanzee

It appears that all chimpanzee troops have a strong leader (a male I’m afraid, but read on) and this individual competes with others to remain top dog, if you don’t mind me mixing my species. They achieve this by creating alliances with others in the troop, constantly nurturing their social networks. They put a lot of time into building relationships with influential females, who then act as the emotional intelligence behind the throne, forging partnerships and heading off trouble.

The leader has occasionally to fight with other ambitious males to maintain their supremacy but as soon as they have won the fight they immediately seek reconciliation with the vanquished, and in doing so avoid repeated attacks. Leaders that fail to be conciliatory rapidly lose their dominant position. Young chimpanzees copy the leadership behaviours of their elders, preparing for the future, but they are careful never to be seen as a threat.

What do you think? Perhaps one or two lessons for NHS leaders? (avoiding the gender stereotypes, of course). Most chimpanzee groups maintain an effective and happy equilibrium most of the time. Now, there’s something for us all to aspire to.

Why the NHS needs general practice

May 27, 2014
 Martin Marshall Prof Martin Marshall, Lead, Improvement Science London

At times of crisis it’s easy to hunker down, to become inward looking. But if general practice responds defensively to the major challenges of increasing workload, reducing funding and ill-informed criticisms by the media and politicians, then matters will get worse. It is time to go on the offensive, to clarify why a vibrant general practice is essential not only to individual patients and to the communities that they operate in, but also to the very survival of the NHS. Four roles that general practice fulfils, day in and day out, are particularly important.
First, general practice is the part of the NHS where uncertainty is acknowledged and risk is managed. In contrast to hospital practice, there is a low probability of disease in patients seen in general practice. It has been estimated that more than 60 per cent of presentations in general practice cannot be explained in terms of recognised disease processes. Policy makers incorrectly interpret this as GPs being over-skilled for much of their work but in doing so they fail to understand the level of sophistication required to make judgements about when to investigate and when to reassure. If GPs referred all people with potentially dangerous symptoms and signs to hospital, the NHS would implode in weeks. Occasionally GPs get it wrong, the vast majority of times they get it spot on.

Second, general practice is the part of the NHS where the interface between professionalised care and self-care is managed. Self-care of the symptoms and signs of ill-health is infinitely more common than care provided by health professionals. Minor changes in people’s help-seeking behaviours can have a massive impact on the use of NHS resources. There are therefore practical as well as philosophical reasons for encouraging a high level of shared care and informed self-management, particularly for people with long term conditions. Promoting self-care effectively requires the deep understanding that GPs have of individual’s health beliefs and the environment that they live in, as well as technical expertise in encouraging behaviour change. GPs play an essential role if policies promoting shared and self-care are to be delivered.

Third, general practice is the place where the up-stream determinants of health are recognised and managed. The environmental and behavioural determinants of ill-health, such as poor housing, unemployment, diet, exercise and stress are widely recognised but highly resistant to remedial action. As members of the communities that they serve, GPs have a deep understanding of what needs to be done as well as having the trust of patients to lead change. General practice is public health with a personal touch.

Finally, general practice is the part of the NHS where the tensions inherent in the multi-dimensional approach to quality are handled. Hospital specialists rightly focus on the clinical effectiveness and safety of the care that they provide – this is what patients want and need when they go to hospital. But someone in the health system needs to bring a balanced view of quality, managing what are sometimes trade-offs between good clinical outcomes and waiting times, between providing safe care and the costs of minimising risk, between meeting the preferences of individuals and ensuring fairness to everyone. Taking responsibility for these trade-offs is neither easy nor popular but GPs do it effectively every day.

General practice will not be able to continue carrying out these roles without a bigger share of NHS resources, without spending more time with individual patients, and without a workforce that has a high level of self-confidence and morale. This is why the RCGP’s campaign for the future of general practice, Put Patients First, requires everyone’s active support.

 

Blog was first published on GP online on 2nd May 2014

 

 

 

 

Rethinking primary care

November 11, 2013
 Martin Marshall Prof Martin Marshall, Lead, Improvement Science London

Most people are inclined to what we might call a ‘provider bias’ when asked to describe how health care is organised and delivered. Familiar structures are embedded in our psyche – primary care, where generalist first-contact services are provided close to people’s homes; secondary care, where a wide range of specialist services are provided in general hospitals; and tertiary care, where a narrow range of services are provided in super-specialist hospitals. If the concept of ‘self-care’ gets any look-in, it is usually as an after-thought and rarely with much conviction.

But this neat world is being challenged, and not just because we are blurring the boundaries between traditional sectors. If the formal institutions making up the NHS are to survive in any form, we need to put greater emphasis on the informal systems that underpin them. At a recent seminar I heard Stewart Bell, Chief Executive of Oxford Health NHS Foundation Trust, one of the most experienced managers in the NHS and champion of things unfashionable, suggesting a radical change in terminology. How about this: Primary care is what people do for themselves to improve their health, like taking paracetamol when they have a headache or looking after their diabetes. Secondary care is what families, friends and members of the local community do for people when they are unwell, like providing a listening ear when someone is stressed, or reminding others to give up smoking and eat healthily. Tertiary care is what general practitioners, community-based nurses and other community practitioners provide for patients when they decide to utilise formal care. Quaternary care is what goes on in hospitals and quinary care is what happens in super-specialist hospitals.

Is this just playing with words? I don’t think so. Language is a product of the way that we think but also influences how we conceptualise what we see around us. It is strange that we seem to be more willing to restructure our buildings than we are to restructure our thinking but doing the latter might be more beneficial than the former. The interface between community and hospital services is important but the one between self-care and professionalised care has the potential to offer far more opportunities to improve the experiences, outcomes and value of care. This is the space in which people manage self-limiting conditions without recourse to expensive and sometimes damaging medical interventions, where people with long term conditions realise the evidence-based benefits of working as active partners with health professionals, rather than as grateful recipients of professional largess. Re-defining what we mean by ‘primary care’ puts patients first and raises the profile of self-care and shared-care in the consciousness of the health system.

The formal health system is important but in the greater scheme of things, not as important as it thinks it is. And it might have a greater impact on people’s health if it focused its considerable resources on helping people to deliver their own primary and secondary care.

Dismantling mantras

September 30, 2013
Martin Marshall Prof Martin Marshall, Lead, Improvement Science London

I’m not a GP or an academic because I like to conform, so it should come as no surprise that I can’t hear a mantra without wanting to challenge it. The quality improvement world is full of popular wisdoms, rehearsed and re-rehearsed by its enthusiastic followers. How about this one: “Data should be used for improvement, not for judgement.”

No shortage of experts in the field have differentiated between the characteristics of data used for improvement, accountability and research purposes. They tell us that data used for improvement can be ‘good enough’, that it is used to indicate rather than to reach definitive conclusions, that bias can be tolerated and that control charts allow us to attribute outcomes to interventions. In contrast, we are told that data used for accountability purposes need to be more rigorous, that it is used to reward or punish, that bias needs to be minimised. And for completeness we are told that data used for research purposes needs to be of top quality, as devoid of bias as possible and that analytical or inferential statistical tests are used to attribute outcomes to interventions. It all sounds very neat and reasonable.

But like all mantras it has a political purpose. Differentiating between improvement and judgement allows improvers to position themselves on the side of the angels. Improvement is benign, positive, enabling; accountability is malign, negative and damaging. Improvers make reasonable judgements, failure is not an option; holding people to account is unreasonable, done by people who don’t even understand the basics of common and special cause variation, never mind the intricacies of statistical probability.

Where the improvement world has come from is understandable but I don’t think that their position is sustainable. Nearly a quarter of a century after quality improvement techniques were introduced into the health sector from manufacturing industries it should be main stream but it isn’t. In most organisations only a small proportion of enthusiasts are engaged with using systematic and data-driven improvement activities. There are many reasons for this and scepticism about some claims of success that are made using poor quality data is one of them. Allowing questionable data to be used in questionable ways does not help to place an improvement philosophy and methods where they need to be – centre stage.

Anyway, it’s naive to suggest that we shouldn’t judge. I’m writing this blog on a train and the man sitting next to me is wearing a very dodgy yellow shirt. That’s a judgement. I’m sure that others in the carriage think he’s a fashion icon. And now you are making a judgement about my judgement. Judging is part of the human condition and what matters is not the judgement itself but the implications of the judgement – and the implications of using data inappropriately are significant.

Rather than service-based improvers, system managers and academics using different data, we should aim for convergence, using data as a common language in a way that allows everyone to focus on a common interest – improving value for individuals and communities.

So, we need to improve the quality of data we use for improvement so that better judgements can be made, and improve the quality of data we use for judgement, so that better improvements can be made. And no, that’s not a mantra, it’s a suggestion.

Mind the Gap

June 21, 2013
Dominique Allwood Dominique Allwood joined ISL in January 2013 as a Fellow in Improvement Science.

‘Mind the gap’ is something most Londoners hear everyday when they travel around on the busy and crowded underground. The warning is telling us to take caution when crossing between the train and platform.

I’ve recently started as a Fellow in Improvement Science at ISLondon.  I’ve had lots of people ask me about my role and about improvement science more generally. The contribution of science to improve healthcare is frequently discussed and the notion of a ‘gap’ comes up a lot in the conversations – the gap between what we know to work from academics, and what is actually put into practice by managers and clinicians in order to improve the health system.

I’ve held clinical, managerial and health services research roles and these experiences have given me some understanding of the issues and challenges we face when trying to unite the two sides of the ‘gap’. Most recently I have come from a busy job as a clinical transformation manager at an Acute Trust. It’s been challenging and thoroughly enjoyable because I have been actively involved in and leading on health system improvement. But whilst undertaking change at the front line, it is obvious that despite intentions of people wanting to do a ‘good’ job to improve health care, there is frequently a lack of focus on using evidence of improvement, looking at what is known and what works. There are very few problems in the health system that are ‘new’ but yet we often approach them as if they are. In our busy day jobs there is little focus to reflect on how we made decisions or why things were done in the way that they were.

A first glance the gap seems to be quite daunting and I’m keen to find out what lies in the ‘gap’ between what is known and what happens. I’m in a privileged position and I’ve been able to have conversations with a range of people within the Academic Health Science Centres , ISLs partner organisations. There is a huge amount of work going in that gap. It’s been fascinating to get an insight and two things struck me the most; the multi-disciplinary nature of the work occupying this gap, and secondly the spectrum on which they all lie. If there was a metaphorical bridge spanning the gap, there would be those starting the crossing from the academic side, and there are others who set off on the journey from the clinical side. My awareness of what lies in within this gap is slowly increasing. The challenge is how to make this more widely accessible and re-frame what may often be seen as an area of uncertainty.

This ‘gap’ on the tube is quite obviously a potential danger. Some gaps are an unknown chasm laying in front of us. However, sometimes gaps are a space of possibility and potential, full of opportunity, some even have a crossing that bridges either side together. My role is a new one that has been created to allow a doctor in training to develop skills and experience to work across the interface between research and service improvement and I hope that this year will allow me to develop my own and others awareness and understanding in this area and I hope to contribute practically to ‘bridging’ the gap through projects I will be undertaking. If you’d like to find out more please get in touch dominique.allwood@islondon.org

I’m a Health Service Researcher, get me out of here!

June 14, 2013
Martin Marshall Martin Marshall is Lead for Improvement Science London and Professor of Healthcare Improvement at UCL.

Science hasn’t always been as fashionable as it is today. It used to be seen as something that only pointy-headed weird people did, a bit scary to everyone else. But then along came Susan Greenfield and Brian Cox, science was popularised and stars were born. Why should actors and football players have a monopoly on fame? Science can be edgy and fun, a subject that school children look forward to with excitement rather than with dread.

So I wasn’t completely surprised to hear about the on-line resource I’m a scientist, get me out of here! http://imascientist.org.uk/ . The model will be familiar to fans of reality TV. School children go on-line during their science lesson and get to ask a panel of five real-life scientists whatever important questions they have on their minds. Like why does food go mouldy? Or can I clone my mum? Or why do the hairs on my arms stand up when I’m scared? Students submit questions which the scientists try to answer by the next day. They then have live online Facebook style chats, ask questions, learn more about what it is like to be a scientist, and let the scientists know their opinions. Questions and discussions take place over a two week period and then the voting starts. One scientist a day is evicted, perhaps because they provided the least convincing answers, or were just plain boring. After 5 days, and 5 harrowing (for the scientists) rounds, the last scientist standing wins £500 to spend on a science communication project.

Wouldn’t it be interesting if the answer to the ‘Dissemination’ section on a research grant application form said ‘We are going to play I’m a Health Service Researcher, get me out of here! with a group of managers and clinicians from our local hospital and general practices’. It would certainly make a change from ‘We will publish our findings in a highly ranked peer-reviewed scientific journal’. I can just imagine questions like how do we get our clinicians to follow guidelines? Or what are the implications of merging two hospitals? Or what impact do financial incentive have on professional motivation? The answers would be revealing and, like the school children, I doubt if your average manager would allow a Health Service Researcher to get away with answers that weren’t convincing or useful.

So there’s an idea for promoting evidence-informed service improvement. Anyone want to try it?