My last post was a poem that really struck me. I’ve been wondering why, and I think it was because it articulates the need for help to be practical, to be real, and to have relevance and credibility for the person accessing that help. Just wanting to help, wanting to be useful, is not the full story.
What attributes would an effective link worker have? They’d have to be comfortable around people, good at connecting with professionals, community groups, officialdom and patients. They’d be able to gain trust, and then walk alongside people who may be disempowered in the face of the clinical professions, enabling communication. They’d need to be enquiring, able to find out and keep in contact with key people within organisations, to understand how to get the best from them. They would be able to understand the needs of each person that they support, and advocate for those needs to be met.
What evidence do we have that individuals need this kind of support?
We know there is a gap, data tells us that even though patients tell us they could raise questions in a consultation, in reality, this doesn’t always happen. For 10% of patients, they know they won’t ask if they don’t understand. For a further third, they think they could ask, but in reality they don’t. It is those with the least health literacy that need this support the most, otherwise realistic medicine is going to be beyond their grasp.
The new GP contract includes an aspiration for employing link workers so that every General Practice has access to a link worker, and that link worker can work with patients without need for a separate referral. It remains to be seen whether the people that need this support the most get the most access.
So, it seems to me that our link workers could be powerful allies for patients, decoding the language that is already building up around the concepts of Realistic Medicine, and keeping it basic, keeping it real, and keeping the patient at the heart of our consultations.
We don’t have a link worker identified in our area yet, but she or he will be on the project team.
If you type patients, quality and care into google, the results suggest that this is something that we do for and to patients. Discussions about change agents take me to pages about how to engage clinicians within the healthcare system, but nothing directly about patients as systematic change agents.
I want to flip this on it’s head, and inspire patients to shape the health service, seeking provision that meets what matters to them. A 180 degree revolution. Clearly, there needs to be some strategy, some oversight from health care providers, so that those with greatest need don’t lose out to those with the strongest lobby. Both parties are required to create the service.
The current term for this process is co-production. On a personal level, working as a GP, this is our bread-and-butter. An effective consultation supports the patient with diagnosis, providing information, management choices, and opportunities to meet again to discuss progress.
While I was looking for articles about patients as change agents, I came across the concept of the Patient Activation Measure, a tool to assess how ready patients were to engage in these discussions. The tool is used on an individual, case-by-case level, where the doctor-patient relationship and the problem to be managed is the scope of the co-production. How could we lift this to a more strategic level? Could we use the Patient Activation Measure to see how successful systemic change is in increasing the number of patients able to use the tools of realistic medicine, able to develop that agenda with the clinicians they meet?
As a GP partner in Scotland, I am responsible for ensuring that our practice systematically provides safe appropriate patient-centred care. We provide opportunities for patients to feed back to us about their experience of healthcare, and give us suggestions about improvements. These tend to be about small things – how comfortable our seating is, whether we should have Radio 2 or another station in the waiting area.
Nationally, Care Opinion collects patient feedback, enables organisations to respond and reply, as well as being searchable. But this doesn’t of itself, change the relationship between clinicians and the public. Much of the positive feedback includes stories about care where the principles of Realistic Medicine has been at the heart of care. Within this movement, I feel I am getting closer to system-wide patient-led quality improvement.
The place where I feel this project really sits is as part of the House of Care. I seem to be trying to create an environment in which the left-hand wall is nurtured. Imagine a house which has, at it’s centre, conversations about care, support, realistic medicine. The foundation and floor is the social context, all of the sources of support in a community. The roof, sheltering this all, is the system and processes that bring the patient and clinician together. The conversation has on one side, individuals ready to engage in a therapeutic dialogue, and on the other, clinicians who are committed to partnership working with patients.
So far, most of the Realistic Medicine discussions that I have been involved in have focused on the clinicians, the ‘right-hand wall’, and on the roof. However, we could possibly be talking only to each other, unless we have individuals and carers that are speaking the same language, individuals and carers who can start these conversations spontaneously.
This model allows for work at local, regional and national scale. The British Heart Foundation has just published a report on a three-year project that used the House of Care Model in five health communities. The report describes how patients were involved in championing this approach, how important an enabling infrastructure is, how to flex the model to fit local need, and the importance of culture before paperwork.
Today I was going to meet up with Carmen Morrison from the Western Isles branch of the Scottish Health Council. She was also planning to get to Barra for a meeting, and because of the Autumnal Gales, the meeting didn’t happen – the Sound of Barra is not very nice in a storm.
Carmen was involved in drafting the SHC’s report on Realistic Medicine and has a lot of experience when it comes to involving the public. I shall have to pick a day when it is not stormy for our next planned meeting.
I think I have been putting off writing this particular post: I know what realistic medicine means to me, but it is a protean concept. I can add all sorts of bright ideas into the mix, or understand it differently depending on my perspective. Putting it down on paper feels like pinning down a butterfly. The infographic below sums up some of the key concepts. First off, I should tell you my back-ground.
Most of my recent career as a General Practitioner has been about practicing evidence-based medicine. This is medicine based on what research tells us works best for particular conditions. The 2004 GP contract was heavily invested in ensuring that primary care was based on evidence; GPs were awarded points for meeting targets of good quality, and points became financial prizes. For many long-term conditions, a recipe of pills, a suite of targets were created, and like the bright, competitive people we are, we raced to be the best. For some of our patients, this will have improved their health.
But people are individuals, and not everyone benefits from every intervention. We’ve all had that patient who has struggled, brought low by the burden of their ill-health, and their worries about our targets. Each one of us will be able to bring to mind the cancer patient who has gone for the fourth-line treatment, when in our hearts, we want them to understand that comfort, dignity, and spending time with family, may be more realistic than potentially harmful, wasteful treatment, chasing false hope.
And there is that word: realistic. This is not about disregarding the guidelines. It is about remembering that we are treating people, trying to achieve the best outcome for individuals.
So, is realistic medicine about what is achievable? Or must it include what is desirable for the individual? Who decides where the balance is? To be able to provide the best support to a patient who is deciding between many options, we need to create a bond of trust, where all the relevant facts are known, the variables balanced, the good and not so good possible outcomes evaluated, the risks evaluated in a way that is relevant to the patient. The decisions are a joint responsibility, and we need to be clear, to be realistic about what treatments can achieve. Realistic Medicine aims to be holistic, to put the patient at the heart of decision-making about their care.
Tied up in our ideas of realistic medicine is the concept of unrealistic expectations of what can be achieved. What is unrealistic? And where is the harm? There is harm in over-treating diabetes in older type 2 diabetics, quite clear-cut. There is harm in over-treatment when unrealistic hope for a cure is not openly discussed. There is harm in wasting resources on treatments that have little value to the patient, or undertaking unnecessary tests that produce anxiety about results.
Growing with the concept of Realistic Medicine is the concept of value. Value brings with it the sound of money. This is not about cutting costs, though. This is about avoiding waste, about providing the best we can with the resources we have. In many cases, redesigning services releases capacity for much more appropriate care. In others, the care that is given is more valued for being personalised and appropriate.This can be a realistic approach to the use of our resources, our time, our clinicians.
Values are also about what we hold dear ourselves, about what we aspire to be as clinicians; honest and trustworthy, kind and compassionate, bold and courageous. We can advocate for a fairer health-care system that delivers care that meets the needs of the population, that adds value through better processes. We can seek innovation and improvement, better leadership, a supportive and empathic workforce culture.
While I was thinking of all of this, I had an epiphany, that this is not just about clinicians, about the clinical workforce and the NHS. This is about everyone. To have these expectations about how we work, we need a common language and understanding, not just between colleagues, but in all our conversations. Patients move through the NHS, spreading their expectations across departments, wards, and amongst their families and society. They can spread ideas through networks, infiltrate clinics and inspire new ways of working, if we empower them. That is a big ask – data shows that while over 90% of people say they are comfortable about asking clinicians about their treatment, only a half to two thirds have actually done this at all.
Nothing ventured, nothing gained. If I can bring the values of realistic medicine to a small practice population, empower people before they become patients, and coach them into getting the best out of their clinical encounters, we can contribute to this cultural shift to Realistic Medicine.
Next up – the Scottish Health Council – working with the general public.
I’m still pondering on who should be involved in this adventure, what exactly we are trying to achieve, and how. In the meantime, every day, something happens that reveals a new dimension, new ideas to try and new resources to explore.
Before I start changing everything, I thought I should do an inventory of what we do in our practice to support patients to be ready for a dialogue about their choices. Here is my photo-inventory.
Signposting cards. I have used these for a while, and then recruited them into a project to reduce the time patients wait in the surgery for their appointment. I give them to patients to look things up after the consultation. On the back, there is space for recording the next appointment. I could add the ‘five questions’.
Pre-consultation leaflets: part of the same project was to see if patients could be supported to make the most of their appointment. This seemed a brilliant idea, but patients are only be persuaded to use the forms if they were pressed upon them by the admin staff. The posters in the waiting room are still there, and the forms are at reception.
We have also tried to direct people to contact the right person for queries about referrals, appointments and investigations, and to get the best from their hospital appointments. We should really do a proper interface project, but most of the consultants visit from out-of-the area, so that hasn’t taken off yet. However, the poster already has the ‘five questions’.
We have also supported our practice population to attend workshops run by the Scottish Health Council to empower them to speak up about what matters.
So, for the quick look round the surgery, we have some solid foundations. We also have a patient participation group facebook page and a practice website.
I strongly believe that people,our patients, are a under-used resource for revolutionising health care. Enpowering them to spread the concepts of Realistic Medicine, they will spread through our health and care systems, asking for change, reaching the cynics as well as the enthusiasts.
The idea for this project came from attending a workshop on values and values-based improvement in health care, how to ensure that the care we offer is of genuine worth to the person who receives it. The workshop was lead by the Realistic Medicine team, and during the day, each of us was challenged to develop an idea for a Value Improvement project.
My project is about engaging the public with realistic medicine. I kept all my notes from the workshop, and now I am making a start. I have a list:
Start a blog (I can tick that one off, but now I should keep adding)
I should refine the ‘pitch’ – so I can tell people about this and generate excitement. I also should use this pitch in a project charter.
What am I doing already that I can recruit into this project? I have signposting cards for decision support, I could add the five questions. I could use our PPG facebook page and practice web-site. I could use the health promotion board for a month. Learning in the loo with QR codes?
What support from the public would be easy? Am paipear, An Radio spring to mind.
I should pace myself, ensure that I try one thing at a time.
How will I create something that can be spread?
If anyone wants to add to this list, please go ahead.
I am a GP in Benbecula, in the Outer Hebrides, and I have been working here for over 25 years. I’ve been discussing the Chief Medical Officer’s Annual Reports with colleagues, and I’m very enthusiastic about the theme she is pursuing.
The main theme is ‘Realistic Medicine’ – and I’m not finding it easy to describe this in a short blog paragraph. However, if we are all to realise and practice Realistic Medicine, then patients may well be the people who, as they move through the NHS, ask the right questions and work with staff to create an NHS with realistic goals and values.
My idea is to see if we can bring the concepts of Realistic Medicine to our small population, and empower people to spread the concepts along their clinical journeys. And if it works here, it could work in other places as well.
The actual reports are listed here. In my next post, I’m going to try and tell you what Realistic Medicine means to me.
Hebridean Adventures in Realistic Medicine 