Depression, the inside story

Anyone interested in how our system within our own lifetimes treated people should read this article. It is harrowing. Unfortunately I think mental illness is still seen as a weakness, "just snap out of it, for gods sake" is often the response. I am aware of employers who have failed in their statutory responsibility to ensure those with mental illness receive the same entitlements and protections afforded to every employee. We are not as civilized as we think.
A quote from the psychiatrist who treated the patient:

"Our patients are our best teachers. Jackie has taught me a huge amount about depression: what it feels like, the impact on sufferers’ and their family, and what does and doesn’t help.I have seen the toll taken by this ubiquitous disease, no less devastating in its impact than other chronic conditions. Jackie, an able and enthusiastic student, could barely finish her course at University, her employment prospects have been blighted, her social life restricted, and her capacity for pleasure and fulfilment curtailed. At their worst psychiatric services reinforce sufferers’ feelings of isolation and powerlessness." 

Angry Bird Medicine

A wonderful title to a great blog entry on the BMJ blogs site. Talking about reducing medicine to an App that can be downloaded to ones phone. He has a fantastic quote, “6 years of medical school and 10 years of training can now be put onto an App and sold for a few dollars – where did I go wrong?”

I dont think a 99 cent app on your phone is going to take the place of a doctor just yet, but the natural progression is that knowledge becomes a commodity, it moves down the value chain, and it no longer becomes cost effective for a particular expert to broker that knowledge. So for example, there is no reason why someone with hypertension cant be monitored at home, blood pressure readings relayed by phone to a central station and feedback given around diet, medications etc, all without the person ever leaving home.

Clinically Integrated Systems

Following on from my thoughts about disruptive innovation, what structures in the UK and Irish setting might prove disruptive? Starting from the assumption, which may be mistaken, that some disruptors will be players in the current system, what could one possible future look like?
I believe the likeliest candidates are current general practice and primary care structures. They have the benefit of decent infrastructure, a critical mass of clinical, (not just medical) staff, and a population base that is large and varied enough to allow sub-specialistation. What are the missing ingredients?

1. Seamless integration between priamry care and hospitals; to deliver this, I believe there needs to be consultant presence in the primary care teams. Consultants would work between hospital and primary care, with benefits to staff and patients, (improved access to specialist opinion, greater communication between professionals, enhanced learning opportunities for all)
2. A payment system that rewards health, and is not just based on following processes, (e.g. check blood pressure every visit). What would this look like? Look at it from the patient perspective. What he/she wants is health, as few visits as possible, as little interruption to daily life, mot missing school or work. Can this be done. I believe it can, but it will require a fundamental shift in the way health, (as opposed to healthcare) is delivered.
3. A recognition that an unplanned hospital admission represents a failure of care for the team providing care
4. Quality and outcome metrics allied with an IT system sensitive enough to provide real time data

There is an interesting paper just published on the BMJ site by Chris Ham discussing this. They report the experience of Torbay, summarised below:

• Reduced use of hospital beds (daily average number of occupied beds fell from 750 in 1998-9 to 502 in 2009-10)
• Low use of emergency bed days among people aged ≥65 (1920/1000 population compared with regional average of 2698/1000 population in 2009-10)
• Minimal delayed transfers of care

"hospital providers could also take the initiative in moving in this direction, especially in areas where general practitioners are relatively weak and specialists strong. London is a case in point, not least because it has several academic health sciences centres that present the potential to extend high quality care from hospitals into the community. In this context, integration might build on the strengths of academic health sciences centres by allocating them a capitated budget in conjunction with general practitioners and community health service providers. Patients would be able to choose between integrated systems based on academic health sciences centres and could also access care outside these systems in order to create an incentive for providers to deliver responsive care of high quality."

Wow, Oh Wow

That was Muir Grays Twitter post on seeing this weeks BMJ. Apart from the papers referenced below (Reducing Variation March 24th), there are a number of other papers worth checking out. A report from the Netherlands again finds a marked variation in utilization of medical interventions. An editorial on variation in the NHS; a look at how to redevelop care for long term conditions, and a lot more.

Why such emphasis on variation? Surely the areas with low utilization will balance out the high users for a zero sum game. This is unlikely to be the case, there is mounting evidence, mainly from the US, but also from other countries, that outcomes are not affected by the amount of care given above a certain amount. Therefore there are huge opportunities for reducing waste, saving money, and a lot more good stuff.

Reporting Poor Performance by Doctors

A very concerning piece, but not that surprising to those in practice. A study of >1000 UK doctors found that almost 30% would not report concerns about a colleagues poor performance. The main reason for this was concerns about retribution. It brings to mind a conference I attended 2 years ago in which a keynote speech was by three well known, (non-nmedical) whistleblowers. They made the point that whistleblowers are often motivated by anger or revenge, and that if they were faced with the situation again, they would not reveal their misgivings. This was very sobering; one assumes that whistleblowers (an awful term) are motivated by altruism.

Progress of the Safety Movement

Some (relatively) disappointing news recently. An analysis of the Safer Patients Initiative was published in the BMJ (here and here). This was a large scale intervention comprising a large number of components of care. Unfortunately, there was no evidence of any difference in outcomes between control and intervention hospitals. What could the possible reasons be? There are a number of hypotheses,

1. hospitals will get safer regardless of interventions, and do not need this type of large scale change, (unlikely)
2. These interventions were too complex, encompassing 43 different interventions, (probable)
3. Management and clinician buy in, expertise, knowledge and support were insufficient to show a difference, (highly likely)
4. The interventions sought has insufficient evidence to underpin their use, (highly likely in some cases)
5. Many hospitals, (both intervention and control) already had high levels of quality in some domains, hence the big effects were less likely to be seen, (likely)

So what lessons can be drawn? I think there are a number.

1. Large scale change is difficult, messy, a long term commitment and often fails
2. Leadership, at management and clinical level is critical
3. Improvement and quality must be seen to be the only way to do business, not an optional extra
4. There must be a better system of measurement; even today measuring mortality is contentious. The ideal measurement system should be one that measures patient outcomes from the perspective of the patient, and reimburses the system, not a provider for optimal outcomes. See Micheal Porters work from Harvard for more on this