Friday, August 31, 2012

Spare us this deluge....

It's absolutely mind boggling....anywhere you look nowadays, it seems to be the rage....guidelines, documents, position statements...there seems to be absolutely a deluge of them. And everybody's at it...NICE, Department of Health, Kings Fund,local Commissioners, SHA....you name it and there is an abundance of it..coming at us from all angles. As a clinician, you are trained to do things which are basically quite simple..see a patient who has come to you because of their problems, give them the best possible treatment you are aware of or your training had provided you with, ensure you are doing no harm ( remember the physicians primary mantra..do no harm?)be courteous with all concerned..and hopefully you see the said patient later who has benefitted from your expertise.That sounds quite simple, doesn't it?

But oh no, there are documents, guidelines, performance based incentives we must follow. Look at screening guidelines..there's now evidence pouring out that breast screening, bowel screening etc are resulting in over investigation, over treatment and beyond all, engendering anxiety in a population which is avoidable.  Recently I was asked for my opinion on an frail elderly lady admitted with a fall due to a hypoglycaemic event on the orthopaedic ward, Her overall average stood at 8.5% and to me, it sounded quite reasonable..why give her more drugs, more costly interventions when a) there's no evidence and b) it may cause her to have hypos and make a frail lady suffer?

In a sensible world free of multiple guidelines and documents...one may even say in the olden days....these sort of cases would involve a GP chatting to a specialist and both agreeing over the phone that this wasn't reasonable and it was best practice to "leave alone". But nope, not anymore...the QOF says we must get that level down....and the practice nurse concerned feels obliged to add in another drug....to make her control "better". Look what guidelines and documents have done...reduced the individual to a number....no longer is it about the "person in front of you", in fact we have now moved on to actually causing harm. Ask that poor old lady, I am sure she isn't worried about her "numbers".. But for sure is frightened of having another "nasty turn".
Any type 1 diabetes patient will tell you about their angst at being "told off" for their "poor numbers"...the reason they start getting afraid of seeing a healthcare professional...don't believe it, come on to social media, read a few blogs...and see what guidelines and targets have reduced us professionals to. Are they all bad? Of course not...but as a professional, what I want is something that is evidence based and frankly, one source will do, thank you very much.

And then you have data...anyone you meet nowadays is dead keen on showing you data.."local variation" is the buzz word...and your head spins...which one is correct, which one isn't? For most folks, whenever data is published and it shows them in a poor light, the standard response is the data's wrong or someone's hatching a conspiracy against their services. Here's an example..as per data published in different quarters, local GPs have been checking feet in about 85% of cases (Portsmouth GPs are amazing) the mortality rate inside the hospital for anyone admitted with diabetes is one of the lowest in the South coast ( Portsmouth Diabetes team is beyond compare).. But hang on..the amputation rates are one of the worst in the country ( Portsmouth diabetes care is rubbish). How on earth do you marry all those numbers together?? A red top paper would look at that and come up with perfect headlines.."Data from Portsmouth has shown that high amputation rates has resulted in less people dying, thus all diabetics must have their legs amputated"....and looks like we have finally entered the world of Monty Python.

I was asked recently whether I wanted to take into the GP surgeries I visit '"data to reflect poor practice". Now our whole local ethos is built on building bridges with our primary care colleagues...and the very thought of an opening gambit whereby I plonk down a sheet to the GP showing poor practice...sent a shudder down me. A polite no was offered back to the individual....don't get me wrong, all for challenging poor practice...but you need to show me data which is true, data which will stand any scrutiny and more importantly perhaps share in a less confrontational way than "here you go mate..explain that!". How about a different approach where you all agree to a set level to at tin, wipe the slate clean, approach all surgeries to get to same level of competence...and when you do approach individual surgeries, you will, perhaps, be able to find surgeries which may already be that level ( fabulous..less work for specialists to do as educators)  or someway to get to that level ( ergo needs input, time and patience). Far less controversial, far less confrontational...and certainly far less time will be spent on everyone thinking the data produced is either a cock up or a conspiracy.

Ah...but I already hear people asking about "performance management"... How do you know or measure whether those doctors and nurses are doing what they should be doing? Well can I venture or suggest something simple? How about something radical like actually measuring things which actually matter to the patients? For eg, how about measuring whether patients with type 1 diabetes are actually being reviewed after their admission from a ketoacidosis event? how about looking at whether GP surgeries and hospitals are helping to lessen heart attacks, strokes etc..rather than chase numbers? how about some outcomes based on...evidence? Outcomes based on the reason a patient comes to see us or we went to medical school...to get someone "better". People want better health, not necessarily healthcare systems.

So to those who love doing those documents and guidelines, spare a thought for the physician on the coalface. We are simply put, deluged. A bit of respite and a bit of forethought is asked for. Something simple, practical, evidence based is all we ask for. For those who like spewing out data, please, don't use it for political gains, don't use it to bash healthcare professionals to "score a point". Draw a line, let's use some common sense..and let us see patients without the sword of Damocles hanging over us. That cannot be too much to ask.

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