Saturday, April 05, 2008

Can Lord Darzi get it done?

A great article from the London Times about Lord Darzi and his attempts to reform the British Nation Health Service. Recall that I was his guest a few weeks ago and was asked to talk about quality and safety and transparency approaches here.

Here's an excerpt:

The basic structure of the NHS is not up for debate. Darzi's search is for best practice within the system. Working groups in each of the nine strategic health authorities (SHAs) in England are examining eight areas: maternity and newborn; staying healthy; children's; acute care; planned care; long-term conditions; mental health; and end-of-life care. The groups in each SHA will submit a report and Darzi will then write his report. What if different regions have completely different ideas about how to organise, say, their stroke care? His working thesis is “localise where possible, centralise where necessary”.

And, this somewhat wistful comment:

He admits that he lies awake at night thinking about how to “shift this big machine”. And he finds it hard to hear criticism. “What upsets me most is when the public are saying 'what we need is respect and dignity'. If we are not doing that, what the hell are we doing?” Perhaps wary of headlines about his surgeon's knife, he says that the only lesson for his political job that he takes from his medical career is “not to think like a surgeon”.

He is a plain-spoken, pragmatic person:

“It is all obvious stuff, but we have never done it this way,” admits Darzi. He says that the problem is that “if you look at a journey of a patient, it's fragmented. How do you integrate that care?” He cites the example of a patient with kidney pain who is referred by a GP to a consultant and then sent for an X-ray on a different day, then back to the consultant for an initial assessment. “If you are shopping in Tesco you wouldn't do that. You need to have access to competency at the time you need it.”


e-Patient Dave said...

> “You need to have access to
> competency at the time you need it.”


I can barely say how infuriated I was, some years ago, when my father (in Maryland) was "serially referred" from doctor to doctor with a three MONTH wait each time.

Does it make a difference? That infuriation was the single biggest factor in my telling my primary, two years ago, that I wanted to pre-schedule a shoulder referral without waiting for my upcoming physical: I didn't want to wait 2-3 more months to get the shoulder treated. (I was mildly uncomfortable, not urgent.)

And as it happened, that shoulder x-ray incidentally found my advanced cancer six weeks before any other symptoms showed up, which quite likely saved my life.

It's a quirky example but it's an existence proof that these nasty delays interfere with life-saving delivery of treatment.

Lord Darzi is right. A system that has such delays is BROKEN.

Anonymous said...

"What we need is respect and dignity." Patient-centeredness is an elusive, poorly-funded ball in the medical arena. What gets you to the top of your craft is science-based skill and sheer ambition, something physicians do not share with most of their patients. We are competitive animals, and hospitals need specific interventions to demand their elite learn the skills of empathy. Is anyone listening to what patients are demanding?

Anonymous said...

It's interesting that he mentioned Tesco. At a recent healthcare presentation I attended, the speaker put up a slide which showed that the industry in the U.S. that ranks highest for consumer satisfaction is supermarkets. Perhaps there might be some lessons for hospitals and doctors especially with respect to customer service and price transparency.

Anonymous said...

It's not just access to competency when you need it. The patient is forced to compartmentalize her body in order to fit into the stovepiped structure of the medical system. The patient sees a separate specialist for each body part, and too often it's up to the patient to navigate across the boundaries.

Patients don't just need on demand competency -- we need an integrated health care system that aggregates the care the patient needs and delivers a whole care model to the patient.

It's not Tesco we're looking for. It's Google.

Anonymous said...

I believe Lord Darzi is very well intentioned. However, the quote used “What upsets me most is when the public are saying 'what we need is respect and dignity'. If we are not doing that, what the hell are we doing?” in a lot of ways this indicates the problems patients have with doctors. I wish I had the link on me, but there is a study that was looking to determine why patients 'no-show' (miss an appointment without calling the office in advance) and perceived disrespect by the doctor was a big issue. We as doctor's may know that we have all the respect in the world for our patients, but if the perception is otherwise we need to be cognizant of that and make a real effort to fix those perceptions. In some of the market research I have been doing, long wait times and difficulty finding available doctor's appointments weigh down on patients views of the profession. Creating tools to alleviate these issues and increase transparency will be paramount in making the system more efficient and easier for patients to navigate.

Anonymous said...

There are episodes of excellence in most health care organizations, but with few exceptions, health care systems are not organized to elicit excellence. What interests me is conversations I have with patients include horror stories, but when I talk with professionals, typically they feel all is well. Can we hope to succeed when this disconnect between patient experience and professional insight remains? And who is accountable for measuring and designing protocol to reduce the gap?

Anonymous said...

I think there's a real risk with these large multispecialty clinics, which are likely to be a key component of Lord Darzi's final recommendation, that the NHS may weaken (lose is too strong a word) two of its biggest strengths.

First, the continuity of care between patients and GPs.

Second, increasing access to specialists with clinics like these may put the NHS on a slippery slope and eventually force even further open patient access to specialists and weaken their 'GP as the gatekeeper model.' That gatekeeper system is obviously important to controlling costs in any global budget/socialized medicine system.

Or maybe not...