On Monday, 24th October 2016, the Academy of Medical Royal Colleges published a list of forty treatments and investigations that confer no benefit to patients and therefore might be appropriately discontinued. The initiative is part of the Choose Wisely campaign, which started in North America. Although the campaign is driven by the principle “first, do no harm”, it does have relevance to the NHS financial crisis.
Doctors routinely find themselves doing things that they know confer little or no benefit to the patient. We have all ordered investigations ‘just in case’, despite evidence that this is entails a huge waste of resources. The factors that make doctors do things against their better judgement are complicated. They include patient pressure and fear of censure. Some activities are dictated by political decisions. Most of us find all of this dispiriting. If we could discontinue costly activities that are of little or no benefit, then we might avoid restricting access to interventions that work. The Choose Wisely campaign is a good start. We will need to shift policy makers thinking if we are going to change practice.
Back in 2008, Robert Higgo and I had a book published called ‘Clinical Skills in Psychiatric Treatment’. It received good reviews and it was highly commended in the BMA medical book competition. Sales were respectable. The book made two major assertions. One was that psychiatric treatment works best when the psychiatrist and patient develop a treatment strategy together that is adhered to over time. The other was that in health care, genericism does not look impressive on paper, but it works well in practice.
Eight years ago, these were moderately controversial opinions. Dedicated in-patient or acute care teams had just started to appear, and the functionalised model of mental health care was being adopted all over the UK. Some psychiatrists were enthusiastic. Whilst we accepted that specialist teams had important roles (indeed, Robert Higgo worked in an Assertive Outreach Team at that time), we had grave misgivings about a fully functionalised model of care. Patients had not been consulted and we did not think that they would like being treated in this way. We believed that dedicated inpatient consultant psychiatrist jobs were likely to prove unsustainable. They seemed to us to be a recipe to produce burnt-out doctors.
In making choices about the way that we organise services, we must stop doing things that do not really work, but we also need to be careful about losing elements of treatment that are important and effective. Fully functionalised models of care solve some problems, but they create others. There is a substantial new problem in our system of care, in that we have inhibited the ability of clinicians to form sustained therapeutic relationships with patients. This is not evident everywhere, but it is of serious concern.
In all fields of medicine, placebo treatments are remarkably effective. Placebo is not a non-treatment. It may involve dummy tablets, but it includes all of the non-specific therapeutic elements of interaction with a health professional. Prominent amongst these is the relationship itself. A paper last year showed that the quality of therapeutic alliance in psychological therapy for early psychosis can have a very substantial effect on symptoms. The effect size, for good or ill, is large.
Common experience tells us that what we all want when we see a doctor is someone we can get along with. All treatment is contingent upon trust. Where ever treatment is in any way complicated (i.e. most of the time in psychiatry) mental health professional and patient need to know each other.
This is not just about psychiatry. Over a short period of time, the corporate NHS seems to have abandoned continuity of care as an important principle of medical treatment, although no individual has articulated this as a policy. Treatment is increasingly atomised, with individual patients repeatedly passed between teams and clinicians in single episodes of care. Patients do not like this much. Although it appears ‘efficient’ in a production line sort of way, there are obvious pitfalls. As patients move across multiple interfaces between clinicians and teams, treatment cannot follow a coherent individualised strategy. Important elements of history are often lost, including detailed risk information and previous treatment responses. As no professional knows the patient very well, treatment tends to be programmatic, following a guide-lined care pathway. These programmatic pathways may be a good fit for whole populations, but they rarely fit well for individuals with more than one health care problem, for example, a large proportion of older people. When treatment continues for long periods, inefficiencies and repetitions accumulate. Patients become fed up, and are easily lost to follow up.
Most clinicians enjoy working within proper therapeutic relationships. The art of clinical practice consists of skills developed over many years that can only be fully deployed in a continuing therapeutic relationship. When you can see a clear result, job satisfaction improves. Treatment can take individual circumstances into account, which improves its effectiveness. Clinical judgements are better informed and of a better quality. There is much debate about a loss of human warmth towards patients by health professionals. Warmth is much more likely to flourish in sustained relationships rather than endless encounters with strangers.
The great strength of genericism is flexibility. A single team deals with a range of problems, following a single overarching plan. Staff can be deployed as circumstances, rather than systems, dictate. In contrast, multiple teams necessitate multiple minimum staffing levels to maintain viability. When resources are short, multiple small teams become non-functional much more quickly than larger generic teams. There is little ability to prioritise and to maintain a service in a small highly specialised team. Sick leave, for example, can easily bring a small team to its knees, which can then paralyse the whole of the rest of the system.
To reiterate, all of this is true of British medicine in general, not just psychiatry (although psychiatry is the bit that most concerns me). I am not arguing that we should return to a golden age of hospital firms, white coats and non-specialisation, for golden ages are illusory. Some things about modern psychiatry are much better than what went before, for example, acknowledgement of the central importance of the patient’s wishes. Nonetheless, all over the UK mental health specialist teams are being reorganised in the face of financial pressure. This is being conducted ad hoc, with no generally accepted pattern of best practice. It should be possible to restore some important and threatened elements to treatment in this process and to make a virtue of a necessity.
My contemporaries from medical school have shown a strong tendency to retire early, fed up with many aspects of the system they now have to work within. “Medicine by numbers” is a common complaint. As a sort of a social scientist, I have referred to this in previous blogs as Fordism. We confront a huge medical recruitment crisis over the next few years. This is likely to be exacerbated by Jeremy Hunt’s alienation of younger doctors and his sudden hostility to foreign born doctors, whom he seems to want to go away once he has managed to expand medical schools to the point of self-sufficiency. Hunt’s plan is neither realistic nor honourable.
One of the things that would help us to recruit and, importantly, retain doctors of all ages would be a more satisfying working life. Encouraging continuity of care and proper strategic treatment planning would make our working lives more pleasurable. It would improve patient satisfaction and it would probably be more cost-efficient. What is there not to like about that?