When rules are barriers

a to bI saw a photograph of a hospital outpatients department from 1904.  It looked remarkably similar to my hospital today; lots of sad, bored-looking people waiting patiently to be seen.

When you think about it, very little has change in the basic process of medicine.  The patient identifies that something’s wrong with them and they try to find another person, who might know what it is and be able to help.  You could illustrate it like this:

Patient has a problem

Doctor has a solution

The bit in-between

The starting point is the same as it always been:

  • You notice something’s gone wrong (react to a problem)
  • You search for some help from an ‘expert’ (this could be informal or formal)
  • The ‘bit in-between’ can take a circuitous path, a long time and may never work out

In theory, this process should be amenable to great improvement using information and communication technology.  It’s really just about bringing a problem and a solution together, which IT is great at doing.  So, why don’t we do it?

In short, I think it’s ‘culture’: the way we do things around here.  When you’ve got something wrong with you, you’re vulnerable and tend to default to what you know.  The doctor has a vested interest in your need (he/she has great status and earning power by meeting your need).  So, both parties are in a comfortable relationship.  In transactional analysis terms, it’s like a ‘parent-child’ relationship.  Both parties know what’s expected of their role and there’s no pressure to change.

But, it’s the ‘bit in-between’ that’s the problem.  It’s full of frustration, wasted time and poor outcomes.  The NHS seems to institutionalise these poor processes.  It is incredibly resistant to change, as any effort to change is immediately seen as an attack.

However, ‘culture’ does change, be it ever so slowly, as the way that people interact day-to-day changes.  IT changes the way we interact, think of social media, texting, messaging, etc.  These external social changes will permeate healthcare and slowly shift the status quo.  Doctors, who rely on possessing ‘elite’ information will be particularly vulnerable as patients will be able to garner the same information for free.  GPs will be especially at risk as they represent an intermediary, or ‘middleman’ between patient and expert.  Disintermediation has a proven track-record of making processes more efficient (think of buying insurance, for instance). 

A practical illustration is rectal bleeding.  Algorithms exist for improving decision-making concerning those patients with bleeding from their anus.  A few simple questions sign-posts the patient to the appropriate specialist without the need for a generalist intermediary.  This saves time, money and suffering.

At present, such a system would be ‘illegal’ in the NHS, since there is a rule as old as the hills, which states that no patient can access a specialist without going via a GP.  Such anachronistic rules act as barriers to innovation and until they are changed, they will effectively inhibit process improvement.

The ‘rules’ are created by politicians and advisers at a ‘high’ level, and operationalised by NHS managers at a ‘low’ level.  By the time they reach the ‘frontline’ they can bear little relation to the original intention, having been altered by misinterpretation, misunderstanding, and sometimes deliberate sabotage.

So, the NHS is in need of deregulation, that is, removing unnecessary rules that simply preserve the current, mediocre system.