Jane Dacre

Jane Dacre, member of the Rethinking Medicine working group.

The NHS is a victim of its own success, with millions of people benefitting and living longer as a result of its work. As our population ages, we accrue a selection of different long term conditions, and are learning how to live well with several comorbidities. 

This poses a serious problem to physicians, because our healthcare system can no longer cope with the increasing demand. As a rheumatologist, I have seen the strain on our out-patient service. We simply cannot keep up with the number of people being referred, and being cared for with long-term follow up.

I know I’m ok 

​Over the last twenty years or so, we have made significant improvements to the way we manage conditions like inflammatory arthritis. We have been cautious about the potential adverse effects of some of the new drugs, and keen to follow safe guidelines to protect our patients. We have been doing this in the best interest of the patients… or so we thought. 

Instead, we have created a dependent culture amongst our patients. We have not been helping them to help themselves or make their own choices. We follow patients up so we can see how they are doing, without thinking that our patients themselves are usually perfectly capable of knowing if they are OK or not. Many of them find it a poor use of their time to attend their regular out-patient appointment just to tell the doctor they are doing OK and have a blood test. There must be a better way.

Rethinking out-patients

There is a tendency in medicine to over-diagnose, over-investigate and over-treat. These tendencies occur in out-patient services as well as in all other areas of practice. As part of rethinking medicine, we need to rethink out-patients. We need to ask ourselves what the benefit is to the individual patient: do they really need the investigations we are suggesting, or is it just habit? Do they need to be coming to out-patients regularly at all?

As an interesting piece of context, a Royal College of Physicians project on out-patients and sustainability estimated that five percent of the traffic on our roads is related to the NHS. A large part of that must be patients coming back and forth to and from hospitals for their regular out-patient review. Out-patient services are not good for the environment! 

Telephone clinics 

Considering all this, I decided to try something different. In my own practice, I rearranged my follow-up rheumatology clinics to be delivered over the telephone. I audited the outcome, with interesting results. Within these 15 minute telephone consultations (which involved a shared clinical decision-making type approach) I was able to agree a plan for out-patients discharge for more than half of the patients, with a clear and agreed plan for self-management. Several of those still requiring follow up were happy to be contacted by telephone. There were no formal complaints. 

I was much more efficient – the clinic was an uninterrupted series of booked calls, so I fitted in more consultations in the time available. I used an office area, so did not take up clinical space. Occasionally there were problems – eg patients with cognitive or communication problems, or those who needed a physical examination – and face-to-face appointments were made in these instances. There were also some patients who just wanted to be seen in person, but crucially, most didn’t.

When routinely getting patients to travel back to the hospital for review, we need to think carefully about who we are treating. Is it the patient, or is it ourselves?

We have now developed a protocol for telephone clinics, with guidance on who can safely and sensibly be discharged. Our clinic waiting list has gone down and we have time to see those patients who really need to be seen. 

Although I thought I would miss the face-to-face contact, I don’t. Chatting over the phone is just as good. I worried about not being able to examine people, but have hardly ever felt an examination was really needed.

If we want to rethink medicine, we need to rethink the way we have always done it. Rethinking out-patients makes a good start. When routinely getting patients to travel back to the hospital for review, we need to think carefully about who we are treating. Is it the patient, or is it ourselves?

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