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I’m an Uncertainty Specialist

By Emily Bellshaw, on 10 May 2017

I had a fascinating discussion with a middle-aged woman in my practice recently. She had been told by our practice nurse that she had pre-diabetes and had been prescribed metformin, a drug used to reduce blood sugar levels. She wanted to speak to me to understand what ‘pre-diabetes’ meant. She was really angry. ‘Have I got a disease or not, Dr Marshall’ she asked ‘and do I have to take these silly tablets?’

These are good questions. I could have introduced a bit of artificial certitude (a George Bushim) into the consultation but for once I wasn’t running late. I felt like answering yes, you have, and no, you haven’t to first question and maybe, but maybe not, to the second. Classic answers to questions that arise from the zone of uncertainty that GPs operate in for so much of the time. The fundamental problem, which I appreciated only later that evening over a glass of wine with my wife, was that I thought we were preventing a disease by prescribing metformin but she thought I was giving her one.

My uncertainty problem is that screening for pre-diabetes is both a good and a bad thing, a paradox. Most importantly, it is an arbitrary judgement. The cut off point for diagnosing so-called pre-diabetes was recently reduced by a group of experts in the United States from a fasting glucose of 6.0 per cent to one of 5.7 per cent. Overnight this increased the prevalence of pre-diabetes by 3 fold. Does this sound OK? Are we creating illness?

Huxley said that ‘medical science has made such tremendous progress that there is hardly a healthy human being left’. So where do you stand? Are you a disease deny-er or a disease monger? Good GPs can only make sense by being both. At the same time. The paradox of being an uncertainty specialist.

Martin Marshall
GP, Newham
Professor of Healthcare Improvement, UCL

The general practice rescue package: celebrate, briefly, and then the work of implementation begins

By Emily Bellshaw, on 22 April 2016

Professor Martin Marshall

 

 

 

 

 

 

 

 

 

 

Professor Martin Marshall

Lead, Improvement Science London.

The 21st of April 2016 will go down as a good day for general practice, perhaps one of the best in recent decades. A few tweets ago I said that the announcement had to be sufficiently substantial and coherent to FEEL BIG to struggling practices. It had to say that general practice was valued, that it had a bright future. Given the context of economic woe and media interest in failing hospitals, this new investment in general practice is better than many hoped and remarkably close to the ambitious demands of the RCGP.

Several commentators have attempted to place the package in a historical context. The proposals are different from the 1966 charter, which focused on building a basic foundation for modern general practice. Different too from the 2004 contract, which focused largely on improving clinical care for long term conditions. The General Practice Forward View (interesting to compare NHSE-speak with front line clinician-speak of ‘rescue’) is in some ways more ambitious. It recognises that general practice needs stabilising right now, urgently, but it also starts to shape a different looking general practice for the future.

We all know that Simon Stevens is a clever man but to start a health policy document with the words ‘There is arguably no more important job in modern Britain than that of the family doctor’ was inspired. I can be as sceptical about political rhetoric as the next person but sometimes we should suspend our discourse of lament and just celebrate a serious lobbying success.

OK, enough celebration, let’s get down to work. What next? Here are a few thoughts:

1. Some of the ‘new’ funding is recycled from previous announcements but most of it appears to be really new – a genuine commitment to give a good proportion of the ‘sustainability and transformation’ money promised to the NHS in the recent budget to the part of the system where it will achieve greatest value – general practice. But let’s not be naive. The hospital sector has its own crisis. Acute Trust chief executives have political influence. The public (and MPs) will protect their hospitals. So the pressure will be on the system to put its money where it always has. Just last week, NHS England was telling CCGs to commission more services from their local hospitals in order to reduce their deficits. The ‘11% battle’ has not yet been won.

 
2. General practice will look different in 10 years time as a result of this package. Non-doctors will play a much bigger role, perhaps seeing the majority of patients presenting with ‘straight forward’ problems. GPs will see fewer patients, focusing on those with more complex problems, with considerably longer appointments, and they will lead, mentor and supervise a wider multi-disciplinary primary health care team. I’m not sure whether this is a pragmatic response to the shortage of trained GPs, or whether it really is desirable. We have plenty of experience that non-doctors do a superb job in general practice and their salary costs are lower. But the much-cited Starfield arguments in favour of general practice are based largely on expert medical generalists providing care. Will other health professionals be as good at managing uncertainty and risk? They might be good for individual patients but are they good for the health system? There must be a commitment to rigorous long-term evaluation to answer this fundamental question.

 
3. No one believes that life in the front line of general practice will suddenly get easier. We know that work load will continue to rise because of demographic changes, patient expectations and continuing shifting of care out of hospitals into the community. A bad outcome of this package would be that in the coming years general practice doesn’t quite go under but only just about keeps on coping. General practice will only thrive (and that must be our ambition) if we use the new resources to create space for GPs – space to provide the quality of care for patients that we all strive to provide, space to continuously improve the care that we provide, space to develop ourselves as professionals and space to work with others on developing new ways of working. Actually, just space to feel joy in being a GP.

So, celebrate, briefly, and then the work of implementation begins.

Martin Marshall
Professor of Healthcare Improvement, UCL
GP, Newham, East London

A discourse of lament and a discourse of joy

By Emily Bellshaw, on 1 April 2016

Professor Martin Marshall

 

 

 

 

 

 

 

 

 

 

Professor Martin Marshall

Lead, Improvement Science London

I recently had a chat with a health manager from New Zealand who was in London for a three month sabbatical. He told me that prior to his arrival he had read about how unhappy doctors are in the NHS, about vacant posts, mass emigration and early retirement. These stories were reinforced by introductory conversations that he had with the leaders of national professional bodies. But then he started talking to front line clinicians about their work and he was surprised to hear a completely different story, one dominated by moral purpose, full of passion and commitment.

‘You must have been directed to the small band of incurable optimists’, was my sceptical response. But he disagreed. He described how, if he started a conversation with a group of doctors about the challenges of working in the NHS, then what he got back was a graphic tale of woe, about financial cut-backs, unreasonable workload, staff sickness and disabling bureaucracy. But if he talked to the same people about their interaction with patients, their eyes lit up.

Sociologists tell us that professions classically describe themselves using a range of different discourses. The discourses of the medical profession are often critical of political and social change. A discourse of lament has become a dominant one in recent years. This negative discourse is criticised by some commentators but it is a legitimate narrative that serves an important purpose. It highlights the very real risks of trying to keep a public service running with inadequate or poorly allocated resources and undervalued staff. Professional leaders have learnt that impassioned laments grab the attention of politicians and are much loved by their more vociferous members. Tactical laments are even more effective and that is why the newspapers and professional journals are full of them.

But laments, understandable and useful as they are, have side effects. Are we reaching a point where the medical profession is contributing to its own poor morale and making the recruitment of new doctors and the retention of old ones even worse? It is easy to talk yourself into a hole and even easier to reinforce other people’s unhappiness. Misery is contagious. But so too is joy and whilst it is hardly fashionable to talk about joyful discourses in pubic, they are out there, in every consulting room and over every cup of coffee.

So perhaps it’s time to rebalance our professional discourse. As the Dalai Lama says, ‘choose to be optimistic, it feels better’.

Martin Marshall
GP and Professor of Healthcare Improvement, UCL
27th March 2016

Confused about general practice?

By Emily Bellshaw, on 12 February 2016

Professor Martin Marshall

 

 

 

 

 

 

 

 

 

 

Professor Martin Marshall

Lead, Improvement Science London.

When I first became a GP, general practice was organised in a way that was so easy to describe to people. We had practices serving defined local communities and we had Family Practitioner Committees (FPCs) which provided a bit of light-touch administration. And that was that.

Compare this blissful simplicity with the plethora of primary care organisations which now provide and commission care. The other day I tried to explain the current structures to a medical student but I could tell from her face that I wasn’t making much sense. Practices remain, I’m glad to say, albeit a bit bigger and a bit less relaxed than they used to be. But now we have (in alphabetical order, because this taxonomy makes as much sense as any) accountable care organisations, CCGs, clusters, federations, integrated provider partnerships, locality groups, mega-practices, multi-speciality community providers, networks, NHS England, placed-based provider groups, primary and acute care systems, primary care homes, super-partnerships and probably lots of others, the inventors of which I’ve offended with my forgetfulness.

There are a few people who are able to provide a coherent description of these structures, explain their purpose and their relationship to each other, but not many. In part I guess this is because most of them seem to be in a state of constant flux, buffeted by the winds of fashion and Orwellian Newspeak. Even the big daddy of re-disorganisation, the purchaser-provider split, is being quietly air-brushed from history. A quarter of a century after the abolition of FPCs, it is reasonable to ask whether this complex set of new structures is simply the result of a judicious mix of historical accident, politics and organisational amnesia, or whether they add value to our quest to improve care for patients.

There is actually some logic to each of the new structures. We have known for many years that there is no ideal size for health care organisations and that form should be determined by function. We know that small and well-bounded organisations find it easier to be more responsive to their local communities and that they promote a strong sense of shared responsibility amongst their staff. Small organisations are often highly efficient because they are able to tap into the most valuable asset of the NHS, the good-will of the staff. We know that when organisations join together in networks they often become better at sharing scarce resources and spreading learning. And we know that large organisations are usually more able to address population health challenges, such as service-wide integration and inequalities.

So in this complex world we do need to be flexible in accepting the need for multiple forms to address different functions. But the reality is that many of the ‘new’ organisations in general practice are remarkably similar in form and purpose, despite their different names. In place of a free-for-all, some evidence-informed planning would be helpful.

Where do we go from here? Excuse my Virgo traits but it would be nice to tidy up the landscape a bit, in a way that makes it easier to explain general practice to my medical student, to our hospital colleagues and perhaps even to GPs themselves. But most importantly, let’s not get too excited about structures. The evidence is clear; organisational form matters less than shared values and purpose, conversations and relationships. That’s where we need to put our energies.

This blog was first published on the BMJ website on 11th February 2016

Martin Marshall
GP, Newham; Professor of Healthcare Improvement, UCL

NHS integration: can accountable care organisations deliver a truly GP-led NHS

By Emily Bellshaw, on 7 January 2016

Professor Martin Marshall

 

 

 

 

 

 

 

 

 

 

Professor Martin Marshall

Lead, Improvement Science London.

General practice must engage with Accountable Care Organisations

Sometimes it makes a lot of sense for GPs to keep their heads down when ‘new’ ideas are trumpeted by government. It is good to remind ourselves of Rudolph Klein’s sage aphorism: ‘innovation is a function of amnesia’. Too often bright new ideas are a rehash of old initiatives that didn’t work in the past and won’t work any better just because they have been given a fancy new name.

So what about Accountable Care Organisations (‘ACOs’), the latest idea to emerge from the US which has caused a frenzy of excitement amongst policy wonks in NHS England? My advice is lift your heads up and take a look. The name might change (the Kings Fund has already coined a new term, ‘place-based care’) but I don’t think that the idea will go away.

What are ACOs? In the context of the NHS they are essentially a partnership between primary, acute, community, social care and third sector providers who have agreed to take responsibility for providing all care for a given population for a defined (and long) period of time. Most importantly, the partnership is held to account for achieving a set of pre-agreed quality outcomes within a given budget.

Think about it; the implications of this simple model may be significant. ACOs could herald the demise of the purchaser-provider split. They remove the need for frequent competitive tendering of contracts. They are likely to eliminate the micro-management of processes of care and allow professionals to focus on long term outcomes (clinical, functional and experiential) and population health improvement. They incentivise providers to preferentially allocate funding to the most cost-effective part of the system (general practice) and to focus on addressing the broader determinants of health. They encourage providers to disinvest in wasteful and ineffective interventions and will deter hospitals from empire building. And all of this would happen because the deeply embedded sectoral barriers and dysfunctional incentives currently in place in the NHS are replaced by a shared set of values, a chance to build a stable set of relationships and a common set of objectives. The model isn’t rocket science but its implications are radical.

The building blocks for ACOs are being put in place right now across the country with the formation of a growing number of ambitious provider partnerships, some areas combining their health and social care budgets and others awarding long term, outcomes-oriented contracts for older people’s care. New legislation isn’t required to create ACOs, nor are distracting top-down structural reorganisations.

The biggest danger is that at a local level large acute trusts will seize on ACOs as a way of getting a bigger slice of the financial pie. Robust primary care partners are required to ensure that this doesn’t happen. Some people feel safer within their traditional boundaries, anxious about jumping into bed with new powerful partners. But ACOs provide a rare opportunity to realise the rhetoric of a general practice-led NHS, and to address some of the poor policy decisions of the past.

This blog was published in GP Online on 14th December 2015
Martin Marshall is a GP in Newham, East London and Professor of Healthcare Improvement at UCL

Making time for improvement

By Emily Bellshaw, on 22 December 2015

Professor Martin Marshall

 

 

 

 

 

 

Professor Martin Marshall

Lead, Improvement Science London

 

The habits of improvers

Paul Batalden, a much respected quality guru, once described how people who deliver health care have two roles – to do the day job and to improve how they do the day job. This is a neat way of framing the challenges of professional practice but in the current environment it highlights a major challenge for GPs; at a time when many practitioners are struggling to keep their heads above water, how realistic is it to expect them to be able to stand back and find the time to learn and put into practice the skills required to be an effective improver? What is the right balance between doing, and learning to do more effectively?

Evidence from patient surveys, routine performance measures and CQC inspections suggests that despite these workload pressures most general practices have the skills to do the day job to a remarkably high standard. Currently, however, the majority of GPs are less aware of the range of options to help them to improve how they do their day job. We use time-honoured improvement interventions like guidelines, clinical audit, significant event analysis and peer review. But few clinicians are trained to make use of approaches that have emerged in the last decade based on the science of improvement and on systems thinking. As a result, the skills that GPs demonstrate to deliver care behind the closed door of the consulting room are often not matched by their ability to improve the systems that they are working in. This isn’t good for the NHS and can be deeply frustrating for individual clinicians and practice teams.

We are developing a better understanding of the characteristics of people who are effective improvers. We know that they utilise a broad range of technical tools to facilitate systematic improvement, including improvement science approaches such as process mapping, Plan-Do-Study-Act cycles, driver diagrams, care bundles and run charts. But more importantly, effective improvers have what a recent Health Foundation publication referred to as a set of ‘habits’ which make them more able to improve what they do. Improvers are committed to learning by being inquisitive and reflective. They have well-developed influencing skills, demonstrating empathy and an ability to deal with conflict. They are resilient, optimistic and able to tolerate uncertainty. They demonstrate creativity by being both open to and constructively critical of new ideas. And they make connections by being system-oriented and strategic in their thinking.

So, we know what an effective improver looks like but, going back to Batalden’s challenge, how realistic is it to expect GPs to allocate time to improve the day job when the volume, intensity and complexity of the work that they do is increasing at the same time as resources are becoming tighter?

The answer is that in this environment it is even more important that practice teams learn new skills. Using the science of improvement will help them to understand how systems work, to generate and test innovative solutions, and to differentiate between work that adds value and activities that are wasteful. It will give them a deeper understanding of why things work and it encourages people to focus on the most important determinant of high quality care – the shared values, motivations and behaviours of the people who provide and use NHS services. GPs want to be able to influence the system that they work in and, in order to do so, learning about how to be an effective improver is likely to be an effective use of their time.  To learn more, take a look at the RCGP’s Quality improvement for General Practice; a guide for GPs and the whole practice team. Perhaps learning about improvement science could be built into your next Personal Development Plan?

This blog was published in the RCGP’s GP Frontline in December 2015.

 

Martin Marshall is a GP in Newham, East London and Professor of Healthcare Improvement at UCL. He is a member of the RCGP Council and is leading a programme embedding improvement science into general practice across UCL Partners

NHS integration: Can accountable care organisations deliver a truly GP-led NHS?

By Martin Marshall, on 15 December 2015

Professor Martin Marshall

Professor Martin Marshall

Lead, Improvement Science London

 

 

 

 

 

 

 

 

 

Sometimes it makes a lot of sense for GPs to keep their heads down when ‘new’ ideas are trumpeted by government. It is good to remind ourselves of Rudolph Klein’s sage aphorism: ‘innovation is a function of amnesia’. Too often bright new ideas are a rehash of old initiatives that didn’t work in the past and won’t work any better just because they have been given a fancy new name.

So what about accountable care organisations (ACOs), the latest idea to emerge from the US which has caused a frenzy of excitement amongst policy wonks in NHS England? My advice is: lift your heads up and take a look. The name might change (the King’s Fund has already coined a new term, ‘place-based care’) but I don’t think that the idea will go away.

What are ACOs? In the context of the NHS they are essentially a partnership between primary, acute, community, social care and third sector providers who have agreed to take responsibility for providing all care for a given population for a defined (and long) period of time. Most importantly, the partnership is held to account for achieving a set of pre-agreed quality outcomes within a given budget.

Focus on long-term outcomes

Think about it; the implications of this simple model may be significant. ACOs could herald the demise of the purchaser-provider split. They remove the need for frequent competitive tendering of contracts.  They are likely to eliminate the micro-management of processes of care and allow professionals to focus on long-term outcomes (clinical, functional and experiential) and population health improvement.

They incentivise providers to preferentially allocate funding to the most cost-effective part of the system (general practice) and to focus on addressing the broader determinants of health. They encourage providers to disinvest in wasteful and ineffective interventions and will deter hospitals from empire building. And all of this would happen because the deeply embedded sectoral barriers and dysfunctional incentives currently in place in the NHS are replaced by a shared set of values, a chance to build a stable set of relationships and a common set of objectives. The model isn’t rocket science but its implications are radical.

The building blocks for ACOs are being put in place right now across the country with the formation of a growing number of ambitious provider partnerships, some areas combining their health and social care budgets and others awarding long term, outcomes-oriented contracts for older people’s care. New legislation isn’t required to create ACOs, nor are distracting top-down structural reorganisations.

The biggest danger is that at a local level large acute trusts will seize on ACOs as a way of getting a bigger slice of the financial pie. Robust primary care partners are required to ensure that this doesn’t happen. Some people feel safer within their traditional boundaries, anxious about jumping into bed with new powerful partners. But ACOs provide a rare opportunity to realise the rhetoric of a general practice-led NHS, and to address some of the poor policy decisions of the past.

Evaluation: rigour, relevance and naivety

By Martin Marshall, on 25 June 2015

Professor Martin Marshall Laura Eyre

Martin Marshall, Professor of Healthcare Improvement; Laura Eyre, Research Fellow, UCL

 

 

 

 

The Nuffield Trust, like many similar organisations, is inundated with requests from people working in the NHS who want help to evaluate improvement initiatives; a subject already touched upon in a recent blog by the Nuffield Trust’s Alisha Davies.

These requests highlight a big problem; demand for evaluation is increasing but the supply of expert evaluators is limited. So the Nuffield Trust organised a conference bringing together evaluators, commissioners of evaluation and potential users of evaluation learning to try to find a solution.

The discussion covered three time-honoured questions that researchers often hope evaluation can answer.

  1. Does this intervention work?

This question is much loved by researchers and by passionate advocates of evidence-based practice. It is a simple question, compelling but troublesome. If you were to ask us this question then we wouldn’t need to know much about your subject area or your context to give you the answer. The answer is ‘it depends’. Or if you want a bit more detail, ‘sometimes, but not very much and not in any predictable way’.

There is no binary answer to this question because improvement interventions are often unstable, have social as well as technical elements, are implemented in complex (sometimes chaotic) organisational and policy environments and because the main variable is the human condition in all its beauty. To expect such interventions to ‘work’ or ‘fail’ is at best naïve.

  1. How does it work?

This is an important question for those who are taking part in an improvement project and for those who are interested in the generalisability of the learning to other settings. It is a question that evaluation funders are increasingly asking and for which qualitative researchers are adding enormous value. Attempts to answer this question are revealing a fundamental problem – we often don’t know what ‘it’ is or how ‘it’ is expected to make a difference. Addressing these questions is taking our understanding of improvement forward in leaps and bounds.

  1. How do we make it work better?

This third question is the most important for practitioners and the most challenging for evaluators. The concept of researchers bearing some responsibility for action is shocking to some academics but the field of participatory research has a long and honourable history in some sectors (education and community development in particular) and is underpinned by rigorous theories and methods.

For some reason the ‘objectivity’ of the biomedical sciences has encroached on the practice of social science in the health field. In doing so it has discredited an approach to evaluation which has the potential to increase the impact of science on service improvement. Thankfully, practical approaches to break down the boundaries between research and practice are emerging, such as the ‘Researcher-in-Residence’ model which was much discussed at the conference.

We are a long way from mainstreaming participatory approaches to evaluation in the way that has been achieved in the US and Canada. To achieve this requires evaluation commissioners, funders, universities and academic journals to think more broadly about the nature and the practice of science.

The Nuffield Trust conference represents the start of a long journey.

 

The 10 minute consultation; the unacceptable face of general practice

By Martin Marshall, on 6 May 2015

Professor Martin Marshall

Professor Martin Marshall

Lead, Improvement Science London

‘Perfunctory work by perfunctory men’. That’s how an eminent physician once described general practice. ‘A ridiculous claim’ cried GPs, rising to the defence of their discipline, ‘specialists just don’t understand the nature of general practice. They don’t value our ability to make quick decisions based on a deep understanding of our patients and their context, our exceptional skill at managing risk and uncertainty, of using serial consultations to optimise the effectiveness of our diagnostic and therapeutic interventions’.

GPs went even further. Not only could they deal with the presenting problem in 10 minutes, but they could also deliver the other components of the consultation models that they learnt about in their training. Like managing on-going conditions, offering advice about prevention and health education, modifying help seeing behaviours. Was there no end to their efficiency?

But it’s time GPs stopped fooling themselves. In 2015 the 10 minute consultation is an anachronism. It is damaging to patients, damaging to clinicians and damaging to the reputation of general practice as a speciality that provides holistic and patient-centred care.

If we are honest with ourselves, perhaps the short consultation that characterises general practice in the UK and in some other European countries was never really viable; it is certainly becoming less and less so. The pressure is mounting as the complexity and intensity of the consultation increases. More patients to see, more problems presented, more information sources to search, more solutions to consider and balance, more templates and forms to complete, more ideas to discuss and negotiate. Something has to give and it shouldn’t be the quality or safety of clinical care that patients receive, or the humanity that underpins that care, or the mental health of clinicians struggling to maintain a sense of achievement that they have understood and sorted out a problem. It is the travesty of the too brief encounter that must give.

Even within the constraints of the established system and the strangely modest expectations of too many patients, clinicians, managers and policy makers, there is good research evidence that time matters. For most patient groups longer consultations are associated with greater patient satisfaction, a stronger focus on health promotion and disease prevention, increased willingness to address psychological problems and fewer prescriptions. Time is a key component of the effectiveness of the clinical encounter, rushed consultations are the enemy of high quality care.

Some years ago a GP professional leader complained to the then Secretary of State about the time constraints in general practice. ‘Show me the legislation that restricts the consultation length’ the politician retorted. Some of the solutions do lie in professional hands. Some practices already offer 15 minute appointments, actively support patients to self-care, utilise triage and make more effective use of nurses, pharmacists and healthcare assistants. All of these approaches help and should be used more intensively and in a more coordinated fashion. But the solution is also a political one; we need more GPs and an aligned set of values and incentives that encourage longer consultations.

Perfunctory work done by perfunctory people? It can’t go on.

Monkey Business

By Martin Marshall, on 26 November 2014

Professor Martin Marshall

Professor Martin Marshall

Lead, Improvement Science London

I recently listened to a fascinating presentation at the annual conference of the Dutch Royal College of General Practitioners. The speaker was the curator of Amsterdam Zoo and an expert in chimpanzee behaviour. She’s spent most of her career observing troops of chimps and has become fascinated by their leadership behaviours. She is convinced that doctors have much to learn from their primate cousins and with respect to my profession, I’m inclined to agree.

It appears that all chimpanzee troops have a strong leader (a male I’m afraid, but read on) and this individual competes with others to remain top dog, if you don’t mind me mixing my species. They achieve this by creating alliances with others in the troop, constantly nurturing their social networks. They put a lot of time into building relationships with influential females, who then act as the emotional intelligence behind the throne, forging partnerships and heading off trouble.

The leader has occasionally to fight with other ambitious males to maintain their supremacy but as soon Chimpanzeeas they have won the fight they immediately seek reconciliation with the vanquished, and in doing so avoid repeated attacks. Leaders that fail to be conciliatory rapidly lose their dominant position. Young chimpanzees copy the leadership behaviours of their elders, preparing for the future, but they are careful never to be seen as a threat.

What do you think? Perhaps one or two lessons for NHS leaders? (avoiding the gender stereotypes, of course). Most chimpanzee groups maintain an effective and happy equilibrium most of the time. Now, there’s something for us all to aspire to.