Today, we witness the publication of King’s Fund report Patients preference matter: Stop the silent misdiagnosis, by Professor Al Mulley and colleagues, which makes a strong case that the medical profession have largely failed to diagnose what patients want.
Have we really been so poor at doing this?
Today’s report details many studies across disparate specialities that would suggest so. For example, when patients with abnormal bleeding from the uterus seek treatment, they may be offered one of a number of treatments, ranging from a hysterectomy to simply waiting for the menopause. A randomised trial showed that when well informed there was a statistically significant decline of hysterectomy rates from 48 per cent to 38 per cent.
Professor Mulley advises that we need to tackle 5 erroneous assumptions that is largely ingrained in the thoughts and work processes of healthcare professionals ranging from frontline clinicians to the commissioners of care. An example is the recommendation to stop believing that variation is a problem. To highlight this, he hypothesises that the use of NICE guidance to reduce variation can simultaneously exacerbate the problem of the “silent misdiagnosis of patient preferences”. He then goes on to describe a high level strategy on how we can convert ideas into action to deal with this widespread issue.
This report follows hot on the heels of the long awaited information strategy published last week that made a commitment to give all patients in England online access to their GP records. Later the same week, the Department of Health began the process of consultation on a proposal to secure shared decision-making and choice for patients.
These back-to-back reports and consultations would suggest that the overriding concept of a partnership with our patients is a novel 21st century idea. Looking back however, the 1995 edition of the GMC’s Good Medical Practice clearly states that it is the duty of doctors to give patients the information they ask for or need about their condition, its treatment and prognosis; in a way they can understand and respect the right of patient to be fully involve in decisions about their care.
So what is different this time?
Technology and the internet has significantly lowered the barriers to access tools and personalised information required to better inform patients decisions. Furthermore, patients have the ability to interact with other patients and professionals without the constraints of time or geography. With the increasing digitisation of health records, it is also becoming increasingly easy to collate and analyse data on patient preferences to inform delivery of healthcare.
One consistent finding from the report is that a fully informed patient usually selects the option of more conservative treatment options that tend to cost less. Commissioners may be incentivised to provide shared decision making services, such as health coaches, with the goal of cost reduction. I will argue that this would prove less effective than if the intervention was delivered by the patient’s own doctor or a member of the team. However, it is not in the financial interest of the provider within the purchaser-provider split model that is used in the NHS.
A greater challenge is the requirement for a significant process and cultural change in the way doctors deliver care to patients. This needs to happen happen on a background of the largest reorganisation of the NHS in history, the introduction of revalidation, a push to measure performance and outcomes, and at a time when investment in the NHS is shrinking relative to healthcare needs.
Professor Mulley’s report eloquently makes the case that doctors do not understand what patients want.
On the flipside, I do not think that our leaders and public fully understand the support that doctors need to prevent us from drowning in this sea of change.