In the Californian sun, near a beach 20 miles from the Mexican border, a man and a woman are talking:
“You don’t respect me – you can’t even look me in the eye.”
“But you just don’t understand my priorities – I need you to get to the point, to be ready for me.”
Not some US daytime soap opera, but the dialogue generated by a Kaiser Permanente away day aiming to improve communication between doctors and nurses. Using a parallel with “Men are from Mars, Women are from Venus”, the facilitator explains how nurses tend to be more interested in the quality of interactions between people, doctors more concerned with processes and performance.
The results of poor communication and collaboration between the professions were set out: duplication or omission of care; worse patient outcomes; increased frustration; decreased morale; and rising staff absenteeism (resulting in the normal ratio of 1 nurse to 4 patients on a typical med/surg ward increasing to 1:10 at the worst times). But the Kaiser leadership, both administrative and physician, also stressed different types of impact: reduced quality and patient satisfaction scores; decreased membership (i.e. enrolled patients); and falling revenue. The morning session ended with a call to arms: “We’re all on this journey to excellence together. We all have our parts to play to make this business flourish”.
In these days of increasing healthcare costs and competition for enrolled members, it is not enough to be a high quality provider – that’s taken as read by healthcare consumers. Instead, the focus is sharply on customer service - in part, as a component of good clinical care. But perhaps the main driver is really the American culture of getting what you pay for – and as people are paying significantly more and more for their healthcare each year (average healthcare premiums for an individual in 2010 were $421 [£270] per month plus co-pays and deductibles up to several thousand dollars per person per year), so they are demanding more and more from the providers of that care.
And providers are responding. In San Diego, the Kaiser Permanente hospital is 40 years old. Inside, it’s like any standard hospital and most NHS staff would not feel out of place here. It has also just been voted Top Hospital in the county by LeapFrog. However, to some Kaiser staff, it’s a dreary scruffy tired facility, and the hunt is on for land on which to build a brand new facility – bigger, with more services, more kit, and earthquake-resistant (not something that usually bothers NHS planners!). The search for a suitable location is complicated by the need to avoid airspace restrictions (the city is a major defence posting), the need to be accessible from freeways – and the need to be in the right part of town, somewhere where the Kaiser brand will be easily visible to as many people as possible, and close to the middle-class residential areas of the kinds of members Kaiser wants to attract. Certainly, not too close to the Mexican border – the swathe of non-Kaiser providers located in southern San Diego neatly soak up those patients that travel across the border for healthcare or other reasons before they have to travel as far north as the existing Kaiser facilities.
Whilst physicians and nurses to some extent work oblivious to these decisions, they are involved in other methods of ‘managing the competition’. When a neighbouring hospital started to claim its specialist care had been rated top quality in the county (though not, this time, by LeapFrog), Kaiser were quick to point out that most of the specialists were actually Permanente physicians using that hospital’s facilities to care for their patients whilst Kaiser expanded its own facilities. Kaiser also makes it easy for good physicians to come work for them: Permanente physicians are shielded by their medical group from the growing bureaucracy, coding and billing requirements that many of their peers in other arrangements have to deal with, thereby allowing them to concentrate on being clinicians.
This use of customer service as a driving market force is in train across the country. So-called ‘concierge’ medical practices are shooting up in large cities on both coasts. Based in a patient environment more akin to a top-end hotel, they offer same day 20-30 minute appointments with a dedicated primary care physician, complemented by cellphone, email and web-based access, for an annual fee. For consumers over here, that’s new, exciting – and growing in popularity.
The emphasis on consumers is, in many ways, promoting better standards of clinical care: better communication with patients about their management means less over-use and misuse of tests and treatments and under-use of preventive measures. But in some ways, it is also worsening the inequities in healthcare delivery: private providers are competing for those consumers with whom they can most easily communicate: the educated, employed middle classes. The planned expansion of health insurance to the whole population will see a new class of insured patients potentially able to access these providers – but can the level of customer service currently being provided be maintained at lower margins? Some have expressed their doubts …
The moral of the story for the NHS is, to me, two-fold. Firstly, customer service, whilst important, cannot become the overriding value in the service: to do so will at the very least sacrifice equity and cost-effectiveness. Already, the policy of ‘any willing provider’ coupled with the NHS being free to all at the point of delivery sets England’s healthcare market up for just the sort of two-tier healthcare that the US is experiencing.
And secondly, if choice is part of providing good customer service, then the NHS is going to have a problem. The population of San Diego has a choice of services at (at least) eight major hospitals, each competing for the same insured population and each of which has on average 400 in-patient beds. The equivalent sized population in England would have a choice of three, maybe four, similarly-sized hospitals. Given the size of the financial challenge facing the NHS, providing US-style consumer choice is going to be simply fiscally impossible.