Points of View

Clinical decision-making behaviours driving demand for healthcare

1 – Two million clinical decisions every day in the NHS

Why have we have failed to manage demand for healthcare?

The established, rather passive view is that demand is driven by demographic changes, technological advances and rising expectations.

The corporate response has been technical through QIPP schemes and financial instruments such as pricing and incentive schemes along with “whole system” pathways and patient flow methodologies. More recently through Population Health and its well placed desire to target resources to those most in need, but having no mechanisms to stop doing things for those least in need.

Looking at variation in care, both in supply and outcomes, is a promising tool, but it tends to lead again to redesigning pathways and systems rather than highlighting attitudes and beliefs.

In our blind spot is the fact that every day sees 2 million clinical decisions in the NHS. Each of these decisions is based upon a behaviour that reflects a clinician’s learning and organisational culture.

If we are serious about targeting our resources effectively, we need to take good hard look at clinical decision making as a behaviour and take collective responsibility for it.

2 – An ethical dilemma…what is the right thing to do?

I have been a GP partner in the same practice for 28 years. Focused on the practical aspects of the here and now of everyday clinical care. Ethics seems like a remote privilege for clever people in academic departments.

Ethical theories give us a structure for understanding what is the right thing to do in a given set of circumstances.

The NHS was set up in 1948 in a welfare state as a utilitarian construct which has not changed. The right thing to do being the thing that benefits the most number of people within a finite budget.

For this to work it requires us as individuals to behave in a utilitarian way, if your problem is worse than mine, you can go first, I trust the professionals to make the best decisions and recognise that things can go wrong.

Society has changed, people have been actively encouraged to become consumers. If I want something and can afford it, I shall have it. Our definition of the right thing to do has become egocentric, ie what is best for me.

The egocentric approach rejects the passive acceptance of what is on offer. Individuals make their own risk decisions regardless of the impact upon another person. Trust is placed more upon oneself than on the judgement and benevolence of others.

Neither utilitarianism nor egocentricity is relatively better or worse than the other. But the problem for the clinicians in the NHS is that the planners plan in a utilitarian way and clinical practice is now based upon an egocentric culture, drives up demand and breaks the budgets.

This ethical dilemma plays out in the consulting room, on the ward, in the clinics and emergency departments.

 If I said you have a 1 in 10 chance of having cancer, would you like me to do some tests? I guess you would, but what if it was 1 in 100 chance, or 1 in a 1000? The tests are free by the way. NICE guides us to a 3 in 100 risk level. In a practicing lifetime doctors will meet patients with a 1 in 1000 chance and its not NICE that the patient takes to court when their cancer has been missed!

I was trained to work in a utilitarian system in which GPs managed clinical uncertainty through long term relationships with patients and their communities and being able to use the passage of time as a diagnostic tool. In an egocentric society, clinical practice is based upon fear, we are taught to protect ourselves through tests and second opinions, in pursuit of clinical precision.

This is the behaviour which is increasing demand, it is probably not good for patients and threatens the existence of the NHS.

3 – The Corporate Blind Spot

The utilitarian/egocentric clash of cultures is driving a worrying divide between the corporate and the clinical communities.

With the NHS financially constrained by cost of increasing demand, the corporate community (planners and managers) is focussed on the utilitarian need to live within its budget. The response to this corporate risk is all the governance systems and processes that any large organisation must have. Its not a lot different to running a large hotel, more about the form than it is the function.

The clinical response to this corporate risk is what I have been subjected to throughout my years as a GP and what clinical leaders have been required to lead, ie prescribing budgets, referral processes, incentive schemes etc. These are not clinical objectives, I do not go to see a patient to perform admissions avoidance!

Clinical risk is about not making mistakes and we have a clinical approach to it, Clinical Governance. This works well, but with an egocentric hat on, driving clinicians to risk avoidance and fear based medicine, ie more clinical stuff!

The blind spot: What is the corporate approach to the clinical risk?

If we, both the clinical and corporate community, understood the behaviour of clinical decision making, and we acted together to address the fear of getting things wrong, would we reduce demand? I think so.

4 – Influencing clinical decision making behaviour, the job to be done

Organisations spend money on some good technical things that consultancies sell them, such as organisational development, pathways design, financial risk models. But the hard stuff is the soft stuff, how much do we spend on change management, ie behaviours?

Clinical leaders are chosen because they have the skill to bring the clinical community to managing the corporate risk, but do we really value a clinical leader who reminds the board of the clinical risks? I have seen so many good clinical leaders moved on because they are perceived as not moving away from their clinical colleagues.

Every clinical community can sit down with its corporate community and define its own clinical decision making framework, here is a suggestion, its not perfect, but its good enough as a starter.

Once all of the elements of decision making are understood, through the clinical risk lens, not corporate risk lens. A focus on those elements which are in the gift of the clinical community can create a range of interventions that the corporate community can support.

If demand problems apply to your organisation, start a new conversation. Take your eye of the financial ball, understand the clinical behaviours, support decision making, and the money will look after itself.