25 Sep, 12 | by BMJ Group
There is increasing acceptance that the current model of healthcare is wrong. Rather than episodic care triggered by acute events and delivered in hospitals, there needs to be continuous care that includes the patient as a key asset able to self or co-manage his or her condition(s). So much of the discourse on the future care model focuses on educating patients but if the general idea is to provide more care in the community surely we also need to think about the levels of knowledge amongst community-based clinicians?
Imagine a model in which what we know about a condition can be broken into five levels. Right now, we often drag patients into hospital for anything from levels 1 to 5. In the future care model patients are encouraged to act upon things within level 1; level 5 is what the super-specialist acts upon, with level 4 being what a specialist acts upon. This leaves levels 2 and 3 to distribute amongst community based clinicians.
During my primary care attachment at medical school I was told that general practitioners’ primary role was to act as a nationwide triage service. While this may be a simplification, I see this as level 2—the knowledge needed to know when something is serious and requires intervention.
Proponents of the future care model, then, are asking GPs to take on level 3—essentially what is currently early specialist management. This is easy to say but in my view hard to do for two reasons.
Firstly, early specialist management is more complicated than it has ever been. To illustrate this, I have pulled out guidance for anti-hypertensive treatment from 1993 and 2011.*
In 2011, the National Institute for Health and Clinical Excellent (NICE) described step one of antihypertensive drug treatment as (you don’t have to read it all the way through):
- Offer people aged under 55 years step 1 antihypertensive treatment with an angiotensin-converting enzyme (ACE) inhibitor or a low-cost angiotensin-II receptor blocker (ARB). If an ACE inhibitor is prescribed and is not tolerated (for example, because of cough), offer a low-cost ARB.
- Do not combine an ACE inhibitor with an ARB to treat hypertension.
- Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged over 55 years and to black people of African or Caribbean family origin of any age. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic.
- If diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.
- For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide.
- Beta-blockers are not a preferred initial therapy for hypertension. However, beta-blockers may be considered in younger people, particularly: those with an intolerance or contraindication to ACE inhibitors and angiotensin II receptor antagonists or; women of child-bearing potential or; people with evidence of increased sympathetic drive.
- If therapy is initiated with a beta-blocker and a second drug is required, add a calcium-channel blocker rather than a thiazide-like diuretic to reduce the person’s risk of developing diabetes.
In 1993, the World Health Organisation and the International Society of Hypertension described the initiation of treatment thus (it’s worth reading this to get a sense of how vague it is):
Several classes of drugs can be recommended as first line treatment of mild sustained hypertension. They may be listed in order of proved benefit based on mortality-morbidity studies as, firstly, diuretics; secondly, β blocking drugs; and, thirdly, angiotensin converting enzyme inhibitors, calcium antagonists, and α adrenoceptor blocking drugs.
The average reduction in blood pressure induced in groups of patients by each of the different categories of drugs is similar, but there are large variations in the reductions in individual patients. The appropriate choice of a particular class of antihypertensive drugs for a patient may also be determined by the person’s other characteristics because differences in the risk profile and in side effects are extensive in different patients.
The choice of the initial drug treatment for an individual patient is a challenge for the physician and should not be restricted on theoretical or economical grounds to any one or two of the various classes of drugs which have been tested so far, although it is also the physician’s responsibility to give due consideration to cost.
In 18 years, our deeper understanding of hypertension has meant that clinicians need to explicitly consider:
- The age of the patient
- Which drugs cannot be prescribed together
- The ethnicity of the patient
- A consideration of co-morbidities
- Whether the patient is pregnant
- Avoiding increasing the risk of other diseases
And this is just hypertension—a single, if important, condition. Consider how much more there is to remember across all of the major conditions.
The second reason why it’s hard for GPs to take on more specialist management (what I have called level 3 of what we know about a condition) is that specialists will be reluctant to let them do so. Specialists rely on their training to interpret what they see and make decisions. If the future model of care relies on them “letting” less specialised colleagues perform what was “their” duties there will be an understandable degree of discomfort, if not open resistance.
I used to be the Medical Director of Map of Medicine, a company that produces clinical pathways to help local communities design services. I met countless local leaders—managers and clinicians—that wanted to redesign pathways so that GPs handled more patient care. The prevailing view seemed to be that by putting the information into a pathway, GPs would know what to do and specialists would relinquish their previous sphere of responsibility. We saw this especially in endocrinology, cardiology, rheumatology, and nephrology, perhaps because, as we saw in the hypertension example above, clinical knowledge has become so refined that early specialist care can be systematised into logical steps.
It really is not that simple. Just because the knowledge can now be reduced to logical steps it does not mean that people, especially clinicians, are going to be comfortable delegating more of what was their sphere of responsibility to a less specialised colleague. You see this also playing out in how reluctant many clinicians are to let patients handle more of their own care.
If we’re truly going to change the model of care we first need to understand how different levels of knowledge can be delegated across those involved—from the patient to the super specialist. We then need to ensure that at all levels people understand the “hand off” points, the ways in which one level segues into the next and responsibility goes from one person to the next. For instance, the specialist needs to know that while the patient is handling level 1, the GP is keeping an eye out for things in level 2, can administer level 3, and will approach the specialist for level 4, if required. The specialist, of course, will also be able to approach the super-specialist for level 5, if ever needed.
Does all this sound complicated? It’s not, but at the same time it won’t be easy to implement. However, this kind of strategic approach to knowledge and responsibility management is, in my view, what’s required to create the one thing that is essential to the future model of care – trust. Trust between all clinicians and patients will be the glue needed to hold the future model together, especially in its experimental infancy.
Competing interests: I do not have any competing interests relevant to this post, although I did recently describe the above model to a prospective client.
Pritpal S Tamber is the director of Optimising Clinical Knowledge Ltd, a consultancy that helps organisations improve how they use established clinical knowledge. He was previously the medical director of Map of Medicine Ltd, a company that creates clinical pathways to help health communities design services. He was the editorial director for medicine for BioMed Central Ltd and he was also the managing director of Medicine Reports Ltd. He has twice been an editor at the BMJ, the first time as the student editor of the Student BMJ.
* This has been corrected post publication. The sentence orginally said, “guidance for anti-hypertensive treatment from 1983 and 2011.”