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Tackling some of the tribal divisions within health

Attending recent conferences, I was struck by two comments which, in their own ways, say much about the silos and divisions within the health sector.

During a session where GP registrars were brainstorming ideas for improving the image of general practice, someone suggested that specialists should be re-named “partialists”, as a way of highlighting the value of the generalist.

(As a by-the-by, I’ve never quite understood why general practice has been so desperate to be viewed as a specialty given the many merits of a generalist workforce and the acknowledged downsides of a specialist-based health system. Maybe, just maybe, it’s something to do with the skewiff remuneration system…)

The other comment came during an informal conversation at an Australasian College of Health Service Management conference, where one battle-weary state health bureaucrat suggested that taking the states out of healthcare (ie having a federal/regional system) would, amongst other things, “remove one layer of hate” from the system. Some of the context to the discussion was the fierce tribalism and competition that goes on, whether between professions, services or bureaucracies.

No doubt many different interpretations could be drawn from these comments but for me a linking thread is the need for systematic efforts to build more cooperative, collaborative relationships between the many tribes of health.

One of the more interesting presentations at the Association of Health Care Journalists conference in Philadelphia last year was by Associate Professor Christine Arenson from the Thomas Jefferson University in Philadelphia, which has pioneered interprofessional education.

This has been defined as: “The collaborative process by which teams of health professionals develop curricula and courses, coordinate and plan practical experiences jointly, and team teach groups of interdisciplinary health professional students to provide holistic care throughout the lifespan.”

Arenson, Co-Director of the Jefferson InterProfessional Education Center, said the historic silos in health professional education have had profound implications for patient safety, as the various professions have not learnt from the outset about each others’ competencies, scope of practice, or how to work effectively together.

“We have a health care system which has been driven by professionals in competition with each other for scope of practice and perceived increasingly scarce dollars,” she told the conference. “One of the first things many industries do is train them to work in teams. We’ve never done that, we have just assumed they will figure it out.”

Her university brings together students from medicine, nursing, physical therapy, pharmacy, couples and family therapy, and occupational therapy. Arenson described some of the difficulties of the long journey to introduce interprofessional education, which included breaking down some of the barriers between faculties.

“We had to bring people to the table together to get to know each other and to develop trust,” she said. “It takes a lot of time and resources. Our experience shows that it requires a tremendous amount of leadership at most senior levels of the organisation.”

All of which is a long-winded introduction to the piece below by Professor Peter Brooks – a longstanding, vocal advocate of the need for health workforce and education reform, and Director of the Australian Health Workforce Institute at the University of Melbourne.

In the column below, first published earlier this month by Medical Observer, he suggests that every health professional should rise each morning and ask themselves ‘what did you do yesterday that could have been done by someone else?’

***

Try task shifting – it could set you free

Peter Brooks writes:

How can we go on delivering high quality healthcare with an ageing population of health professionals and an ever-increasing demand for our services?

The cost of healthcare is getting out of hand with healthcare costs increasing at a much greater rate than GDP and with most state governments spending about 30% of annual new spend on health.

This is not sustainable even in the short term, so we need to think of other ways of delivering services – just like every other industry over the past 30 to 40 years.

Think how the banking industry, construction, legal have changed the way they do things, altered the skills mix of workers and seen how they can improve productivity.

Our dental colleagues have embraced this with gusto. Do you spend all the time with the dentist? No way – you see the dental technician, the hygienist and sometimes the dental assistant – always the dentist albeit briefly for the bill. We need to do the same – but urgently!

The Productivity Commission Report into Australia’s Health Workforce (2006) suggested that it was 20% inefficient – with significant differences between the public and private sectors. Has anything changed? Not much.

We are starting to slowly engage nurses and allied health professionals with some tasks but we get bogged down in demarcation disputes or regulatory issues.

We must do more; there is a whole range of tasks that we, the medical profession, could delegate to others. Do we really need to fill out repeat prescriptions, carry out medication reviews, review chronic disease or carry out routine procedures such as gastroscopy or even simple anaesthetics?

Other countries have nurse anaesthetists, colonoscopy technicians and a raft of other ‘assistants’ who work in a team situation through a delegated care model.

How come the US, Israel, Canada, UK and Europe can embrace physician assistants (PAs) and deliver equivalent care to more patients and yet we cannot seem to recognise them despite trials in South Australia and Queensland? These studies showed that PAs worked well within the health system, delivered high quality care and were well accepted by patients and other health professionals.

In other parts of the world they teach medical students, and in private practice actually increase practice income by allowing more patients to be seen.

Every health professional should rise each morning and ask themselves ‘what did you do yesterday that could have been done by someone else?’ You will be surprised at the response.

Accept it not as task shifting but liberation – allowing you time to work to the top of your scope of practice and not have to do mundane tasks that could be done by someone else.

New models of care are also about using technology, telehealth, smartphones and other devices to help us (and patients) save time – think of the time saved travelling or waiting in doctors surgeries/hospitals if 20% of consultations could be done by phone.

It is happening elsewhere and we are not engaging in these innovative practices. What a service we could provide to rural and remote areas if we really used technology sensibly and developed proper trials to assess its value and cost effectiveness.

It’s taken about 20 years since the benefits of telehealth were first known for it to get item numbers, but let’s hope we don’t have to wait that long for an item number for a phone consultation.

***

Update (2 April):  On related themes, this post by an NHS hospital CEO, Dr Mark Newbold, stresses the importance of collaboration in health.

He says a culture of openness is more powerful in facilitating collaboration within an organisation than either a decentralised structure or technology. He writes: “Relationship-building and openness are key, alongside the maturity to set narrow goals aside in favour of joint working aimed at achieving larger, shared ambitions”.

Newbold describes himself as “very interested in creating a more open and engaging style of hospital management, and in exploring new models of hospital service provision through collaboration and community integration”.

Comments 2

  1. interestedperson says:

    Peter Brooks is right of course. Demarcation in the health industry is much more rife than in most other industries. Many unions are scorned for their demarcation squabbles but at least their various territories are marked out and protected overtly. In the health industry, the protection of patches is masked in professional double speak and implicit hierarchic institutional arrangements.
    And, yes, let’s use technology to save time waiting for health services. We are currently designing a major health centre and I complained mightily when the architects produced a plan showing a large area titled “Waiting Area”. Why should we presume that sitting around waiting is necessary these days when communications are so flexible and accessible?

  2. fionamc says:

    I enjoyed reading Melissa Sweet’s article. As a non-health professional working in the health sector to promote interprofessionality I find the antagonism sometimes found among the various disciplines frightening to say the least. I would recommend that all read “The Velluvial Matrix”, the title of a speech given by Atul Gawande to the commencement class at the Stanford School of Medicine in 2010 which can be accessed at

    http://www.newyorker.com/online/blogs/newsdesk/2010/06/gawande-stanford-speech.html#ixzz14vV6jW8T

    I have included here the final section of the speech
    ” When you are sick, this is what you want from medicine. When you are a taxpayer, this is what you want from medicine. And when you are a doctor or a medical scientist this is the work you want to do. It is work with a different set of values from the ones that medicine traditionally has had: values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and, perhaps above all, humility—for we need the humility to recognize that, under conditions of complexity, no technology will be infallible. No individual will be, either. There is always a velluvial matrix to know about.”

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