Matt Hancock, secretary of state for health and social care, has published a report, The future of healthcare: our vision for digital, data and technology in health and care. This sets out plans for a fully digitised NHS. The paper record is gone, history. Data will be cloud-based, many consultations will be virtual, and internet connectivity will be high speed. Matt Hancock wants to make the NHS a world leader in digital tech innovation. “NHSX” – “a specialist bridge between the worlds of healthcare and technology” – is due to be launched next month.
The reaction of the Royal College of General Practitioners to the proposed initiatives has been, I would say, lukewarm. Fix the basics first, is the broad message. What is the point of having your head in the clouds if the computer keeps crashing and it can’t even print out a prescription?
I read about this in Insight, a quarterly publication for members of MDDUS, the Medical and Dental Defence Union Scotland, quarter 2, 2019. In the same issue I also read about a new British Medical Association survey which has found that eight out of ten doctors are at substantial risk of burnout. The BMA surveyed 4,300 doctors and found that more than a quarter of them had received previous, formal diagnoses of mental conditions, and four out of ten said they were suffering from psychological or emotional distress which affected their work, training or study.
I wonder if Mr Hancock is familiar with the biochemical concept of the “rate-limiting step”. You have a series of biochemical reactions – say the Embden-Mayerhoff Pathway that converts glucose to pyruvate, prior to its conversion and insertion as Acetyl-CoA into another pathway, the Krebs Cycle, critical in energy production. All of the reactions take place at a certain rate. In any such sequence there is a specific reaction that will be slower than any of the others. The entire process can only function at the speed of its slowest component. We had to learn these pathways by heart at Med School. They are very beautiful entities, but to be honest, intimate knowledge of them doesn’t have much direct application to clinical practice…
…except in one way. Things they don’t tell you at Med School: in the emergency department I became aware of the fact that the processing of a patient through the system is usually governed by a rate-limiting step. It pays to identify, early on, what that step might be, and set it in motion. For example, if you realise the patient will need a specific investigation that will take time, order the investigation early. Don’t wait until you’ve done everything else because you will waste time. The rate-limiting step will dictate the shortest possible length of time within which your patient can be managed.
Consider now the current waiting times experienced by patients in the community. It is well recognised that many patients requesting a GP appointment may have to wait for a fortnight before they are seen. Imagine they have a neurological problem necessitating referral to an NHS neurology out-patients clinic. It is well recognised that they may need to wait for six months, or even a year.
Consider now the contribution of Mr Hancock’s “super-fast broadband” towards shortening the duration of the rate-limiting step. It is evident that digital technology’s potential to ameliorate the inertia of the NHS is negligible.
We have to remind ourselves, constantly, of what Medicine is. What does Medicine attempt to achieve, and what are its procedures? What, if you will, is the Embden-Meyerhoff pathway of the medical consultation?
It never varies. I should say, it should never be allowed to vary. The patient meets the doctor in an environment that is quiet, secure, and confidential. The rituals of courtesy are observed. Then the doctor asks the patient what the problem is, and then he sits still and listens intently. Under no circumstances should he emulate the interviewing techniques of Andrew Marr or Fiona Bruce or Jonathan Dimbleby or Emily Maitlis. He must be completely quiet, and receptive, so that he steps into the patient’s shoes. For a moment, he becomes the patient. This act of empathy, the taking of the medical history, very often turns out to be the consultation’s rate-limiting step. It is always, without exception, its most important component. It has got nothing to do with a computer, a smart phone, a manager, or a Health Secretary.
Medicine is an intensely human activity. The medical consultation, with the medical history at its core, is the essence of what any medical practitioner with direct patient contact does. Get the medical consultation right, and all else will follow. I should translate this into practical, workaday terms. A full-time GP should offer something like 20 to 25 consultations per day (fifteen minute appointments) to a maximum of 100 consultations a week. Down south, the RCGP needs to tell that to Mr Hancock.
To give you an idea of how desperate they are down south, last night I got an emailed job offer from a GP recruiting agency for a locum (5 day working week) for the month of July on the south coast. Remuneration: £27,650.
I said no.