Realistic Medicine - Feedback Report

Annex A

Evaluation of written and email feedback

There were a total of 48 emails and letters which included a mixture of individual and collective responses. The feedback was positive and supportive of the themes and questions raised by Realistic Medicine. The overall view is that this is a suitable ambition. The "elements of this are not new, however further work is required to fully embed and change culture." There is wide spread acknowledgement of the good work already going on, as well as barriers in the current system to implement such an approach.

Shared decision making - Shared decision making was one of topics with the greatest number of responses.

There was consensus that every "clinician should be encouraged to enquire into every patient's preferences." The importance of the multi-disciplinary team communicating well and understanding the patient's wishes was highlighted: "As doctors we are involving patients in decisions much more than we used to.

However, we have to remember that we can heavily influence patients in their choice by the way we word the options."

Shared -decision making at the end-of-life and importance of avoidance of overtreatment in order to improve people's "quality of death" was raised along with the need for anticipatory care plans as a tool to potentially help with this. A national conversation with people about death and dying was suggested.

"Sufficient time" was highlighted by many as the key barrier to shared decision making. Also expressed was concern that allowing more time for improved communication would be difficult due to workload pressures. Several respondents commented that a "lack of continuity of care" makes shared-decision making more difficult. Other barriers to shared-decision making include examples where decisions are made without the patient being present, for example, in a multi-disciplinary team meeting where a treatment plan is created without the patient present. Concerns also raised included clinicians making "value judgments" about individuals' ability to engage in discussions about their own care and that patient expectations may go against simpler care options.

Personalised approach to care

Some respondents noted the need for the use of multi-morbidity guidelines rather than a focus on single conditions: "I think it will be difficult to reverse the tide of increasing investigation and treatment of patients because all the guidelines relate to single disease management."

The importance of people being at the centre of their health and care was seen as important with one suggestion being to encourage and "enable communities to take collective responsibility for health initiatives." A lot of respondents emphasised the need for political and public buy-in for Realistic Medicine to be successfully implemented.

Reducing harm and waste

"The document is helpful in challenging how our actions as clinicians, directly impacts upon patients and other health services, often adversely."

"We particularly endorse the proposals to avoid overtreatment and excessive prescribing, while increasing attempts to support individual and population lifestyle changes."

Many observed that a change in culture is needed. "A culture needs to be available that permits doctors to not over treat - for example, treating an elderly patient in community and not hospital." It is important to recognise that "our own actions put demands on NHS" and that "not following treatment plan" is often "well intentioned."

A clear theme from many respondents was the need to reduce investigations and treatment at the end of life. Personal stories were shared including the frustration of admitting "the frail elderly with multiple co-morbidities" to hospital as no other options are available. There are "two main factors in this. First, clinical confidence to watch and wait and second is public expectation."

Some respondents suggested ideas that could reduce harm and waste: "There should be nationally agreed protocols for commonest illnesses." This would also make it easier for "nurses to treat." We need to "use the learning from morbidity and mortality meetings to improve services."

Value based healthcare was suggested as an approach to reduce harm and waste. The Right Care programme led by Sir Muir Gray looks at "allocative, technical and personalised value determined by assets, resources and decisions."

Variation

There was agreement of the need to reduce unwarranted variation: "Data critical to improve variation in practice" and that there needs to be a commitment to focus data gathering on clinically driven end points. "The data should be shared globally." The "challenge lies in conditions for which a gold standard is not available."

Innovation and improvement

It was suggested to improve care we need to "encourage clinicians to question everything they do", share learning and learn from the good as well as areas that have not worked well. One suggestion was that there should be secondments to different boards to facilitate learning from one another. Data is seen as vital to innovation and improvement.

Barriers to improvement and innovation were highlighted including that some "struggle due to lack of resource." It was also noted that there is an onus on clinicians to innovate but in order to do this they need "support from their organisation in order to effect change."

One respondent proposed the development of an "online resource to spread Realistic Medicine learning."

IT and Data

For each of the subject areas within Realistic Medicine the importance of good IT and available data was reported to be critical to success. There is a need for better integration of health information, including the need to roll out of the electronic patient record: "Fully integrated IT systems with patient records visible across the spectrum would be beneficial."

It was also proposed that data needs to be collected for outcomes and shared widely, in order to compare practice and learn from this. In order to discuss risk with patients it was stated that, "There needs to be clear data available about number needed to treat and number needed to harm". It was suggested that this could link with electronic prescribing.

Respondents suggested that there also needs to be easier access to online resources for doctors.

Patient and public involvement

There was clear emphasis on the importance of patient and public involvement in Realistic Medicine.

"Realistic Medicine requires to be the combined responsibility of the healthcare team and all the clinical professionals within it, working in partnership with the patient and their carers/families to reap the added value this concept can provide."

One reflection on the balance was: "The public are in a difficult position, they are given health advice on warning signs but then stand accused of seeking medical assistance for conditions that are self-limiting."

"In order to achieve meaningful success in outcomes that success needs to be jointly defined by health professions and the public answering the question 'What does good look like?'"

Education

In order to bring in a 'Realistic Medicine' way of working, many highlighted the need for training and education. "Staff, clinician and public education will be key." "We strongly believe that staff development and training is essential to progress."

There were many comments about the need for a focus in both undergraduate and postgraduate training that would enable implementation of the principles of Realistic Medicine. These included "advanced communication skills," "data acquisition," "how to handle uncertainty," and how to "improve bedside skills."

Enabling doctors to cope with uncertainty was the skill that was highlighted most. "Challenging… that our role is to heal, sustain life and fix the problem." Developing a tolerance of uncertainty, "holding and feeling more comfortable with risk, and having the difficult discussions about futility and reality will require a change in the undergraduate and postgraduate training of doctors."

This support and education also extends to between peers. We need to try and "keep a good balance between experienced consultants and younger consultants, as the former can help with 'realistic' approach to patients and support their more junior colleagues, but the younger consultants may bring knowledge of newer ways of doing things and perhaps more of an appetite for change."

Time for reflection

It was proposed that there is a need for reflection: "one challenge is somehow allowing staff time to reflect on what and how they do things."

"Doctors want and expect to be innovators and leaders in improving outcomes for patients. To do this well, they need time in their busy working lives to learn, teach and reflect. It is good to see the CMO's strong support for this crucial part of doctors' work, and her recognition of the benefits in productivity, as well as avoidance of burnout, that can flow from it."

Staff wellbeing

Respondents suggested that the "key to this is ensuring that doctors at all levels in the profession are valued and recognised for the work that they do in delivering excellent patient care." The risk of workload pressures impacting on doctors who would otherwise be enthusiastic about embracing new ways of working was also expressed.

Permission

People expressed "fear of litigation," and "complaints" if the level of investigation or treatment reduced. "If the prevailing view is to treat or investigate then it takes a brave physician to take a more holistic view and recommend the opposite to our patients."

Offers of involvement and support

The emails also expressed many offers of support for the Chief Medical Officer and the Realistic Medicine message, and a willingness to be involved in Realistic Medicine projects going forward. These were welcomed.

Other comments and suggestions included:

"Realistic Medicine is assisted greatly by 'realistic policy'".

There is a need to "reduce [the] gap between primary and secondary care" to successfully implement Realistic Medicine.

"Caring for those with greatest need first" should be one of Realistic Medicine principles, it is included in Prudent Healthcare.

There should be "more focus on prevention."

In order "to get value for money [we]should have a much narrower publically funded formulary and annual review of medications should be compulsory."

"National planning is preferable" rather than Regional planning

One person gave a summary of what needs to be in place for Realistic Medicine to work: "In summary well trained doctors, who know the data in their field, able to handle uncertainty are essential to provide patients with realistic and personalised healthcare, within a health service using the skills of a multidisciplinary workforce, all of whom can contribute ideas around improving the way we provide care, or even better prevent illness in the first place."

Summary of conclusions of written and email feedback

• Realistic medicine has been well received.
• Across Scotland there is an acceptance that there is a need to evolve from current practice and embrace Realistic medicine.
• Key barriers to its implementation include time, data access and availability, concerns about litigation and complaints.
• There needs to be a focus on education and skills training.
• 'Shared decision making' and 'reducing harm and waste' were the main priorities that gained most support. Reducing 'over-treatment' especially at the end of life was emphasised.
• Integrated IT systems and clinically driven data are needed.
• Shared learning is important.
• Policy and 'top down' support is needed to enable Realistic Medicine.
• Public consultation and engagement will be required.

Evaluation of survey feedback

73 survey responses were received as of the end of June 2016. Feedback was from a broad range of roles and from across the Health Boards.

What is your role?

The survey asked 4 questions that required a written answer:

1. Which of the main themes do you view as the top priority?
2. What would enable you to make changes and improvements to your practice and the service you deliver?
3. In your own practice what could you do to bring about improvements?
4. What actions by others in wider health and social care system, locally or nationally, will help to bring about improvements?

The thematic analysis of these qualitative answers is reported here.

Note: quotes received in the survey are provided throughout this section.

1. Which of the main themes do you view as the top priority?

People were asked to choose their top priority. 1 top priority - 6 lowest

For those that gave their top priorities the reasons were as follows:

Personal approach to care:
Caring for patients is the purpose of and basis for the practice of medicine. Patient centredness improves engagement, decision making and quality of care.

"A personalised approach is key to a holistic approach to medicine; it is accepted now, certainly by medical educators and students, that the day of patriarchal medicine is over and it is time to move from treating the problem and move to treating the patient as a whole."

Change our style to shared decision making:
"Because we need to find a way of ensuring that patients get the treatments that benefit them and that their priorities which may be different from ours are recognised."

Reduction of inappropriate variation in practice and outcomes:
The main issues shared were the need to increase effectiveness and equity. As well as seeing a reduction in variation an achievable target.

"Concern about the obvious variation that is evident across even a small country like Scotland. While we must allow for patient choice, we must also try harder to standardise care to enhance the value delivered to patients. There are obviously many causes of variation - some "good" some "bad" - and some of the bad reasons for variation include clinician choice and an over-production that may be driven by hubris, or pharmaceutical company influence (not always direct)."

To reduce harm:
Respondents see 'do no harm' as a fundamental part of medical practice. Many reflected on the harm they had seen and the need to reduce this.

"I believe that reducing and preventing harm should be the top priority for all clinical staff. This applies not only to ensuring our interventions are safe but also that we do not intervene unnecessarily. An unnecessary intervention and the potential for resultant overdiagnosis can be more harmful than many of the patient safety indicators to which we work at present."

To manage risk better:
Risk is a core part of work and failure to manage risk properly can contribute to a range of problems.

"Educating society regarding the uncertainty of medicine and the facts of risk are essential to deliver a realistic healthcare system."

Improvers and innovators:
Improving quality of care and practice is essential but not always encouraged. Improvers and innovators require the focus as the other challenges have already the necessary level of priority or should be done anyway.

"We all have areas of practice which need improving so should learn from the best, to help reduce health inequalities."

Respondents commented that the options are interrelated and interdependent. "Through a personalised approach, shared decision making and support for improvers and innovators we will collectively reduce variation, manage risk better and as a result reduce harm."

2. What would enable you to make changes and improvements to your practice and the service you deliver?

The answers covered three broad themes: structure and management; resources and information sharing and communication.

Structure and Management
This is a need for a flexible approach with facilitation of multidisciplinary working. There needs to be "better management support" and "better working with managers."

There needs to be support for change and improvement. "Different hospitals, units and consultants communicating with each other about their different practices, and being more responsive to feedback from junior colleagues." Services need to be better coordinated.

There should be reassessment of targets and indicators. "A high level political decision to move away from a waiting time/target driven service, to one that is "user" centred in every way."

Resources
There needs to adequate levels of staffing in all disciplines including administration staff. There needs to be a reduction in the amount of paperwork and "bureaucracy."
"Time" is key for all aspects. Time for "planning and reflection" and "to focus on improvement" were particularly highlighted.
In addition there needs to be "realistic expectations from society and an honest discussion regarding what we can achieve with the resources available."

Information sharing and communication
There needs to be better access and use of data. "I need better access to IT and better data collection to look more easily at what I do now and how I could improve it. There is lots of really useful information gathered - but it's very tricky to access it as a practicing clinician."

Learning and data should be shared "across Health Boards or across Hospitals." There needs to be "improved inter-specialty communication."

3. In your own practice what could you do to bring about improvements?
The answers included six main themes: patient focus, ongoing learning, collaboration, system improvements, staffing and working practices and barriers.

Patient focus
Many expressed the importance to regain the patient focus in their own practice. "Finding time to make that difference to the individual patient, by taking an extra 5 minutes in a busy morning to ask whether someone's pain is well controlled, or discuss if they still want to take a statin at the age of 92."

Others suggested that there could be broader support for patient networks and groups. "Continue and develop strong partnership with patients and an understanding of what are the individual values."

"Engage patients in their own management - we only see them for an hour a year at most have time to give them structure and solutions to help them in their daily life. Look at systems and processes to keep them safe and away from harm."

Ongoing Continuous Professional Development, learning and reflection
The importance of taking time to reflect in order to improve was noted. "I seek outcomes of my performance to reflect and act on."

"I, like most doctors constantly self-improve through education. I also take part in audit and quality improvement. Much of which is in my free time. Admin time and improved rotas will improve this."

Collaboration
It was felt to be important to collaborate, share ideas and engage staff in order to bring about change. There should be "better cross team reporting and communication."This collaboration needs to use evidence and have an awareness of risks and outcomes.
Some respondents gave examples that this kind of collaborative work is already ongoing. "We meet on a Tuesday afternoon to work on quality improvement."

System improvements
There were examples of system changes that would enable individuals to make improvements. We need to "streamline processes." Examples included reporting, audit and improved handovers.

We need to "seek out data and challenge local clinicians to justify significant variation." We need "authentic conversations about the stuff that really matters. Increased focus on what does not add value."

Staffing and working practice
The desire to improve team continuity and stability was noted. "Better multidisciplinary working. We need to understand the roles and straits for other health care professionals before we can ask them to consider change." We must ensure a "good skills mix" and have "devolved leadership at the heart of it"
"Better use of IT to improve information management to inform decisions on appropriate investigation."

"Continue to promote a culture of responsibility for our own actions - their effect on patients, ourselves, our colleagues and the service in general." "Gain confidence in discussing with patients what interventions and treatments are realistic, proportionate and least likely to cause harm."

Barriers
A few expressed feelings that they had done all they could and that "the clinical environment" did not allow them to do any more. Some expressed the need to reduce bureaucracy and increase resources.

4. What actions by others in wider health and social care system, locally or nationally, will help to bring about improvements?

The answers included six broad themes: recognition and support for staff, remove system barriers, practice changes, broader policy changes, patient involvement, and health and social care integration.

Recognition and support for staff
There needs to be recognition and support for staff. "Compassion as a compulsory asset. In our healthcare system we must cultivate an attitude of unconditional compassion towards all our patients and towards each other." Better understanding from all staff of frontline roles. "Empowering clinicians" to make changes is vital.

Remove system barriers
There needs to be "clear messages from leaders followed by action to remove system barriers."

Suggestions for the removal of systems barriers included "Break[ing] down barriers between boards to allow better networks."; allowing easy "sharing of data across boundaries."; "Developing communication tools (ideally patient held) that ensure that important conversations are clearly documented and shared among different teams including health and social carers in primary and secondary care."; and "Investment and education in e-health across Scotland."

Practice changes
Change was supported around the way we practice in order to "shift from interventions to supporting lifestyle change." "Agreement around avoiding interventions in the morbid population, emphasis on individual valuing their own health and adapting lifestyle appropriately." There was an emphasis on continuity of care.
There were calls to "promote primary care and smooth interface with other sectors."
We need to widely share what went well.

Broader policy changes
"Politicians stressing patient responsibilities as well as rights and honesty in our achievable aims within our current constraints."

Specific policy suggestions include "minimum unit alcohol pricing" and "tackling income inequalities."

Central support was emphasised. "If supported centrally, I think that [the Health Board] could take a lead role in "healthcare by design" creating a model of engagement between public, private, third sector and most importantly our patients and carers."

Patient involvement
"Public Involvement is key to success." Good patient engagement and involvement is needed. One suggestion was a "national conversation on how to approach frailty and dementia."

Health and social care integration
"Changes in social and community care to speed and facilitate discharge from secondary care."

"Nationally I would like to see careers paid more so that the jobs are attractive and those who do that really important work feel valued for what they do."

Summary of conclusions from survey

• Agreement with the principles of Realistic Medicine and that if fully implemented it could enable improvement in care.
• Overall appetite to improve the quality of care.
• Key barriers: time, workload, relationship with colleagues, access to data.
• People currently feel they don't have sufficient time to stop, reflect and plan.
• There is a desire to move away from "target driven" medicine.
• All the key aims of Realistic Medicine are interrelated and interdependent.
• Great enthusiasm for collaboration and shared learning across departments, hospital and Health Boards and across usual boundaries.
• Multidisciplinary working, including working well with managers, emphasised.
• Patient involvement seen as fundamental.

Evaluation of social media feedback

The "Twittersphere" was generally supportive with the recognised healthcare hash tag #realisticmedicine reaching 6.7 million twitter feeds and over 3491 tweets from 1235 participants from January to October 2016. Twitter analytics showed 11 countries were reached including UK, Australia and New Zealand, Canada, Finland, Italy Japan, Norway (including Svalbard in Artic Circle) and Sweden, South Africa and the USA.

The Chief Medical Officer's Annual Report and infographic were also welcomed with one person hailing it as "the best CMO report ever" and indeed the first one to have been read by some clinicians. "This was "the only government publication that I have ever felt an emotional connection with" was one such example of how the clinical community embraced the concept of Realistic Medicine. Sir Muir Gray, pioneer in medical screening and Ben Goldacre, academic, physician and the Guardian's Bad Science columnist were some of the more high-profile Twitter followers to praise the Report. Ben Goldacre thought the report was "incredibly smart" and Sir Muir Gray thought it "one of the best documents I have read in 44 years".

There was one Tweet that was more sceptical, which questioned how realistic medicine could be implemented without also having realistic politicians, media and patients.

Other issues raised in Twitter were:

• How Realistic Medicine had spread across Scotland and the globe:
  "America starts to catch up #realisticmedicine"; " TED residency idea worth sharing"; "#ChoosingWiselyCanada on how we, as patients, can help deliver #Realisticmedicine"; "Refining this poster [the Realistic Medicine infographic] for imminent launch in @NHSBorders". We're up for this";

• Agreement with the concept and the engagement programme led by CMO and her team:
  "Inspired hearing @CathCalderwood1 talk about #realisticmedicine. How do [sic] doctors add value and help navigate health in complex system?"; "Ace day yesterday talking about #minimallydisruptivemedicine and Scotland's planned realistic medicine healthcare"; "More medicines, but less healthiness "long on quantity, short on quality" "Read this -then read it again...then use it to plan the future"; Chance of harm reduced by stopping unwanted (by patient) admissions and treatments #realisticmedicine";

• The importance of communications and a person-centred approach:
  "Communication skills should be taught and developed. Shared decision making involves listening not just info giving"'; "The probability of death stubbornly stuck at 100%. We need to have balanced conversations about when to treat"; "High intervention doesn't necessarily mean high satisfaction!"; Doing what patient wants challenging everywhere. #realisticmedicine in Scotland aiming to change that".; "Key role for relationship continuity and trust if de-prescribing is to be achieved." "Increasing monetary spend does not improve patient or family experience in end of life care, it may make it worse #realisticmedicine #tEAMed"

• The importance of training for the care and support workforce:
  " #realisticmedicine does anyone know if we teach risk assessment principally in medical and nursing schools? And in general education?" "We need to train junior doctors that sometimes non action is preferable to action".

• The importance of shared learning and data to bring improvement:
  "Understanding of data is key to implementing meaningful change for our patients"; "we should have 'Never Do's' alongside 'Never Events' to eliminate unwarranted variation #realisticmedicine"; "Reducing variation requires Healthcare professionals to swim against the tide. Need strong swimmers"; "we must be connected 2 Discovery 2 reduce variation & increase outcome based care #realisticmedicine each dot is a patient"; " @profchrisham tells #nhsscot16 about the risks and costs of unwarranted variation and over prescribing #realisticmedicine"; "I'm going to start wearing a badge: 'Want to understand your variation in care? Ask me how!' "Great idea to reduce OPD appointments - we should make this happen"

• Spreading Realistic Medicine beyond doctors to multi-disciplinary teams: "Fed up seeing nurses taken away from time to care by wads of paperwork. Maybe we need #realisticnursing?"; "extra time for nursing means less medications and more shared decisions"