Scottish clinical strategy to support move away from ‘doctor knows best’ culture
National healthcare IT master plans generally envisage a future of more medical interventions on patients. Scotland has just published one that proposes doing less. A move to “realistic medicine” - involving fewer tests, interventions and drugs for many patients - is among the goals of a technology based national clinical strategy from the Scottish Government.
Scotland’s chief medical officer, Dr Catherine Calderwood, coined the term “realistic medicine” earlier this year to open a debate among doctors, saying that medicine can sometimes “over reach” to the detriment of patients, especially those with multiple long term conditions. Realistic medicine is about moving away from the “doctor knows best” culture”, she said. “It’s about more fully involving patients in the decisions about their care.”
The clinical strategy cites “evidence of a growing cultural shift among clinicians, many of whom feel uneasy at times regarding the level of tests, interventions and medications that are provided for patients”.
Rectifying this will demand IT and data. The strategy acknowledges that Scotland, which has one of the lowest life expectancies for men in Western Europe, is currently not making best use of either.
On IT, it notes “the adoption of some clinical IT systems across the NHS has been variable and has not kept pace with clinicians’ expectations”.
On data, it observes that not enough use is being made of “a huge array of information” on outcomes of previous decisions as well as research and analysis. When it comes to patients’ access to their own data, this is possible only in “very limited circumstances”. Today, “most people are currently unable to access their notes online, book appointments electronically, view test results or order repeat prescriptions”, even though the functionality exists within GP systems.
The strategy says that the NHS in Scotland is not planning to develop a single comprehensive electronic patient record in the short to medium term. “However, more work is required to digitise paper records and case notes, share summary information between services and partners, and manage workflow across boundaries.”
Joined up approach
The long term vision is for an electronic patient record which can be viewed and added to by both the health and care services and the patient, allowing a joined up approach to self-management and professional care. Improved electronic information sharing is required between health and social care providers and their third sector partners to ensure that the patient receives the right level of care based on all the information available.
“Electronic systems will increasingly need to support cross-boundary working as we concentrate and integrate resources to deliver the best available care, and support mobile access to meet patient and clinicians’ needs,” the document says.
One priority is electronic hospital prescribing and administration systems to replace existing paper based systems to ensure patient safety. The content requirements could usefully include patient reported outcomes and selected self-monitoring data in addition to the professional data requirements.
The strategy notes that “Over-treatment, wasteful treatment and variation” must be addressed in Scotland. “It is proposed that a significant resource should be put towards a national collaborative movement, similar to the Prudent Healthcare programme in Wales, set up to understand the scope of the issues, and to influence both clinician and patient behaviour so that wasteful and ineffective care is significantly reduced.”
Expanding the range of online services and information for patients will encourage self-management and co-production as well as more efficiently direct people to the right primary care professional, relieving pressure on GPs.
“Services will be based around supporting people, rather than single disease pathways, with a solid foundation of integrated health and social care services based on new models of community based provision.”