Orthopaedics - Don’t turn a good idea into a bad one
Common Weal hasn't had a chance to examine a leaked plan for reform of orthopaedics in Scotland but there is enough in the reporting of a leak of the plan to give some indication of where it is going. It looks like it has some sensible proposals but it also shows why sensible reforms in a system under duress may not work as intended.
The headline is that the government may drop its 12 week treatment commitment, but that is a consequence rather than the intention. The problem is simply that demand is outweighing capacity just now and so it is pushing waiting times up.
At the heart of the proposals in the document are 'regional centres of excellence'. While the aspirational language is annoying (these are simply units which specialise, precisely not excellence but rather efficiency at something routine), the principle is sound. There are some procedures in medicine that are routine and repetitive and best organised on a 'conveyor belt' model.
The current case study in Scotland is the way the Golden Jubilee Hospital has specialised in for example hip replacement. This is a routine operation carried out in the same way. Last year Scotland averaged over 50 hip replacements every day of the year (18,700 in total). The average time in hospital has been reduced from five days to 2.6 now.
Organising these on that 'conveyor belt' method is the reason for the sharp efficiency increase. So yes, this is an example of 'service centralisation', but it is a version of centralisation that makes sense. Most people will have no more than two hip replacements in their lives (though replacements of replacements are becoming more common).
The efficiency of a service that cuts almost two and a half days from hospital in-patient time clearly justifies a one-off journey to a specialist centre further away. There are a number of similar procedures – joint replacements, but also cataracts removal, hernia treatment, laser surgery and more.
These are treatments that are done rarely enough (for the individual) that the centralisation model works. In fact this is exactly how the Danish health service turned around its waiting list problems. Not only did it specialise, it streamlined triage and preparation (in Britain the surgical team do much more of the preparatory work on patients before surgery and that is not an efficient use of specialist time).
For example, in one kind of surgery they found that they got better outcomes with people trained specially in patient care and preparation with the surgical team concentrated much more on purely the surgical procedures.
But there are two caveats to this. The first is that this kind of approach can become a tempting solution for policy makers. Common Weal has been proposing a more Danish approach to our system for a number of years. But that is only half of what we've been arguing.
Because the other half of healthcare is entirely the opposite. When the need for routine surgery is identified it is best delivered quickly and highly efficiently. But the process of identifying what medical treatment is necessary is anything but routine.
This is the big risk. The fact that some aspects of health services are better done via centralised specialisms focussed on efficiency should never obscure the fact that most medicine is complex and does not offer quick, simple answers. Trying to force diagnosis to move faster is a very big mistake. It takes time to explore what is wrong successfully.
That is why our approach to health was titled 'Time to Heal'. While routine procedures get better outcomes from moving faster, diagnosis and some treatments suffer greatly from being rushed and get worse outcomes which in the long run become much less efficient than if time had been taken.
The centralised specialisation of some services should have the purpose of releasing more time to do better at the other aspects of a healths service, not to temp managers into even more central control over how medics operate.
But there is also a second issue. Denmark did this agains the backdrop of a much more effective public realm generally. They planned the location of their specialist hubs, often building them directly on motorways to make access easy. And they have strong public transport links. In Denmark travelling a little further for care just means a little more time.
In Scotland it may mean complex planning just to reach the hub. Clydebank is not where you'd immediately think of positioning a high-volume care hub given transport realities.
The outline of these plans looks solid, but there is a risk that we fail to learn that dropping good ideas onto bad foundations can make them bad solutions. And there is a bigger risk that policy makers take good ideas and cannot stop themselves extending them to places where they become very bad ideas. It would be good to get this right this time.