A Digital Idiot's Thoughts – and a few other random reflections

by David Gilbert

September 11, 2015

More random thoughts than in-depth discussion this time. This reflects my hard week – only a few brain cells left. Three stories…

  1. Can digital stuff help tackle inequalities?

I seldom delve into the digital world. All I can do is Twitter and blogging, and I am overawed by people like Annie Cooper, Victoria Betton and Michael Seres who do enough in this space to satisfy the curious - and Michael always tells me off when I say idiotic things 🙂

But I was intrigued when the aforementioned Seres sent me a short article that challenges the cosy assumptions of digital evangelists. It stated that wearables (FitBit, the Apple Watch, etc) are a “pretty idea” but that “health wearables, at least so far, have very little to do with real care issues, the ones that are costing the US billions to treat every year. For the most part, health wearables are worn by the ‘healthy and well’ “.

I am seeing in my Sussex role how tricky it is for NHS organisations to risk investing in such a volatile and complex arena – which ideas one should ‘take a punt on’, and I challenged twitterites by suggesting that they will do little to ease inequalities. That raised the hackles of a few, and I was told that, with prices coming down (as they have always for new technologies) poorer people will be able to afford this stuff. But that wasn’t quite my point. Prices for all sorts of stuff has come down, more people can afford pretty things, but that doesn’t mean equalities reduce.

I am left pondering: With health inequalities growing, can digital technologies help? If so, how? And who needs to do what to tackle this. Answers on a (digital) postcard, please.

  1. Who decides?

I believe that patients and citizens must be involved in difficult decisions. And nowhere is that more true than in decisions about who gets access to what treatments. In Sussex, we have been discussing guidelines on arthroscopy (a form of knee surgery) that is sometimes unnecesarily done; I have run citizens juries in the past on whether or not to close a local A&E. And I have seen an old friend, who was a health authority manager, pelted with rotten veg when trying to have a public debate about the need to shift services.

The last story perhaps explains why commissioners are so eager to ration services behind closed doors. I was intrigued by a HSJ article that states that one third of CCGs ration (or plan to) ‘non-essential’ treatments. This includes acupuncture, specialist fertility services, non-urgent elective (planned) surgery (‘on the basis of whether patients smoke or are overweight’), hearing aids, surgery for sleep apnoea, hysterectomy for heavy bleeding, fat  grafts, hair depilitation, earlobe repair, chin, cheek or collagen implants. Also, interestingly from my now MSK (musculo-skeletal perspective) post-operative physiotherapy.

I have no doubt that much of this is ‘evidence-based’. I also have no doubt that there are many professional and corporate assumptions being made about ‘worthiness’ of interventions. And similar assumptions about need that strike me as akin to wider societal discussions about the ‘deserving poor’.

However, I don’t know. And we don’t know. Because these decisions are (I am assuming here!) being made largely in secret.

Shouldn’t patients and citizens (who, don’t forget use and pay for the NHS) be involved in these decisions? There are ways to do it - difficult, messy, controversial admittedly - but doable. And, in the long term shouldn't we treat each other as adults? As the inspirational Rebecca Myers says: "We need to discuss difficult issues together and stay at the table"

I met with the always remarkable Paul Hodgkin this week, and we discussed the might of those professional leaders who held what we deemed ‘interpretive power’ – those who interpret data, or the world around them, in order to create meaning and value. These are the ones who say ‘this is what matters’ and that is not - whose power is often unassailable. I sense a few of those types hanging around in CCGs deciding whether or not people are 'too fat' to deserve surgery.

  1. The last few minutes

A few weeks ago, I shadowed an inspiring spinal practitioner called Sally York in one of our local community clinics. I watched her skilfully assess patients for 30-40 minutes before asking them to sit down, and explaining to them their diagnosis, condition, treatment and how they could look after themselves. She was masterful at ‘shared decision making’ and the provision of information. She looked patients in the eye, turned her computer screen towards them so they could see what she was writing and checked their understanding. And most of them nodded.

But I could see patients’ eyes glazing over. It looked to me like this information was sailing way over their heads; that worries precluded them from comprehension; that pain and tiredness just told them to get the hell out, go home and rest. They had been prodded and poked, lain down and stood up, tapped on the knee with a little hammer and looked absolutely knackered.

I mentioned this to Sally later (she, like the best clinicians, was hugely welcoming of feedback), and together with other clinicians and patients, we are going away to devise better ways to provide information - so that patients can go home with the right information, advice and support. I like to think that having someone like me providing a different perspective can help - in the little, but important matters like what goes on in the clinic, right through to strategic decision making on subjects like rationing and the future of digital technology... which brings us back...

I know patient held records are also part of the answer in the longer term. And here we are, all roads lead to the digital: the digital world and the difficulties of implementation in the pressurised world of healthcare. Keep those postcards coming. Please, Michael, don't tell me off for dabbling 🙂

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