The media has been heralding a looming crisis in preparation for the impact of winter pressures on the NHS. However, Dr Peter Bonis, chief medical officer of clinical effectiveness at Wolters Kluwer Health, says that there are ways to avoid the bottle-neck and alleviate pressures on GP practices and A&E departments – a series of small improvements
Every year, around early December, the so-called NHS ‘winter pressures’ hit the headlines. The media talks of a ‘looming crisis’ and ‘winter woes’ as over-stretched GP practices and A&E departments struggle to cope with a surge in patients suffering from cold weather-related illnesses. Often, this annual challenge is labelled the ‘winter ‘flu crisis’ but, in reality, winter weather causes a wide array of problems, including respiratory diseases which share similar clinical features with the ‘flu.
‘Tis the season
At this time of year, GPs are under particular pressure not to add to the A&E bottleneck by making unnecessary referrals to hospital. As it is, nearly 40% of patients arriving at A&E are discharged without needing any follow-up; this strongly suggests that many patients need not have attended A&E at all. Clearly, there is room for improvement here.
As a first step, GPs can play an important role by ensuring the flow of patients between primary and acute care is directed by the most accurate clinical decisions.
Digital health
This is where technology can help – specifically, ‘clinical decision support’ (CDS). CDS comes in many forms, and varying degrees of sophistication, but most are guided by a shared principle: helping the time-pressured clinician make fast, accurate and evidence-based diagnoses and treatment recommendations. UpToDate is one of the most widely used resources, with over a million doctors around the world searching 32 million topics every month.
I’m not suggesting that a highly trained GP needs CDS to diagnose ‘flu, or should consult his or her smart ‘phone to judge whether a patient can be sent home with paracetamol. However, CDS can help when doctors face a high volume of patients with similarly non-specific symptoms – as is common with the range of cold weather-related illnesses.
In this case, when time is short, CDS can help them make fast, accurate diagnostic judgements. In the common case, of ‘flu, CDS may not be needed to make a diagnosis but it could be consulted to decide on the next steps, such as ordering an x-ray or evaluating whether prescribing anti-virals or antibiotics is recommended, given a patient’s other conditions. We commonly see these questions posed in UpToDate – showing there is a real information need, even if it appears like bread-and-butter work for a qualified physician.
Don’t underestimate ANP support
Another reason why CDS can ease the winter bottleneck in primary care is that it is well-suited for use by advance nurse practitioners (ANPs) who are trained to handle an advanced scope of practice. ANPs can alleviate pressure in primary care by taking workload away from GPs, allowing them to focus on the most complex cases.
ANPs can help to avoid bottlenecks by getting patients the care they need faster, without the delay of referral to a GP or hospital. When a referral is needed, they can help prepare the patient with appropriate testing and counselling. Many cold weather-related disorders are well-suited for ANP care but, as these professionals are given more responsibility for making assessments and taking decisions, they need help. CDS technology can play a crucial role in reassuring the ANP and the patient that the appropriate protocols are being followed.
If we expect ANPs to make authoritative decisions at the edge of their expertise, and across a wider range of illnesses, we need to equip them with appropriate tools. I have seen CDS help nurse practitioners broaden their view outside of their comfort zone, identifying those unexpected – and possibly dangerous – symptoms which a more experienced physician might more readily spot.
A series of small improvements
Ultimately, easing winter pressures through the primary and acute care chain is a far bigger challenge than CDS technology can solve on its own – but it could chip away at those bottlenecks in patient flow that are often caused by wrong or delayed decisions. As an analogy, consider the British Olympic cycling team which gradually worked its way up to gold medal glory by making a long series of small improvements, down to the smallest details of its equipment, training and diet.
This model of success through marginal gains has been widely copied in many other sectors. In the NHS, if we think of each decision that CDS corrects or improves as one such marginal gain, they could add up to measurable progress that not only boosts efficiency, but also makes clinicians’ lives easier and improves outcomes for patients.
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