Working 9-5: if only! Towards 24/7 healthcare

 http://youtu.be/UbxUSsFXYo4

If you work in healthcare you can’t have missed the recent outrage around government intentions to move the NHS to a ‘7 day service’. Thousands of people have signed a petition calling for a vote of no confidence in health secretary Jeremy Hunt. Mr Hunt hasn’t endeared himself to me, moly sorting from the point where he tried to shut Lewisham Hospital, a recently renovated site that serves a huge population of South Londoners and was noticeably not failing. Following public outrage and months of protest around the legality (not to mention ethics of making hundreds of sick people travel an hour to another busy A&E department when there’s a decent one nearby), the plans were reversed and Lewisham H still stands.

A 7 day health service is a good idea. People don’t just get sick on working hours and we need to accommodate them, not the other way around. But it’s also not a revolutionary idea. I don’t know if you’ve been to a hospital on a weekend. I have and I can assure you it’s still open. Doctors and nurses work long hospital shifts around the clock every day of the year. It is a fallacy to suggest that they don’t or won’t work weekends – they rarely have a choice. Walk in centres are open weekends, and many GPSs offer a Saturday clinic. Mental health crisis teams cover weekends, keeping people in great distress safe and out of hospital. But Friday night is still not a great time to get ill. Whilst NHS staff do work weekends, it’s usually not the full working force that you’d get on a weekday. Additionally, doctors don’t work in isolation. There work depends on other staff, many of whom do not work weekends. Discharges may face a length delay whilst waiting for assessment from a social worker, occupational therapist or physiotherapist. Scans and tests need to be carried out an analysed. If transferring to another team then liaison is needed, and administrative staff for all the records and associated paperwork. A 7 day service is needed from all staff to keep the operation working.

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Won’t get well: Trying to understand medical non-compliance

How many unfinished prescriptions are left in your medicine box?

How many unfinished prescriptions are left in your medicine box?

This post was born out of discussions with my doctor friends, who frequently struggle with “revolving door” patients. The kind of people you discharge knowing you’ll be seeing them in a few weeks, maybe even a few days. Individuals who  grudgingly accept treatment, as though intent on remaining sick. Those who fail to follow medical advice, despite the pain and risks they then live with. Questions arise as to whether we should treat these patients at all, whether the resources are justified when they seem determined not to look after their own health.

“Non-compliance” has a very punitive ring to it. We comply with authorities, with court orders and sanctions. It suggests the existence of an external control and an absence of choice. The somewhat softer “non-adherence” is perhaps something all of us can relate to. Which amongst us have not been entirely adherent to medical advice? Perhaps we failed to complete a course of medicine, drank whilst on antibiotics or missed a few doses. This kind of non-compliance is one of the highest rated frustrations for doctors, but is very common.

Who is more likely to be non-compliant?

In a review of 102 papers, Jin, Sklar, Oh and Li (2008) found that those who do not comply are more likely to be male, younger, single, to have a lower level of education. Those who have a cognitive impairment (e.g. dementia), a mood disorder or use substances were also found to be more likely to be non-compliant. The complexity of treatment regime, level of medical knowledge, quality of relationship with the prescriber, and stigma attached with the treatment were also highlighted. However, it may not always be as clear “why” an individual is non-compliant, and attention needs to be given to the paradoxical nature of the behaviour.

Beliefs impacting on compliance

Research suggests that cognitive factors may lie behind this “everyday” non-compliance: faulty and inaccurate beliefs that guide behaviour. Patients may believe that the treatment will be ineffective or there will be minimal consequences to non-adherence. They may believe that they are not “truly” ill or that the treatment will impact them negatively. They may believe that the disease is uncontrollable or have religious beliefs regarding illness, or that an alternative method that will help them more.

Readiness to change

stages-change

Thinking of the “stages of change” model, many patients may still be at the ‘pre-contemplation’ stage in relation to changing their behaviour. They will need support, education and counselling to progress to a point where they feel capable of change. When medical emergency forces a patient to receive medical treatment, they may still not be ready to engage in change, despite professionals escalating the situation on their behalf.

A good relationship with a professional will be needed to open up a dialogue in which it may become apparent that patients hold these beliefs. In many cases education may be enough to shift the belief, but this will need to be provided in a respectful manner so it can be well received. Motivational interviewing techniques have been used successfully to help a patient to identify discrepancies between their behaviour and their goals.

But what of people with more “severe” forms of non-compliance? Those who seem to actively avoid treatment and seem to exacerbate their condition?

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