Although a relatively limited range and depth of data was gathered from hospital specialists in this study, firm impressions emerged of similarly changing and challenging new practices based on monitoring performance.
Guidelines in cancer care
The 1995 Calman-Hine report on provision of cancer services in the United Kingdom proposed restructuring cancer services to achieve a more equitable level of access to high
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levels of expertise throughout the country. As explained in detail by John who was familiar with the situation before and after implementation of the guidelines it involved;
‘setting up of this idea of multi-disciplinary teams to deal with cancer for … every specific [anatomical] site, so … the breast team, the GI team, and the key members of that team, clinician, surgeon, radiologist, oncologist and pathologist.’ John
Multidisciplinary teams (MDTs) were formed to discuss and oversee everything; provision of prompt appointments, rigorous and timely reporting of a tissue diagnosis, ensure clinicians’ understanding of the most efficacious treatment options and oncology support services. For John and his pathologist colleagues, this altered their patterns of work and transformed how they felt as integral parts of clinical teams. He reported that the trend, through the 1990s;
‘was to bring us… out of the lab, more into the clinical team picture which has been very good for pathology and pathologists; made us feel a lot more involved and also people can understand the key role of pathologists’ John
John appeared more than content with the team’s expectation that a tissue sample be reported quickly, that the report conformed to a ‘standardised, prescribed report- style and content’ to make it more universally useful and for the first time he felt personally involved and appreciated as the ‘expert of the tumour’, empowered to contribute to patient management. Involvement of the Royal College of Pathologists in setting out expected criteria and local audits contributed to achievement of the required standards.
As a nationally recognised and experienced pathologist, John participated in implementing these changes and expressed his delight at the new standing which pathologists enjoyed amongst clinical colleagues. Keeping up with the standards required had presented no obstacles or unwelcome challenges and he happily used networks with colleagues to facilitate delivery of results. It is perhaps unlikely that, given the task of improving cancer care for patients, the writers of the Calman-Hine Report actively considered the knock-on effects of this more prominent role on the morale of pathologists, but this was primarily how it was narratively represented.
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When the Report’s recommendations were to be put in place, Liz’s gynaeoncology department was already implementing the principal elements. We have already discussed how she believed that many patients inappropriately found their way to her clinic leading to her complaint that ‘only 15% of 2 week waits are cancer.’ Clearly in spite of attempts to direct only high-risk cases to cancer diagnosis clinics it seemed many patients who attended had a gynaecological problem but not a malignant one. For these, a referral to a benign gynaecology clinic would have been completely appropriate and Liz stated that, due to a high proportion being diverted to the 2-week wait cancer clinics, benign clinic appointments were in low demand – her ‘benign’ gynaecological colleagues appeared to be under much less pressure.
Comparative figures available on ‘conversion rates’ i.e. the percentage of patients attending two-week wait clinics who are found to have cancer, revealed that Liz’s department was in fact experiencing a slightly higher rate than the 13.5-14.3% in some gynaecology clinics (Twomey, 2006). Her major problem arose because her skills were only suited to cancer treatment allowing her no facility to manage benign conditions. Designers of cancer care pathways may not have anticipated that a gynaeoncologist would consider a conversion rate of this level unacceptably low or predicted the delays and frustration re-referral would provoke.
Similarly, full consideration of how GPs would behave when interpreting the significance of ill-defined symptoms which could suggest cancer would be difficult to accommodate when designing a new referral route. Comments reported from the consultation process had largely focussed on issues of capacity in specialist clinics and pathology services and on a dialogue about referral criteria, together with ensuring that sufficient resources would follow initial diagnosis (Department of Health, 2000).
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Recording pre-operative procedures in operating theatre suites
Graham found his anaesthetic work placed him at the interface between care delivered on the ward and what followed in theatre and was responsible for oversight of the patient until fit for ward-level observations. He spoke of discovering from records that prescribed pre- medication had not been administered by nursing staff prior to transfer to the theatre suite, and his need to check through detail of all aspects of pre-operative management. In his experience with well-trained and professional teams he believed that this had been dealt with efficiently and thoroughly but new regulations had recently generated an additional layer of paperwork;
‘we have had imposed in the UK sort of a surgical brief…to formalise the whole process. So the whole team sit in the coffee room before the day starts, running through the list, what are the potential problems, what are the requirements...and then before each patient is operated on, they are anaesthetised on the table, again, there is a surgical pause, running through confirming the name, the site of operation, the antibiotics going in. So that’s all done now, but it’s done to us in the theatre’ Graham
He asserted that, for well-run teams, this formalisation and the time spent filling out documentation or in formal discussion was unnecessary and felt like an unwelcome imposition on the team. While conceding that some ‘subsets’ which hedescribed as ‘shoddy hospitals that weren’t doing anything’ had improved through implementation of the surgical brief, he remained convinced that it was better to have an ‘inbuilt’ expectation of good practice than an externally imposed system with documents to be completed, his preference was to maintain standards by universally good practices and self-regulation. Since it is impossible to document each minute aspect of patient care, perhaps this move towards concentrating on certain documented aspects could militate against global professional attention which protects staff and patients from unforeseen risks.
166 5.8 Summary
Experience-grounded narratives following introduction of QOF and other targets, rules or incentivised criteria provided evidence of their effects on how doctors worked with patients, how their professionalism was challenged through curtailment of clinical autonomy and by countering their sense of professional identity.
Introduction of the QOF placed greater pressure on both clinician and patient to gain tighter control of biophysical parameters in specific areas of chronic disease management which demanded detailed monitoring and focussed interventions and shared decisions. Multiple objectives superimposed on GP consultations altered how doctors addressed issues brought by patients and lowered GPs satisfaction in how they had responded to patients’ expectations. Indications that doctors tended to overrun appointment times may confirm that they attempted to address items on both agendas but comparative observational studies of behaviour would be required to exclude confounding factors.
Standards of care for long-term conditions included in QOF (2004) which were already improving before implementation showed greater relative improvements in regions of social deprivation while conditions not attracting QOF payments fared less well and evidence suggested that higher than predicted QOF achievement implied prioritisation of this by practice teams (Gubb and Li, 2008, Roland, 2006, Elovainio, 2010). In keeping with feelings of deprofessionalisation in these interviews, concerns were expressed elsewhere about a diminution in professional identity of doctors who responded to external regimentation and the lure of payments rather than employing interpersonal skills and responding to patients’ needs (Heath et al., 2007, Heath, 2012, Lester et al., 2013).
Adaptive strategies reported here resembled observations elsewhere and depending on existing personnel or situations could stimulate re-creation of hierarchies and boundaries to fit new team relationships (Grant et al., 2009). The wider effects of limitations on referrals to specialists appeared less thoroughly documented - perhaps because evidence was not yet
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available or due to variable progress and non-uniform processes throughout the NHS. Links between clinical decisions and costs are important not only where doctors retain professional authority but where funding is managed by an insurance body or state controlled (Millman, 1977). Although GPs were shown to have poor knowledge of prescribing costs, rewards for alteration of prescribing behaviour reduced costs across a wide range of dissimilar practices and among interviewees seemed unproblematic (Bateman et al., 1996, Ryan et al., 1990).
Doctors in this study expressed comfort with an honest response to patients including citing cost-effectiveness as the primary reason for changing medication or not recommending referral to a specialist. Specialist claims that GPs might make symptoms ‘fit’ a pattern for referral which did not jeopardise targets were not corroborated by GP narratives in this group but elsewhere decisions with financial incentives or penalties were shown to affect clinical choices (Lundin, 2000).
It is not difficult to imagine, and anecdotally true, that patients can view decisions which affect doctors’ income with suspicion – as has been prominent in public media and controversy about how financial incentives might modify clinical judgement where this is not backed by clearly demonstrated reasoning, ultimately threatens trust in doctor-patient relationships. It appeared that a widening gap of understanding alternative perspectives existed between GPs and hospital consultants; general satisfaction with co-operative work of 1999 contrasted with recent poor quality of interaction or communication (Marshall, 1999, Etesse et al., 2010, Martinussen, 2013). From both sides came admissions of less direct contact and subtle differences between how GPs and consultants spoke of their own enactments of professionalism suggested that these perspectives would merit investigation beyond this study.
168 Chapter 6
Inflicted narratives; consequences of team working in the NHS
"We trained hard, but it seemed every time we were beginning to form up into teams, we would be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing, and a wonderful method it can be for creating the illusion of
progress while producing confusion, inefficiency and demoralization" From Petronii Arbitri Satyricon AD 66. Attributed to Roman general, Gaius Petronus,
Against an historical background of clearly defined and hierarchical medical teams, movement in primary care and hospital settings of the NHS has been towards organising a multidisciplinary workforce into integrated teams (Wise et al., 1974, Bate, 2000, Brown, 2007). To improve services, this policy-driven shift has been analysed for effectiveness in delivering a holistic services to patients, with team organisation demonstrated to support safer working practices and to reduce stress levels for members who otherwise felt vulnerable (Junor et al., 1994, Jefferies and Chan, 2004, Firth-Cozens, 2001). Analysis of total costs including medication and use of other services, suggested that team management could deliver services of comparable quality with lower expenditure (Borrill et al., 2000b, Zimmer et al., 1990).
My focus in this research was not to duplicate work which examined implementation of multidisciplinary teams, or to investigate their effectiveness, but to understand how working within teams affected the working lives of doctors. Presentation of narratives relevant to teamwork is preceded by brief consideration of the nature and practices of team working in general terms and with particular reference to health care.
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