The path that leads to understanding healthcare

It's Sunday afternoon, which reminds me of how bad a time this was for one of my sons when he was a young child. His good cheer would start to dissipate from about lunchtime, to be replaced by something altogether much bleaker. As often as not, the evening would end with tears.

That was what the prospect of the coming week did for him. And yet, oddly, he enjoyed school.

I would try to comfort him by pointing out that this Sunday evening melancholy would probably only last until he was 65. Of course, I was wrong, but hey, I didn’t realise then that the retirement age would start to climb long before he reached it.

Still, it’s true that Monday morning syndrome is a pretty universal condition. Why, even Garfield the cat suffers from it, and what affects a cartoon cat must surely affect us all.

Funnily enough, it’s not a condition from which I suffer at the moment. This is because work has done something for me which hasn’t happened for a few years. It’s give me the opportunity to focus on a topic which is a hobby horse of mine – some might even say an obsession. Give me a podium and a projector these days and I’ll drone on about it endlessly. It probably doesn’t bore people who hear it for the first time, since the enthusiasm of a speaker tends to excite a reciprocal reaction in an audience, my poor colleagues must find it truly tedious.

The subject of my fixation? Pathways. Not the ones you cut through jungles or stroll along on country walks. Not the spiritual ones leading to moral high ground or low. I’m talking about pathways of care.


In healthcare as in life, you have to follow the pathway 

Over the last few years, it's becoming increasingly clear that we have to stop thinking of care in terms of events taking place at points of time. It's not easy to get away from those old habits of thought. In the general view of medicine, what matters is what happens at a particular moment, saving a patient in an emergency department or carrying out heroic surgery in the tense atmosphere of an operating theatre. Incidentally, it really is called ‘heroic’, usually because it stands little chance of success but will undoubtedly cause a great deal of suffering to the patient, which always makes me wonder whether the surgeon is the real hero of the story.

To doctors, too, what matters is what they’re doing right now to help the patient, and what happened before is only a source of information, what happens next a mere vague outline plan.

Increasingly, though, if you want to understand what is being done for patients and judge whether they’re receiving the most appropriate and effective care, you need to lift your eyes above this level. You need to understand what was done before the surgery and to follow it up afterwards. You need to compare all that with the treatment other people received. Did they perhaps not have surgery at all? Are they any the worse for it? Or are the results better if they have the operation?

As soon as you start asking that kind of question, you’re no longer talking about healthcare events but about pathways. The events are still there, of course, but strung together into pathways, like beads on a necklace. Taking the long view sees events only as components of something bigger, and that’s a much richer view.

One of the reasons why this is becoming more important is the sheer number of conditions that are the subject of chronic care, extended through time, as opposed to acute care, delivered over a relatively short period. Heart disease, diabetes, respiratory problems and many other medical conditions need treatment over a long time. That’s even truer of an area of illness we tend to talk about less, though it’s likely to affect one in three of us in our lifetimes: mental illness. Mental healthcare seldom takes less than a few months, often lasts a number of years, and can continue throughout life.

To think about healthcare in terms of extended pathways poses all sorts of new problems for information handling. In particular, it requires us to bring together items of information from many different areas and link them in a sensible way.

That’s what my present job has given me free rein to do. Since it’s something I’ve wanted to work on for years and have only touched on superficially in my previous roles, you can imagine the extraordinary (if slightly geeky) satisfaction it gave me recently to work with my colleagues to build views of events in care pathways. The other day, I scrolled through the records of care delivered to a patient who had suffered a stroke: not just the emergency attendances or the outpatient clinics and inpatient stays, but the time in care homes, the visits by district nurses, the physiotheraphy sessions either in or out of hospital.

For the first time, I was able to see a full pathway of care. I’m not a clinician so I can’t judge whether the care was the most appropriate. What I do know is, in that slowly scrolling list of records, I had all the information a clinician would need to make the judgement.

It gives me a buzz to know that, thanks to the outstanding support of highly proficient colleagues, I can now make a tool that powerful available to our clients.

Tomorrow's Monday. The prospect of a new week, of commuting back into the office, inspires no dread. Unlike my son in his childhood, I’m suffering from no Sunday evening blues at all.