Bears, bells, healthcare and how do we actually get it right first time?

I was recently privileged to sit through a short lecture by Bill Bryson, someone for whom I have had affection for many years. I had been struck by his earnest humour and thoughtful charm the first time I heard him speak at the BOA a few years ago and was excited to be able to hear him again at a much smaller Orthopaedic forum.

Mr Bryson gave a thought-provoking talk set off by his usual amusing anecdote about ‘bears and bells’. However, taking the opportunity to converse with the trainees in the auditorium, he went on to give one of the most profound and beautifully-delivered commentaries on what is wrong and right with modern healthcare I have heard in a number of years. Bryson told of the fate of Katz, the other protagonist of A Walk in the Woods which I am sure will be familiar to many. He traced the difficulties experienced by his childhood friend as a result of the development of simple complications from diabetes, which led eventually to an exceedingly poor outcome of amputation and unaffordable healthcare costs. I was shocked to hear that, despite this clearly representing a need for emergency surgery, a patient who is unable to pay has these costs offset against their home. When (eventually) his estate is settled after his death, the hospital will pursue his estate for these costs, and if (as may well be likely) they are not recoverable, they will not be written off – but passed on to Katz’s heirs. Mr Bryson elegantly used this tale to highlight what is good about the NHS: tailored care for patients, irrespective of their ability to pay, suitable no matter what the complexity. He appealed to the trainees to keep the spirit of the NHS alive as they move through to consultancy to care for patients, irrespective of their ability to pay.

At the same meeting, Professor Tim Briggs gave a short lecture around his ‘Getting it Right First Time’ (GIRFT) concept, a report that has seen him visit a vast array of units across the country. The report itself is wide-ranging and will be familiar to most. It covers everything from planning for revision surgery to the costs of joint arthroplasty. Each unit has had its own summary report produced following a visit, and on the surface the ethos seems an excellent one – through standardisation we may be able to improve outcomes – be they cost-based or clinical.

Whilst both lectures were well-received, I couldn’t help myself thinking that Mr Bryson had a more important argument. Healthcare is about individuals, and one size might not fit all. Clearly, designing systems with checks and balances is important, NHS trusts should not be paying over the odds for implants, and maverick surgeons should not be putting patients at risk. However, one does also have to ask: is medicine really a simple check sheet – a list of a few pathway items designed to turn what is the most complex of modern systems into a simple flow sheet? The GIRFT project is, however, without a doubt the most ambitious undertaken by a president of a professional association – visiting first hand units to look for institutional strengths and weaknesses and produce an even-handed report on where things may be improved – this a welcome start, but it is just a start.

There have been a few papers of recent years, the most notable of them in the Bone and Joint Journal, arguing in essence that the problem is much more complex than this. There is increasing evidence that personalisation of healthcare may offer better value in the future and the ‘one size fits all’ approach may be more accurately described as ‘one size fits most’. We know that in complex problems such as metal-on-metal revision, choice of surgery affects outcome, but not universally between patients.¹ In more complex problems such as distal humerus fractures,² an interplay between surgical and patient factors (such as sustaining a head injury or the use of bone graft) has an effect on the risk of complications, and that cost-effectiveness in distal radius fractures is a complex interplay between patient, implant and surgical factors.^3,4 The truth is that healthcare for even a relatively simple intervention such as a knee arthroplasty cannot be summarised on the ‘back of a fag packet’, and whilst outcomes for some orthopaedic diagnoses are influenced by factors as diverse as osteoporosis⁵ and catastrophising thoughts,⁶ any attempt to simplify healthcare into a formulaic approach is just plain wrong. I agree wholeheartedly that we do need to ‘get it right first time’, but a simple ‘Del-boy-esque’ approach runs the risk failing to appreciate the complexity of the problem or provide personalised healthcare, risks cutting corners or focuses on the easy to standardise portions of healthcare delivery. The risk is that in the name of value eventually the quality of the NHS – that which Mr Bryson so carefully argued for, and wasn’t available to Katz - will be lost. After all, we are all here to care for the patient.