Blog: System change is key to choosing wisely – part one

Neil Whittaker is GP partner/owner at Nelson East Family Medical Centre and a medical educator. He is a supporter of the Choosing Wisely approach, and believes system change is the key to more effective and efficient care.

In this two-part think piece provided by the Choosing Wisely campaign, he looks at choosing wisely more broadly, believing that we need to move towards a biopsychosocial model of health care, champion generalism, better manage uncertainty, and focus on quality improvement and learning, rather than always ‘doing’.

Why choosing wisely?

It is good to take a step back from everyday clinical care and reflect on what we are trying to achieve. The New Zealand Triple Aim guides us (improved individual patient care, improved population health/equity and better value for public health system resource). The Quadruple Aim adds our own work-life balance as health care providers.

How choosing wisely?

An emphasis on choosing wisely at a systems level is key in order to achieve the above aims.

We are encouraged to choose wisely at each patient interaction, while taking into account individual preferences, values, beliefs and the unique context of that interaction.

However, the greatest opportunity for significant and timely improvement in health care lies beyond our individual clinician/patient interactions. For example, if we are choosing wisely to address childhood obesity, a systems-based approach is required to achieve the greatest effect [1].

To achieve the New Zealand Triple Aim, I believe we urgently need a substantial shift in our “how” priorities. Choosing system-level change is key to improvement and to enable wiser choices at the individual clinician/patient level.

Choosing wisely means we choose to move towards the biopsychosocial model [2] from the biomedical one. It means we choose to move towards community generalism from hospital-based specialism. It means we choose more training in the community [3] to enable both of the above. It means prioritising the social determinants of health to address inequity and to look after future generations.

Shifting towards community generalism from hospital specialism

If we want more equitable health outcomes, less preventable illness and higher overall survival we need to nurture and value primary care in New Zealand [4] [5]. This means that, if we are to choose wisely, it is essential to increase the proportion of available resources allocated to primary care. This is old news, but has it been listened to and has the system shown that it really cares about primary care [6]?

Moving towards a biopsychosocial model

Our health system is out of date. We are still have a predominantly biomedical system, and we need to shift, with urgency, to a biopsychosocial model [7]. The Māori health model, Te Whare Tapa Whā [8] incorporates four dimensions of wellbeing: Taha tinana (physical health), Taha wairua (spiritual health), Taha whānau (family health), Taha hinengaro (mental health). It is a model we have much to learn from.

In general, it is much easier to prescribe drugs than to follow the evidence and use other more empowering therapies, for example CBT in mild-moderate depression or pulmonary rehabilitation in COPD. Would we be better recording diabetes distress scores rather than HbA1Cs? Do we value the social component of the medical history as much as other aspects? Do patients have the same level of access to evidence-based non-pharmacological therapies as they do to pharmacological therapies?

Pain is predominantly managed in the biomedical model and we tend to refer to the analgesic ladder with pharmaceutical options. Prescribing gabapentin or pregabalin off label or opiates in persistent pain in the hope of a miracle pharmacological response carries a significant risk of harm. The analgesic platform is a more patient-centred model supporting other therapeutic modalities with a biopsychosocial approach. The analgesic platform is a better option if we are to reduce the risks of patients progressing to persistent pain.

But what options does the system provide for a patient at risk of developing persistent pain? Increasing medication is the easiest thing to do but is it the best? Does the system allow and promote wiser choices? To reduce the risk of our patients developing persistent pain and to “get it right first time” we need to have better initial options - a platform of options rather than a ladder.

Shifting to a biopsychosocial model empowers patients and their whānau. It allows better use of clinicians’ time.

It is time to bring our health system into the 21st century.

Author: Neil Whittaker, GP at Nelson East Family Medical Centre 

To read more about the primary care programme at the Health Quality & Safety Commission click here.

References

1. Lancet Commission on Obesity Three Types of Community Based Interventions: https://www.youtube.com/watch?v=8IPvU3D1bEo
2. Introducing the Biopsychosocial Model for good medicine and good doctors: https://www.bmj.com/rapid-response/2011/10/29/introducing-biopsychosocial-model-good-medicine-and-good-doctors
3. Flipping healthcare: an essay by Maureen Bisognano and Dan Schummers: https://www.hqsc.govt.nz/assets/Capability-Leadership/PR/2014-Flipping-Healthcare-Maureen-Bisognano-BMJ-Dec-2016.pdf
4. Contribution of primary care to health systems and health: https://www.ncbi.nlm.nih.gov/pubmed/16202000
5. WHO called to return to the Declaration of Alma-Ata: https://www.who.int/social_determinants/tools/multimedia/alma_ata/en/
6. Study: Primary Care Doctors Increase Life Expectancy, But Does Anyone Care? https://www.forbes.com/sites/robertpearl/2019/04/08/primary-care-does-anyone-care/#3f816e99695f
7. Introducing the Biopsychosocial Model for good medicine and good doctors: https://www.bmj.com/rapid-response/2011/10/29/introducing-biopsychosocial-model-good-medicine-and-good-doctors
8. Māori health models – Te Whare Tapa Whā: https://www.health.govt.nz/our-work/populations/maori-health/maori-health-models/maori-health-models-te-whare-tapa-wha