Million Dollar Murray

"Murray Barr, a homeless alcoholic man in Reno, ran up the largest medical bill in Nevada, more than $1-million in the decade he lived on the streets, a story made (in)famous by Malcolm Gladwell in The New Yorker."

So starts an article in The Globe and Mail, a Canadian newspaper.  It cites a paper published in JAMA (I blogged about it here), which showed that 1% of Americans are responsible for 22% of healthcare costs. 5% consume 50%.  A similar pattern was found by Dr Brenner, who did some ground breaking work with high consumers in Camden, New Jersey.

It seems this is a familiar pattern as these findings also mirror mine.  It is something that policy experts and people in the system are aware of but remain systemically blind too.  We give them names like "complex needs patients" or "frequent flyers".  We spend money on them.  Vast amounts.  We know who they are, we know where they live.  But we don't understand them.

And the way we care for them costs billions of pounds more than it needs to.

They get passed from profession after profession, through service after service, organisation after organisation.  An entire system constructed on the belief that if everyone is given a smaller part of the process then they will become very good at doing that bit and the overall speed and quality will improve.  This logic is flawed.  And incredibly costly, both in terms of the harm it does to people and finances

In reality what happens is the system creates a number of functional islands of help with many hand-offs, over-specification, duplication, over-provision and re-work.  Relationships are transactional and episodic, so no-one ever really understands that the presenting problem isn't the real problem to be solved because no-one develops a meaningful relationship end-to-end over time.  For users this means frustration and repeated episodes of "care".  For staff it can mean never really being able to solve someone's problem and the frustration this brings.  For organisations it means additional cost.  On a massive scale.

And because we have created this incredibly costly architecture, we then concern ourselves with stopping people accessing it.  After all, the main cost in a service like the NHS is the cost of the professional.  So if we can control that time we will reduce costs - right?  This is why we have 8 minute GP surgery appointments, target waiting times,  or assessments where the professional is not where the person lives.  We talk about rationing, prioritising, eligibility criteria and the like when, in fact, nothing of the sort needs to happen.  It is a delusion of biblical proportions.  The NHS is dying of consumption.  Talk of rationing is, at best, premature.  It may even be unnecessary.

Systemically we are institutionally peopleist.  Our systems are designed to manage the deficits that people are labelled with as having not the strengths that they bring to a situation.  We either don't solve peoples problems or we make things worse for them.  We also fail our staff who are left unable to do the simple things that will help people live a good life.

It is no better for those close to the end of their lives.  Gawande puts it beautifully with his observation that "we have created a multi-trillion dollar edifice for dispensing the medical equivalent of lottery tickets - and we have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win.  Hope is not a plan, but hope is our plan"

Despite the evidence that exists that talking to people about their options leads them to make less resource intensive decisions we don't do it.  Aetna, a medical insurance group, ran a two year program where patients were allowed to receive hospice treatment without forgoing other treatments.  They found that visits to the emergency room dropped by almost half and the use of hospitals and ICUs dropped by more than two thirds, compared to the control group.

In a smaller but broader study, they found the use of ICU reduced by over 85%.  The reasons for these findings?  People were involved in decisions about their life and, rather than choose the heroic, life saving interventions - the greater consumption options - they chose to die with dignity and with the ability to say "goodbye" or "I love you", a choice foregone if unconscious and intubated on an ICU.

Our work is showing the same credibility straining results.  In one experiment we used minimal service criteria.  Specifically in one case, the Fair Access to Care criteria was suspended.  Qualification for support was based on whether you were over 18 and were registered with the relevant GP.  It worked.

Why? Because having minimal criteria means that staff can act quicker to rebalance individuals at an earlier point, avoiding the flightpath to dependency that the system is designed to produce.  By not using conventional tactics like creating a waiting list, people did not fall between services, their needs were not ignored, their situation did not deteriorate into crisis.

So far as the numbers are concerned, although there is still more to be done (we are still learning) the team is seeing significant reductions in admission to hospital and lengths of stay as well as admission to care homes and reductions in or preventions of care packages.

A wider cohort study indicates that the experimental group had significantly better outcomes for 30 day readmissions and social care costs when comparing the change between those at one year prior to intervention and three months post intervention.  

These experiments are happening now.  The evidence exists now.  But systemically we remain blind to the benefits that such approaches bring.  It is not difficult or complicated to put relationships at the heart of the design and management of work, but so blinded are we by our love for a management paradigm that is no longer useful that we find it virtually impossible to make the transition at a system level.

And so the thinking that has created this "wellbeing myopia" remains.  the Bill, with all its principles about bringing decisions closer to the people who do the work, a focus on outcomes not targets, the involvement of patients not a reliance on bureaucracy - principles which I and many others support - changes nothing in respect to dealing with this most fundamental of problems.  Why is it even called a Health and Social Care Bill?  For me that just reinforces the arbitrary divisions that exist and the continuing love affair with unhelpful concepts.


The good news is there is a better way.  The bad news is that it means we need to change the way we think.  Only then we will be able to really understand the thousands of "Million Dollar Murray's" that we have on our own doorstep, transform their lives and transform the fortunes of the NHS.

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