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Not enough seats on the plane from Dubrovnik

…. and other tough choices in health care

We are on our way back from a short break in the Mediterranean. While sipping a coffee in the airport and waiting for our gate to come up we hear commotion over the tannoy. An announcement by the first officer of another flight to the UK: on this stormy day the flight had come in late. It had to divert first, then come back in and one of the stewardesses had now worked too many hours in a row and can not man the light back. This has nothing to do with the airline but with the Civil Aviation Authority, from high above thus. The implication is that the remaining crew can now not look after all booked passengers and 29 of them are not able to board the plane and fly home. The remaining three cabin crew could look after the other passengers but 29 names would need to be found to stay behind and wait for the next flight.

The first officer asked for volunteers: for passengers to come forward and stay behind. So that everybody else could fly home. A bit of altruism.

Though not that much as the airline did appreciate that this is not service as usual and offers a free flight back, hotel accommodation till the next flight and to sweeten the deal initial £500 and then £750 per volunteer. There is still a lot of discussion and noise. Would enough passengers be swayed by the deal?

And then came the last twist: if volunteers could not be identified fast enough the rest of the crew would also be on shift for too long and would not be able to man the flight back home. In this case everybody would be delayed and have to wait for the next flight in the coming days: A narrow window of opportunity that was rapidly closing down. Who would volunteer to stay? Pensioners who did not have to get back to work the next day? Those feeling charitable after a week in the sun? Who would step out of the queue? Those taking pity with parents with listless young children? Who can make the decision fast enough?

At this point our flight was called out and we made our way to our own gate. We did not witness the resolution. But it seemed an interesting enough dilemma, an allegory on what to do with limited resources and who is best placed to make the decisions about this: The Health Service in the UK (and almost anywhere else in the western world for that matter) is overbooked. Demanded is increasingly and predictably outstripping supply.

Intriguingly the problem is quiet comparable to our crowded emergency departments that run well beyond their full capacity with crews that are too small and often well beyond their safe hours. But nobody announces over the tannoy that 29 passengers needed to volunteer to fly another day (and there is no Mediterranean hotel on offer either in return). But would anybody be happy to step off the Health Services queue and make space for others. Those towards the end of their life? With poor quality of life? Or does it depend for whom we step out of the queue?

At the same time much of investment in healthcare is aimed towards comparatively small incremental gains, some of them of doubtful meaning: the highest spending is on patients in the last year of their life when self-assessed quality of life is often poor and not at a time where prevention and life-style adjustment would add happy and healthy years. This is not through incompetence of bad will, it is obviously often not known who is in the last year of their life. Simple conversations about care might help to bridge this dilemma. Atul Gawande and his lab have developed guides on how to conduct these. In his book ‘Being mortal’ he quotes a study from the US on introduction of palliative care for patients with lung cancer: Patients are randomized to palliative care integrated with standard oncologic care or standard oncologic care alone. The follow-up study finds thought provoking results: not only did the patients who received palliative care had better quality of life but they also live longer with less symptoms. Relatively cheap care adds high value.

On the 20th of September we launched our local Quality Improvement Hub under the title ‘The Cost of (No) Improvement’. With a number of local and national specialists we analysed what might happen if we just carry on to view healthcare as we do at the moment. And we dug-deep to find out what the reasons are the our mind makes it so hard for us to change. Excellently timed with Professor John Parkinsons’ talk the New England Journal of Medicine published an editorial called ‘Trolleyology’. A common thought experiment in behavioural psychology goes as follows: you are witnessing a tram (‘Trolley’ in the US) come up to junction. It has lost its breaks. If it passes it will kill a group of people waiting at the other side. You can avoid this by switching the track. But: as a result the tram will kill a single waiting person on the next track. People find it exceptionally difficult to make this choice. Many would do nothing, despite the high price. The New England published this because the dilemma is wickedly similar to that facing those organising vaccination for Dengue fever. The vaccination saves significant numbers of lives but it can also lead to fatal complications in a small number of people.

In our plane dilemma, the tram-crash and the Dengue example all choices have negative implications, none is perfect. The absence of actions leads to the worst outcomes but for those who would be the subject of negative side effects this might not be of consolation.

How is this dilemma best framed in Healthcare?

Will patients be willing to fly a slower flight if they are explained the consequences?

Is altruism still strong enough to allow those who need an urgent flight to get back on?

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