High blood pressure? You bet!

Apparently, some people have high blood pressure as they are being dressed in an indiscreet gown and wheeled through the operating theatre doors.

Reassuringly therefore, new national guidelines attempt to significantly reduce the nearly 1% of last-minute cancelled operations in the NHS amounting to about 100 each day.¹

The good idea is to set standards about the blood pressure information GPs send to surgeons. The implication is that a large measure of the problem is down to GPs referring patients with dodgy blood pressure. Are we simply ignorant of our patients’ vital signs under these circumstances or are we knowingly sending them on a fool’s errand? Whichever it is, this initiative is clearly meant to encourage us to be less neglectful.

Anyway, this is classic systems theory thinking where a problem is traced back to its source with a view to working on resolving it there. Preventing it from occurring downstream within the system makes intuitive sense. But there is a hitch in the NHS context.

All problems that patients experience can, more or less, be traced back to their primary care source. So, unless anyone tries following a different strategy in their systems thinking, it seems we are endlessly committed to the same basic outcome: GPs being required to up their game yet further.

Maybe the real issue is that the most obvious alternative approach is also obviously more difficult still than simply pressuring GPs a tad more. This solution would be to integrate the parts better so that the river metaphor ceases to apply. GPs’ and surgeons’ records being more accessible to each other might enable this. But that would require an integrated IT solution that has already had billions of pounds thrown at it with little effect.² A shame then that this latest guideline, like most of its kin, does not come paired with any resource at all.

Never mind. Research suggests that ‘will fatigue’³ is better predicted by our prior expectations than any other variable, so perhaps GPs just need some resilience training to modify our mental expectations.³

Don’t get me wrong: the principle of following problems upstream and trying to resolve them or prevent them there, before they are capable of having a big effect, remains a good one.

Sure Start children’s centres are a case in point, a recent report on which concluding that they are a rare example of an approach that saves money and reduces inequality.⁴ The same document notes however that, now their financing is no longer ring-fenced, local authorities are eroding the service they provide or closing them altogether. Here too, as with the idea of requiring GPs to do more work with a view to solving a secondary care problem, systems theory is being applied to a problem but not consistently matched with the necessary resources for the solution to work.

It is refreshing to hear news such as that from Uganda where sterilised pieces of mosquito net have been found to work just as effectively as the massively more expensive medical mesh for hernia repairs.⁵ Sadly though, efficiencies in complex systems are rarely so simply made.

The truth is this: good ideas and funding to support them are as inconsistently related as ever they were.

If anyone cared about my blood pressure they’d do something about that.

• © British Journal of General Practice 2016