Introduction
‘Sludge’ is defined as policy or practice that makes it unnecessarily difficult to access public services.1 In health care, sludge can take many forms. For example, if a patient needs to complete extensive paperwork and show photo ID to register with a GP, that is sludge.2 Some people do not have photo ID and many find it frustrating or difficult to fill in forms.2 It could also be described as sludge when getting antibiotics for an uncomplicated urinary tract infection means having to visit a GP as well as a pharmacist.3 Travelling between many professionals to explain personal problems can be time consuming, tedious, and embarrassing.3
Sludge is concerning because it wastes patients’ time and causes stress. Moreover, people have a limited amount of mental resources — also referred to as ‘cognitive scarcity’ — and sludge is harder to overcome for people who are already overwhelmed and vulnerable.4 Indeed, sludge dissuades patients from accessing services, especially those from disadvantaged populations.5
To remove barriers to care, ‘sludge audits’ are recommended.1 These are systematic evaluations intended to identify and eliminate sludge.1 GPs provide the bulk of NHS care and are gatekeepers to the rest of the health service. Innovation is also easier within GP surgery teams than hospital systems because GPs have a closer perspective of their patients’ lives and the barriers to care they face. Therefore, general practice is an ideal context to improve care through high-impact ‘sludge audits’.
What does sludge add to the idea of ‘barriers to care’?
The literature on ‘barriers to care’ identifies social and structural factors that prevent people from accessing health services. The concept of ‘sludge’ adds two crucial insights.
First, a specific barrier to care is only sludge if it is ‘unjustifiable’.1 A good rule of thumb is to assess whether GP practices are able to deliver quality care without the specific barrier. For example, regular blood tests to monitor specialist medications are burdensome, but they are not sludge because frequent monitoring is essential to identifying complications or toxicity. However, if patients are asked to use a confusing booking system to arrange blood tests, this is sludge because complexity is difficult to justify: it creates stress, wastes patients’ time, and makes it harder for digitally excluded people to access care.
Second, sludge poses barriers to care that are often overlooked. For example, an appointment booking website with repetitive and personal questions is sludge because it is needlessly time wasting and frustrating.1 Even if all patients eventually figure out how to make an appointment, making patients exasperated is a problem in itself. A negative experience with the booking system may lead to delayed presentation in the future. We cannot confidently study which inconveniences or frustrations in one clinic will result in missed health care in another clinic. Therefore, sludge audits are crucial.
How do sludge audits work?
Sludge audits offer a systematic way to identify and remove sludges in health service processes.1 First, the patients’ process of accessing health care is evaluated from start to finish and all possible barriers are identified. Second, the purpose of the identified barriers is evaluated in light of the inconvenience they cause. Third, barriers that unnecessarily inconvenience patients — sludges — are identified and alternatives are suggested. The New South Wales government has developed a way of conducting sludge audits in health care, promoting a grassroots culture of audit and quality improvement.6
Sludge audits are straightforward for frontline healthcare providers to complete. A sludge audit in colorectal cancer screening found through interviews with patients and providers that long wait times and requirements to complete multiple clinic visits contributed to missed screenings and frustrations.7 Sludge audits have also been developed by Doctors of the World, who support GP registrars to investigate barriers to registration at their practice, deliver training to clarify policies, and then re-audit.8,9 Sludge audits can build a health service culture that values simplifying and streamlining the patient experience. Creating easier routes through care empowers patients to control their journey, letting them focus on things that matter to them such as work, leisure, or caring responsibilities.
Recommended ways to reduce sludge include demanding less of patients’ time, offering in-person and online alternatives, and removing paperwork ‘roadblocks’ that stop patients accessing consultations.10 For example, walk-in chest X-ray clinics have reduced sludge by allowing patients to present directly after their GP appointment to reduce the number of appointments and booking letters for patients to manage. While sludge can emerge through many mechanisms, including deliberate rationing, overzealous professional gatekeeping, and technological innovation, only active intervention can remove it.
Are sludge audits irrelevant?
Not all scholars view sludge audits as worthwhile. For example, a recent argument against sludge audits and other behaviour change interventions claims that they ‘are likely to be insufficient to deal with the myriad problems facing humanity’.11 These critics point to evidence suggesting that behaviour change interventions have a small impact on people’s health behaviours. But removing sludge is not only about changing measurable health behaviours. It is also about improving patients’ experiences by streamlining their care, and removing frustrations. Even if removing a sludge has little effect on the number of patients who attend appointments, simplifying systems empowers patients and builds rapport.
Are sludge audits a distraction?
Critics argue that sludge audits and other behaviour change interventions distract from efforts to create more effective structural changes through taxes and prohibitions.11 However, for most doctors, such structural changes are outside our zone of control. We can, however, influence our own practice or clinic. In fact, it has been argued that interventions such as sludge audits can empower GPs to begin demanding wider improvement.12 Sludge audits identify barriers, inconveniences, and confusion, all of which are closely related to wider systemic issues.12 For example, a sludge audit of practice registration paperwork processes ended up identifying differential policies for people from different countries that appeared to breach the Equality Act.2 Far from providing cover for structural failures, sludge audits put them under a magnifying glass.
Is sludge actually good?
A recent survey found that Americans objected to sludge impacting veterans but supported sludge for people on low incomes.13 These findings indicate that members of the public not only recognise that sludge is a barrier, but also believe it contributes to gatekeeping public services. Similarly, interviews with GP practice staff found that some resisted following guidelines on reducing documentation requirements because they considered it an effective means of deterring undeserving patients.14 But sludge is not a fair means of rationing care. It exacerbates existing inequalities by disproportionately impacting people with time constraints, caring responsibilities, unstable accommodation, or language barriers.1 To the extent that rationing of health care is required, it should be based on transparent decisions about need and potential benefit.
Others might contend that sludge is beneficial when GPs adeptly use a watchful waiting strategy. We would suggest that this is not actually sludge because watchful waiting is a proportionate response to the aim of avoiding overinvestigation. Therefore, any delays caused by watchful waiting are part of good practice and not ‘unjustified frictions’.
How can we develop a culture of sludge audits?
Just as medicine has developed a thriving culture of quality improvement, it is time to empower frontline staff to conduct sludge audits and make our systems easier for patients to navigate. Staff should be trained to perform sludge audits through train-the-trainer programmes, quality improvement collaboratives, and Quality Improvement Project resource packs.8,15 Sludge audits should be recognised in annual appraisals. Removing sludge can make health care less unpleasant and frustrating for patients who are already afraid and disempowered. Let’s use all the tools at our disposal to make GP surgeries as easy and straightforward as possible for our patients and their carers.
Notes
Funding
Wändi Bruine de Bruin acknowledges funding from the USC Schaeffer Center for Health Policy and Economics.
Provenance
Commissioned; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2024
