Realistic medicine: #CochraneForAll interview with Gregor Smith

This is a transcript of a podcast interview with Gregor Smith, general practitioner and Deputy Chief Medical Officer of Scotland, conducted by Casey Quinlan @MightyCasey. Recorded at the Cochrane Colloquium 2018 . Gregor Smith talks about #RealisticMedicine and the development of a Scottish Atlas of Variation, exploring geographical variation in the health and care system in Scotland.



Casey Quinlan:

Casey Quinlan with the #BeyondTheRoom team here at #CochraneForAll, talking to Gregor Smith, who is a general practitioner medico, and was recently, relatively recently appointed Deputy Chief Medical Officer of Scotland. When was that appointment?

Gregor Smith:

Well, good afternoon, Casey. I was appointed almost three years ago now. And it’s been three of the quickest…


Oh, OK it wasn’t last week.


No, but it’s been the quickest three years of my life, let me tell you.


So tell us about your plans for a Scotland Atlas, à la Jack Wennberg from Dartmouth, Dartmouth Atlas, which is one of my favourite things.


Casey, you couldn’t have asked that question at a better time. Do you know that we have just published our three prototype maps this morning. So, so really this is hot off the press.

CQ: I will make sure to put that link in the show notes with this audio.


That would be fantastic. So we’ve been working on this for a while and one of the commitments we made when we started to speak about a programme of work in Scotland called Realistic Medicine is that we would challenge and try to address some of the harm and waste through clinical variation in Scotland and try to get better at identifying unwarranted variation in the system. Of course, not all variation is bad variation but we wanted to try and find a way of identifying that unwarranted variation within the system. And we looked abroad and we looked at some of the techniques that had been used in other places to do that and Jack Wennberg’s groundbreaking work on the atlas of variation from Dartmouth was one of those ones that we became very interested in. We were very fortunate in that Jack was very supportive of our attempts to kind of develop this atlas but we’ve also learnt from other countries who have gone down this route as well, places like England, where Sir Muir Gray has been a great source of inspiration and support but also further afield Australia and New Zealand as well.

Today, we’ll publish our first three maps. Those first three maps are around procedures. They are on hip replacements, knee replacements and on cataract surgery. So, of course, the really important thing about the maps is that they show us in a really graphic, visual way, where the variation exists. It’s really important to understand that it doesn’t tell us why that variation exists, or place any kind of judgement on that variation; we often don’t know what the right level of activity is for these things and it’s only through the conversations that the maps provoke that you start to get that understanding.


All right. So what are you most surprised by in your drive toward #Realistic Medicine?


Well, Realistic Medicine has been an absolute joy for us because when we started this conversation three years ago, I don’t think that we really imagined that it would light the fire under the profession  that it has within Scotland and I think that most surprising for us has been just the degree of support that the CMO (Chief Medical Officer) and I have enjoyed in trying to make the philosophy of Realistic Medicine come to life across Scotland. We’re constantly receiving examples from different parts of the service whether that be in community-based services or hospital-based services, people writing to us, and telling us about their projects or the approaches they’re taking to try and realise realistic medicine in their day-to-day practice.


So, tell us about your vision for population health, particularly in regard to that holistic, wrap round supportive services piece that you, you know, that I’ve read about you espousing in this programme.


One of the things that is really important for us, across the UK but particularly in Scotland is to really maintain the strengths that we have in community care and our holistic approach to care particularly from right across the clinical teams. We want to promote this sense of multidisciplinary team working, cross-professional working in order to try to deal with some of the complexity that we see. You know, we know that it’s becoming much more complex in terms of the way we’re treating patients and certainly workloads increasing for everyone that’s involved in that as well. We think that the way to deal with that is to try to take a much more integrated, holistic approach, working in multidisciplinary teams with each person within that team working to the top of their license, providing as much of the care as they possibly can before any escalation. We are already starting to see new models of care developing around that structure. Health and social care integration has been something which has now been in place in Scotland for the last couple of years. What we see there now is a much more cohesive integrated style of working between social care and traditional healthcare services as well. The missing element, the bit that I’m really excited about and the bit we’re starting to see real progress with is how we bring in the Third Sector, the voluntary sector into that mix as well, with lots of patient- and community-led groups now contributing to the care in these communities as well.


Well now, you’re going to be part of the closing keynote team at #CochraneForAll, what’s the one message you want people in the audience to take away from your talk?


So, I think the main message that I want people to take away is that science and evidence and guidelines are incredibly important and have brought about huge improvements in the way that we deliver particular care to people with long-term conditions but I think that we have to take a proportionate approach and that we have to make sure that that science and evidence is used in a meaningful way for people so that they can share the decisions that relate to their care more readily. That means much greater involvement of people in the development of the evidence. That means much greater attempts to make sure that that knowledge is easily translatable to people, recognizing the very different levels of health literacy that we have, within the communities. And to make sure that we equalize that relationship between the people we provide care to and the people who provide that care.


Well, Gregor Smith, it’s been a real pleasure talking to you and I’m looking forward to hearing your talk.  So, this is Casey out for the #BeyondTheRoom team at #CochraneForAll.

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Sarah Chapman

About Sarah Chapman

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Sarah's work as a Knowledge Broker at Cochrane UK focuses on disseminating Cochrane evidence through social media, including Evidently Cochrane blogs, blogshots and the ‘Evidence for Everyday’ series for nurses, midwives, allied health professionals and patients. A former registered general nurse, Sarah has a particular interest making evidence accessible and useful to practitioners and to others making decisions about health. Before joining Cochrane, Sarah also worked on systematic reviews for the University of Oxford and the Royal College of Nursing Institute, and obtained degrees in History from the University of Oxford and in the history of women’s health and illness in early modern England (MPhil., University of Reading).

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