Neal Maskrey is a former GP and visiting professor of evidence-informed decision making, Keele University
Jamie Hayes is an executive and team coach, honorary professor of medicines optimisation, Cardiff Metropolitan University
Helen Maskrey is a retired public health pharmacist
John Seddon is an occupational psychologist, specialist in organisational change, and visiting professor at Buckingham University Business School.
Once upon a time in a green and pleasant land there lived Gatekeepers and Wizards who looked after the poorly People. The Wizards in their Castles and the Gatekeepers in their Houses worked diligently and according to their ancient arts, using their powerful spells and potions. But many People were waiting a long time in the Courtyards of the Castles to see a Wizard, and it had even become difficult sometimes for a poorly person to see a Gatekeeper. Everybody was unhappy. The King’s Minister, and it was too soon to say whether he was a Wise Minister, had convened a Great Assembly to hear what People thought were the reasons for the National Poorliness Service’s difficulties, and what could be done about them.
It was time for a Wise Gatekeeper from the Centre for Evidence-based Wizarding to speak to the Assembly.
“Minister,” he said, “Over the last two score years evidence-based wizarding has done much good. Using experimental proof of what spells and potions work, and which do not, to guide our work is much better than what we used to do. We used to rely on what expert Wizards thought were the best treatments. But Grand Wizard Sackett wrote in 1996 that evidence-based wizarding means routinely bringing proof of what works into consultations – which traditionally consisted only of clinical expertise and a person’s values and preferences.
…the great failure of evidence-based wizarding is that we did not show Wizards and Gatekeepers how to have those better conversations with poorly People.
“Apart from the truth that the Power in consultations usually rests with the Wizard or Gatekeeper and the values and preferences of patients is still not always considered sufficiently, the great failure of evidence-based wizarding is that we did not show Wizards and Gatekeepers how to have those better conversations with poorly People. Instead, in Evidence-based Wizarding we concentrated on technical aspects of our craft – how to properly combine the results of separate experiments using clever mathematical wizarding, and how to write many scrolls that summarise what works and what doesn’t, and tell Wizards and Gatekeepers how to treat many hundreds of different poorlinesses.”
“That all sounds like good and important work that Evidence-based Wizarding has done,” said the Minister. “But you seem to be telling me that it has done harm as well as much good?”.
“I’m afraid so” said the Gatekeeper from the Centre for Evidence-based Wizarding. “Firstly, many of the People and most Wizards and Gatekeepers now think which spells and potions should be used is clearly defined – according to the scrolls there is only one way of treating a certain type of poorliness, and that is what they must do to be a good Wizard or Gatekeeper, and moreover the treatment is very likely to make the poorly person better. The reality is that most potions work for only a small proportion of poorly People who take them. In a scientific trial, many People get better on the standard or placebo potion. If the new experimental spell or potion is an improvement, it usually only increases the proportion of poorly People who get better – very rarely is it possible to guarantee an improvement or cure. It is not possible to predict which individuals would get better without treatment, which individuals would benefit from treatment, and which People will be harmed from treatment.
Reliable estimates are that up to one third of this increase in Wizarding and Gatekeeping is likely to be low value, and all spells, potions and crystal balls have the potential to cause harm.
“Minister, I know this is complex and not at all intuitive, but the best of evidence can only tell us that one group of poorly People with a certain poorliness have a better probability of a good outcome, not which individual. The right spell or potion for an individual means, as Grand Wizard Sackett wrote, having a great conversation about what the poorly person thinks would be the best option for them.
“And yet for the last score of years the King has paid Gatekeepers extra gold if they treat all the poorly People exactly according to the scrolls. Many people now think treating poorly People according to the scrolls means the poorly People are getting the best treatment, and the Wizard-Lawyers say so too. But Minister, you will recognise that this does not guarantee the best help for every poorly person; not all poorly People want the all the potions and spells as recommended by the scrolls. Indeed, the Poorly Peoples’ Charter says that decisions must be shared between Wizards and Gatekeepers and the poorly person, and that shared decisions can be very different for different People with the same poorlinesses.
“This matters a lot. If individual poorly People are involved in decisions about spells and potions, fewer of them are used and both the poorly person and the Wizards and Gatekeepers are happier with the decisions reached. There are fewer complaints made to the National Poorliness Service and less work for the Wizard Lawyers. Some of the growth in demand for poorliness is due to the ageing population, but much more is due to the People and the Wizards and Gatekeepers overusing new spells, potions and crystal balls. Reliable estimates are that up to one third of this increase in Wizarding and Gatekeeping is likely to be low value, and all spells, potions and crystal balls have the potential to cause harm”.
“Golly gosh” said the Minister. “We shall have to think about this very hard.”
To be continued…
Acknowledgement.
The authors wish to thank Nigel Mathers, Paul Hodgkin, and Andrew and Barbara Herd for introducing the world to the parables of Wizards and Gatekeepers, See: Mathers N, Hodgkin P. The Gatekeeper and the Wizard: a fairy tale. BMJ. 1989; 298. DOI: https://doi.org/10.1136/bmj.298.6667.172
Deputy editor’s note – see also:
The gatekeepers and the wizards revisited (Part 2): The National Kindness Service and shiny crystal balls: https://bjgplife.com/the-gatekeepers-and-the-wizards-revisited-part-2-the-national-kindness-service-and-shiny-crystal-balls/
The gatekeepers and the wizards revisited (part 1): Seventy eight years of fairy tales: https://bjgplife.com/the-gatekeepers-and-the-wizards-revisited-part-1-seventy-eight-years-of-fairy-tales/
Machin A R, GPs are far more than gatekeepers,
Featured Photo by Artem Maltsev on Unsplash
