Workload affects both treatment and referral decisions by “gatekeepers” to specialist services such as primary care physicians and emergency doctors, says a new study co-authored at Cambridge Judge Business School, University of Cambridge.
People with serious ailments naturally desire immediate access to the best specialist. But as specialist care is the most expensive part of healthcare, it needs to be managed, and the process to getting the right patient to the right specialist at the right time is known as “gatekeeping.”
Professor Stefan Scholtes
People may expect healthcare access to vary by the needs of patients, but not in a substantial way due to day-to-day changes in the workload of the gatekeeper – and that has been the common assumption in healthcare literature.
A new study by researchers at Cambridge Judge Business School and London Business School challenges this assumption and provides evidence that gatekeeping behaviour varies significantly with the gatekeeper’s workload.
“The effect of workload is both statistically and clinically significant,” says the study published this month in the journal Management Science.
The study finds that both high and low workload by gatekeepers affect patient care decisions, so more flexible hospital staffing that evens out such workload may help lessen variability in patient experience and also reduce the level of “unnecessary” care.
While the study focused on midwives – childbirth is the most common form of hospital admissions – the authors say the findings have broad policy and cost implications for the workload of gatekeepers. The study focuses broadly on high and low workload periods compared to average workload, and is careful to say that the findings may not apply to individual patients – “since we cannot know the appropriate level of treatment” in specific cases.
“There had been little empirical research into how gatekeeper behaviour is affected by the work environment, particularly with regard to service provision and referrals, so we sought to address that,” says Stefan Scholtes, Dennis Gillings Professor of Health Management at Cambridge Judge Business School and Director of the Centre for Health Leadership & Enterprise (CCHLE). “We think these findings can be useful to help healthcare policymakers in developing future staffing guidelines.”
Among other implications, the study says the findings may have some bearing on the “unnecessary care phenomenon.” Unnecessary care, defined as the dispensing of diagnostic or treatment services that provide no demonstrable benefit to patients, is as high as 30 per cent in some estimates.
“Gatekeepers play an important role in assigning patients to the most appropriate treatment route and, thereby, keeping costs under control,” the study says. “The behavioural effects of workload suggest that too much work for gatekeepers results in a tendency to increase referrals to specialists, while too little work may result in a tendency to provide more discretionary service features. While this behaviour may be rational from a load-balancing perspective, from a patient perspective these findings are consistent with overtreatment at both high and low workload.”
The study was based on over 15,000 births over five years at an unnamed UK teaching hospital. It found that maternity patients in complex cases are increasingly referred by midwives to specialists for physician-led delivery at times of high workload, while there was significantly increased provision of more discretionary services in the form of pain-reducing epidurals in non-complex cases during low workload periods, by over 25 per cent more than during high workload periods. Epidurals are resource-intensive for midwives and put patients on a path to further interventions during labour.
The study focuses on the period 2008 to 2013, a time that, due to cost-cutting in the UK following the financial crisis, there have been more frequent times when the number of mothers delivering has been greater than the number of midwives present – so workload has taken on increased significance.
The study – entitled “Gatekeepers at work: an empirical analysis of a maternity unit” – was co-authored by Michael Freeman, a PhD candidate at Cambridge Judge Business School, Nicos Savva of London Business School, and Professor Stefan Scholtes of Cambridge Judge Business School.