Abstract
I have just completed my 15th nine-hour shift at the Polyclinic in the London 2012 Olympic Village, and my ‘limpic afterglow’ is still very much ablaze. Amidst the memories of unusual clinical experiences – the diverse cultural presentations of jet-lag; early-morning medicals to certify the world's best boxers ‘fit to fight’; sightings of rare stress fractures seen only in people who subject their bodies to extreme forces; and a couple of life-threatening emergencies – and even more unusual social ones – such as gathering with fellow doctors and waiting patients around a wide-screen television to watch the 100 m final – I am beginning to look back on the Olympic Polyclinic experience as a potential treasure trove of lessons in the organization and delivery of services.
The Polyclinic was a new-build, three-storey structure on the edge of the Olympic Village. It had a contemporary ‘green’ design (lots of natural light, open-plan spaces, pleasing angles and even a roof garden). It was equipped – temporarily – with state-of-the-art sports medicine facilities along with dentistry, optometry, podiatry, massage, general practice, dispensing pharmacy, pathology laboratory, radiology (including computed tomography and magnetic resonance imaging [MRI]) and a six-bedded Accident and Emergency unit. After the Olympics and Paralympics, the Polyclinic building will become a part of the National Health Service and (it is anticipated) house a new GP facility along with extended community-based services.
The Polyclinic was staffed almost exclusively by unpaid – but highly qualified – volunteers. Its remit was to provide ‘immediate and necessary’ investigations and treatment to the ‘Olympic Family’ that consisted of athletes (who were mostly young, optimally nourished and supremely fit) and their accompanying officials, coaches, administrators and support staff (mostly middle-aged and variably fit), as well as to the ‘Olympic workforce’ of volunteers, military personnel and contractors. It was part of a wider network of medical services that served 14 Olympic sites, including the different sporting venues (offering both first-aid to spectators and ‘field of play’ emergency services to athletes), and various west end hotels housing VIPs.
My role at the Olympics was a jobbing sessional GP not a strategist or team leader, so what follows is neither the official story of the medical provision nor an evidence-based evaluation. It is mainly – though not exclusively – a reflection on what went well.
Lesson 1: Given the opportunity, professionals will organize themselves and develop appropriate standards
The thinking behind the Polyclinic was that the clinicians, pharmacists, technicians and so on working in the various departments would develop operational routines and implement the highest professional standards with the minimum of top-down bureaucracy. Two weeks before the Olympics began, when the Village was empty save for a few dozen ‘chefs de mission’ sent on to prepare the ground for their country's forthcoming delegation, we physically built the Polyclinic by assembling flat pack furniture, stacking shelves from boxes of supplies and installing recycling bins made from renewable cardboard. We used the handful of early patients to dry-run clinical pathways (such as ‘tummyache and loose motions’ or ‘recent onset forefoot pain’), develop light-touch administrative infrastructures and strengthen the professional and managerial relationships that would prove pivotal when the initial trickle of patients grew to a peak turnover of several hundred a day. We were issued with a short and pragmatic desktop guide, but not a rulebook – and nobody missed the latter.
Lesson 2: All patients and staff should have a unique identifier
As part of the tight security clearance that characterizes contemporary mega-events, everyone who was allowed to enter the Olympic Village – that is, those formally designated as ‘Olympic Family’ or ‘Olympic Workforce’ – was issued with a photo ID printed with their name, unique identifier number and bar code. Those without such artefacts (or whose bar code did not scan properly) were physically excluded from the site until their access privileges were sorted. This meant that the personal demographic details of everybody – and I mean everybody – who either sought the services of the Polyclinic or were involved in delivering such services were already on the system and could be rapidly retrieved by entering a seven-digit number. While I enjoyed the 100% concordance between the patient in front of me and the patient represented on the electronic record system, I knew, even at the time, that this utopian ideal was only possible in a total institution surrounded by an impenetrable perimeter fence. Nevertheless, the experience convinced me that the closer a healthcare system can get to a workable unique identifier, the easier it will be to deliver, monitor and evaluate services.
Lesson 3: Supply breeds demand
From the two mobile MRI scanners parked outside the Polyclinic to the network of top specialists who had agreed to be on 24-hour call in case of emergency, the facilities available to the Olympic Family were truly world class. It did not take long for word to get round that these facilities were not only available and accessible but free at the point of use. Patients seen in the Polyclinic were issued with take-home summaries in a glossy folder bearing the Olympic logo. As requests for consultations grew exponentially, we began to wonder whether these folders, containing the signatures of British doctors and DVD copies of investigations and images, had become (for the discerning health connoisseur) the ultimate iconic souvenir of the Games.
Lesson 4: The line between ‘immediate and necessary’ and ‘health tourism’ is less clear in practice than it is in theory
In theory, it should have been easy to distinguish between a ‘chronic’ condition or risk state which was out with the Polyclinic's terms of reference and an ‘acute’ or ‘urgent’ problem for which the individual was eligible for services. In practice, there was no clear boundary between these. The iceberg of unmet need in the Olympic Family – including poorly controlled diabetes and cardiovascular disease, longstanding but previously undiagnosed mental health problems, potentially serious gynaecological or prostatic symptoms that had allegedly appeared only since arrival in the UK, and so on – was huge, especially for team officials from low-income countries whose own healthcare systems offered variable care at substantial cost to the individual.
One major issue was ‘forgotten’ supplies of regular medication. The excellent drug formulary developed for the Olympic Polyclinic had – probably rightly – been designed to support treatment for the acute conditions likely to affect athletes (e.g. hayfever, minor infections, musculoskeletal injury) but was not oriented to matching the various oral hypoglycaemic, cholesterol-lowering and antihypertensive cocktails being taken by some visitors. Finally, perhaps, there is a potential outlet for the Polypill?
Lesson 5: Informal interaction between clinicians generates rich learning
Polyclinic shifts were long, but the number of patients seen per hour was usually sufficiently few to allow plenty of time for informal interactions over coffee, during impromptu ‘mini grand rounds’ in the radiology reporting room or via the time-honoured ‘corridor consultation’ in which clinicians from different specialties exchanged opinions on interesting cases as they fell into step on their way to lunch. While many patients had simple (and often self-limiting) conditions, a significant minority presented with tropical rarities, small-print complications of unusual diseases or other diagnostic puzzles. Lack of detailed knowledge of the patient's past medical history and lack of familiarity with his or her cultural background added to the uncertainty in such cases. In several instances, it was informal interactions rather than evidence-based algorithms or formalized multidisciplinary meetings that provided the key step to clinching the diagnosis.
Lesson 6: Handovers matter
The weakest link in a healthcare system is often the handover between shifts of clinicians. At its busiest period, the Polyclinic had a high turnover of patients, most of whom needed little or no follow-up. Tests (blood, urine, stool and simple radiographs) were usually sent to exclude rather than confirm serious pathology. But it is in just such circumstances that the rare patient with serious pathology is at risk of slipping through the net. We were fortunate to have on our team both doctors and nurses who ‘obsessed’ (their words) about the system for handing over partly-sorted cases. They developed a ‘blue file’ with a designated front section for red-flag cases and various sub-sections for in-progress tests, actioned results and dated handover notes. Had the Polyclinic been permanent, I am sure all this would have morphed into electronic format – but I suspect that the paper version, physically passed to the incoming shift during the scheduled overlapping tea-break, was at least as efficient.
Lesson 7: High-quality patient information materials support high-quality care
Having been a UK GP for more than 20 years, I take for granted the availability of high-quality, evidence-based patient information leaflets (such as the excellent range of downloads from
Lesson 8: Clinical data have important secondary uses
A recurring complaint in the preparation phase of London 2012 was the lack of robust information on clinical demand from previous Olympic Games. Data were, apparently, available on the number of encounters with medical services, but not on what people consulted for. It was a reasonable assumption that most encounters from athletes would be for musculoskeletal conditions (injuries, over-use and so on) – but what would non-athletes seek medical aid for? Nobody could tell us. The Polyclinic staff took on the challenge of providing better data for those planning Rio 2016 than the London 2012 planners were able to glean from Beijing 2008. To that end, we were encouraged to code every encounter assiduously so as to generate a meaningful aggregated statistics on diagnoses, investigations, treatments and ‘disposals’ (that is, discharges, onward referrals and re-visits). The coding scheme left much to be desired (there were many ways to subcategorize a sprained ankle, for example, but only a single category for the many causes of tiredness and ‘stress’). But it will, I think, produce data that are good enough to use as the basis for such tasks as workforce planning and designing the drug formulary for Rio and subsequent Olympics.
Lesson 9: A commercial IT system that is not closely tailored to the nature of clinical work will feel clunky and demand multiple workarounds
One of my research interests is electronic patient records, so I came with high expectations for the Polyclinic system – and I was disappointed. Apparently the contact for the patient record system had been given to a commercial provider as part of a wider Olympic IT contract, and the same system was rumoured to have been used in several previous Games. Never have so many punch-the-screen moments been experienced by so many, when serving a population so small, for so short a period. The precise details of the ‘clunky’ features are less relevant than what I think is the upstream explanation for them – that system designers did not appear to have included a phase of ethnographic observation of the detail of Polyclinic work and amended the functionality of the system to reflect this detail. As a result, the system was experienced by staff as slow and frustrating to use, and we quickly developed ‘workarounds’ to enable us to get jobs done. If the supplier is planning on providing electronic record services to Rio, its resources would be well spent studying the model-reality gap and modifying the software accordingly.
Lesson 10: Staff as well as patients have health and care needs
The Olympic Village had a very simple social hierarchy – you were either an athlete or you were in the Village to serve the athletes. Polyclinic services to the latter group were effectively occupational health. But unlike standard occupational health services, we were not dealing with people who sought authorization to take time off or obtain modifications to their job to accommodate illness or disability. Rather, the Olympic buzz was such that almost everyone involved in the spectacle – whether volunteer, contractor or official – viewed themselves as ‘Games-critical’ and refused to go off sick. It was not just the doctors who were working extended (and sometimes back-to-back) shifts day after day. Because volunteers were not covered by employment legislation, there were no rules about length of breaks or number of hours worked in the week. When staff went sick or dropped out, their colleagues stepped in to work extra hours. As a result, stress and exhaustion among both junior and senior staff were not uncommon, and when this occurred, performance was undoubtedly affected. Fortunately, there was sufficient extra capacity within the Polyclinic to send exhausted staff off to get some rest – not least because the professionals in charge had assembled a ‘resilience team’ of reserve clinicians in anticipation of just such a need.
Conclusion
For most people, the Olympics is a once-in-a-lifetime experience. A cohort of Olympic athletes is probably the most atypical patient population on the planet. It could be argued, therefore, that the health facilities of London 2012 were so unique that generalizable lessons from the Olympic Polyclinic will be few. On the other hand, the Polyclinic – rapidly assembled and in existence for a few fleeting weeks – was the ultimate natural experiment in which the universal principles of organizing and delivering effective health services were both illustrated and put to the test.
DECLARATIONS
Competing interests
TG was a volunteer at the London Olympic Games. She is a co-investigator on the ORiEL (Olympic Regeneration in East London) research programme funded by the National Institute for Health Research
Funding
None
Ethical approval
Not required
Guarantor
TG
Contributorship
TG is the sole contributor
Acknowledgements
TG would like to thank the London Organizing Committee for the Olympic Games, the clinical leaders and managers of the Polyclinic, and her fellow volunteers for the unique experience that inspired this article. The personal impressions described here should not be interpreted as an official evaluation of the Polyclinic services