The Elephant in the Room is a Drunk!

The current mantra of our healthcare policy makers is "moving care closer to the patient". The reason (excuse) for this catchy little phrase is money. It is now assumed that moving care out of hospitals and into community settings is cheaper and on paper this is entirely reasonable. That's the "what" and the "why". It's the "how" that always terrifies me.

As a taxpayer, I wan't the NHS to be looking to ensure it doesn't spend money unnecessarily. There is one area where it could save itself a fortune if there was anyone brave enough to grasp the mettle. It's drunks!

Before shaving threepence off the community chripody budget, all politicians should be required to spend a Saturday night in the casualty department of the general hospital that serves their constituency. What they will see is an NHS emergency service overwhelmed with young, drunk, vomitting, often-aggressive pillocks who think that ending up having the contents of their stomachs vacuumed is a sign of a good night out.

Our risk-averse managers ensure that we care for these tossers with skills that are in short supply and very expensive to provide overnight and at weekends - how much would extra you want to be paid to be puked over on your Saturday night?

I think the answer is to adopt one of the United State's more sensible policies - the "drunk tank". If you're drunk and incapable, then get shoved in a large cell with all the other serial idiots until you sober up. In the morning you can pay the spot fine and find your own way home. Make sure the cell is tiled so it can be hosed down easily in preparation for the next batch. I don't wish to be uncivilised about it. Female drunks should have their own cell next door.

To start with, some cities will need something the size of an aircraft hangar (and there are plenty of those lying around) but once the message gets through to what's left of their brains, demand will surely lessen?

Your trusted GP?

Back in January this year a young baby, one of our patients, died whilst waiting in A&E. It was unexpected but actually no great surprise. The poor mite had been born with a number of severe heart defects which skilled surgeons were doing wonderful things to fix but only a few at a time.

I have just received "Form B" from them upstairs.

On the front page it says:

"Each agency representative is to complete this form by summarising information available within their agency. Each representative should complete only those sections for which they have information. The CDOP manager will collate the information from the different agency reports to provide an overall case record. This collation will be agreed at the local case review or by the individual agency representatives in consultation with the CDOP manager.

You can see where this is going.

Let's fast forward to page 4:

"Factors in the family and environment:

Include comments on family structure and functioning; wider family relationships; housing; employment and income; social integration and support; community resources.Include strengths and difficulties."

Had enough yet? No?? Page 8 then ...

Is either parent a smoker? Was the baby an asylum seeker? Are the mother and father related to each other (excluding marriage)??

It stops at page 10.

After the death of Victoria Climbie, the NHS spent millions and millions on a massive change on child protection procedures in GP surgeries, most of which would not have stopped Victoria's "aunt".

After Shipman, the NHS spent millions and taking Class A drugs out of GP surgeries because they made the paperwork so awful that it was easier not to bother. Another huge system upheaval not because the system didn't work, but because individuals in the system failed in their duty of care. I can only surmise that this form is a result of the baby P case.

Officialdom's response to a failure is to change the system but it's the people that don't do their jobs that's usually the problem.

Everybody knew.
Anybody could.
Somebody should.
Nobody did.

Here's a suggestion: save the money spent on completing this form (which is arse covering in triplicate) and spend on on front-line social care that might just reduce the incidence of further Baby Ps.

Sacred Medical Records

You are currently spending lorryloads of money creating the ability for clinicians everywhere in the NHS to view your summary care record ("SCR"). Whenever this investment is challenged and for whatever reason, the shroud wavers emerge to say that it will save lives. They give examples of people who would suffer a severe anaphylactic shock if given drugs to which they will react badly. They are correct but that must not be the end of the argument.

Medical records as we maintain them are mostly utterly irrelevant to present or future health care.

Elderly patients have letters in their records telling me that in 1955 they had a baby with a normal delivery at a hospital that long ago became a luxury apartment complex. That baby is now collecting their old age pension.

I know that's an extreme example but very little of what has gone before has any relevance to urgent care or current management.

You are spending billions moving paper and electronic versions of all this medical ephemera between GP practices and from practices to hospitals and back again.

Instead of upgrading the NHS wide area network, let's buy some shredders.

Targets Are Not Management

The Government has made much of its decision to scrap a couple of NHS targets: the "48 hour target" within which time a patients is guaranteed to see a GP; and the "18 week rule" within which time a patient should have been treated in hospital following a referral from a GP. I really disliked these targets but perversely, I am sorry to see them go.

Firstly, what didn't I like?

Well, let's start with the 48-hour target. The way in which GPs fiddled their appointment systems didn't really sort out the structural confilct between seeing the GP when it suits (a future appointment) and seeing the GP "now - it's an emergency" (even though it almost never is!).

Some of the outcomes of the 18-week rule were frankly, bizzare. If a patient tried to change a hospital appointment, they were "discharged back to their GP" (NHSspeak for taken off the system) and invited to join the queue from the start when a further 18 weeks could be counted. This is clearly poor care and there is no excuse or justification for it.

So, why am I sorry to see them go?

I should explain that I am not opposed to quantitative measurements of performance to inform management. Looked at in isolation, these targets are reasonable; if you in some distress it is reasonable to be able to obtain medical help within two working days. Four months ought to be enough time for a patient to pass through the hospital system and be treated (providing there have been no unforeseeable delays).

The problem is not the targets but the way in which The Health Kremlin uses them.

Targets are not management or a substitute for management yet this is precisely how they are used. The orthodoxy is that we set these targets and leave the front-line to reorganise themselves to meet them. What doesn't happen is sensible pragmatic supervision and management of the behaviour of GPs and hospitals that are aspiring to these targets. Providing the PCT or Hospital can let their local Politburo tick the correct box, then the target has worked, even when a short stroll around the patch would reveal some of the nonsenses that have been carried on since the targets first appeared.

Another classic: the "no more than 4 hours in A&E target".

Introduced after countless lurid headlines of patients left lying on trollies in corridors for hours, days, weeks, etc. The target has resulted in a huge surge of patients admitted as in-patients because the precautionary test results (x-ray, whatever) wasn't available within 4 hours; all of this at considerable additional cost and inconvenience to everyone.

Before we had targets and no management.

Now we don't even have the targets!

It Only Works because It Doesn't

In the left corner:

Our PCT, insisting that we provide ever more appointments that have to be bookable two weeks in advance; also insisting that we see patients immediately when they say it's "urgent" even when it's clear it isn't; and also providing minimum number of appointments each GP must provide each week. Their targets are ambitious but we do our best.

In the right corner:

The BMA Guidance on child Protection which says amongst all the other excellent advice: "Doctors have a key role to play in child protection (case) conferences and the BMA considers it important that , as far as possible, doctors attend in person, in addition to sending in a written report containing relevant information such as ..."

In the middle:

The GP. We usually receive less than 48 hours notice of a case conference (that's because best practice is to convene it a.s.a.p). So the GP has usually already got fifteen or so patients each with a ten-minute appointment booked up to two weeks in advance, exercising their right to see the doctor of their choice.

The Outcome.

We rarely attend case conferences and until someone works out the realities of the conflicting demands made of GPs, that situation won't change.

The Moan

It's one of the things that really gets my goat. Managers have produced glossy (and expensive) books containing impressive procedures that are faultless in ambition, aiming for very best practice and overflowing with care. They simply don't work and nothing will change until they look at the realities of general practice. Try asking us - that would be a start.

Uncle Noel RIP

Yesterday I went to the funeral of the last of my mother's seven siblings. Uncle Noel died peacefully at the splendid age of 93. He started as a miner at the age of 14 but continued his education and after the war became the Deputy Master of Worcester Workhouse. What a splendid title! Pure Dickens, porridge and all. For the rest of his working life, together with my aunt, they cared for old people and they did it really well. My Aunty Mair's cooking was legendary!

When Mair sank into the swamp of dementia, it was all the more frustrating (polite version) to see the lack of care that she received despite the determined afforts of a feisty eighty-odd year old husband. Hospitals trying to discharge her because she "wasn't ill as such" and local authorities acting with a complete lack of urgency. After all, Uncle Noel could help (no, they hadn't noticed he was crippled by two very arthritic hips).

After Mair's death, Noel moved into a care home run by MHA (a methodist charity). At last, he received the sort of care that he and Mair had given to others. So thank you to MHA, the staff at Norwood, Ipswich and to Noel and Mair for lives spent providing real care for people not clients.

Is This The Real Meaning of "Efficiency"?

"Phlebotomy" = extracting blood for testing and monitoring patients. Some GP surgeries do it but mostly it's done either in the local hospital or a large health centre.

A few weeks ago we were informed that the afternoon opening hours our local phlebotomy clinics would be reduced.

"Why?" I asked (since afternoons were especially popular with people with jobs). The answer came back:

"The activity within the phlebotomy service has been increasing year on year since it transferred to the Community Provider from the local hospital in 2004/05 with very little increase in funding. We had managed to sustain a quality service within the financial constraints over the years. However with further financial reductions across all provider services it has become necessary to ensure the service that is provided remains of good quality and all governance risks are reduced which has unfortunately resulted in a reduction within the service for some of the afternoon clinics.

We had approached our commissioner colleagues for additional funding last year which was initially agreed for 6 months whilst they reviewed the service, allowing us to resume a full service. Unfortunately the funding agreed this year is not sufficient to provide the same level of service."

I always have trouble with "officialese" so just to be sure ...

"Thank you for your reply which leaves me rather baffled (nothing new there then)!

May I paraphrase?

(a) Demand is increasing
(b) Funding is decreasing
(c) The level of service is therefore reduced.

Or have I missed something?"

Clearly I hadn't and the further response had me reaching for the benzopump.

"Correct.
Whilst funding following the review increased our establishment by 1 phlebotomist only to be then used for efficiency savings. Leaving us with no choice but to provide a service within the envelope of money we have been given."

Just in case you have some difficulty in comprehending the sane and rational world in which I work, allow me to summarise:

1. Demand for the service has increased and thus so have the costs of maintaining the same service levels.
2. The provider asked the commissioner for more money and this was given but only why the commissioner reviewed the service.
3. Having completed the review, the commissioner agreed to increase funding to increase capacity.
4. The commissioner then took the money away again and called it "efficiency savings".
5. As a result, the service levels have been reduced.
   

Be Careful What You Wish For!

I guess everybody now knows the "old Chinese proverb":

Be careful what you wish for;
it may be granted.

A fair number of people must be hoping that the Tories do win the election that can be no more than six weeks away. Let's just suppose they do. Then what?

Trouble, that's what!! Big trouble.

The present lot have presided over and implemented the most right-wing policies ever experienced since the NHS was founded sixty two years ago. They have done so consistently ever since Tony Blah "discovered" health in 2000 (when a junior minister lost a "safe" seat in Kidderminster to a doctor who campaigned solely on keeping the local hospital open).

Now think of Charlie Whelan (a.k.a. Charlie Marx) running the Unite trade union and close fried of Gordon (you know ... "the safest pair of hands we've ever known as a Chancellor" - that Gordon).

Add these all together and you may understand why Labout have got away with it; the biggest privatisation of healthcare and lots more of it already signed and sealed if not delivered. Now fast forward to the second week in May ..

David Cameron walks into 10 Downing Street.
Andrew Landsley (presently shadow health sec.) walks into Richmond House, 79 Whitehall.
Guess who will be walking out?

• nurses
• porters
• technicians
• cleaners
• maintenance people
• drivers
• etc

The "free ride" enjoyed by Labour will be over. Any cuts will be an immediate political cause celébre.

I know several people who will vote Labour not because they admire them but because:

• the country cannot be ungovernable at such a time;
• they should be forced to have clear up the mess they've made.
  

Care in the Community - Been There - Got Nothing

The sudden burst of posts might lead you to think that I have suddenly become more agitated of late but you'd be wrong. It's just that the year end in public accounting is when we all get inundated with requests for "stuff" - I won't bore you with the trivia that is much of my working day. The worst of the storm has passed, so I can attempt to benefit from the catharsis from shouting at the world-wide webosphere.

The current DH obsession with "moving secondary care into a community setting" brings back both some sad memories from my own childhood and also my own view of the last time we heard "care in the community". This was a dominant mantra of the Thatcher years. Why sad?

Well, my elder sister was born brain-damaged and remained a young child for the twenty one years she spent on the planet. At the age of twelve, in the early fifties, she was sectioned and sent to St Lawrence's Hospital in Caterham. She wasn't a danger to herself or to anyone. It was simply because my parents couldn't care for her due to my mother's failing health. Every other Sunday, we visited for two hours (having to queue outside the main gate until precisely 2pm). The journey was bus, train and then bus again and it took two hours each way. The wards were crowded and the nurses were amazing. Most of the inmates were there because that was the only structure in place at the time to provide such care. Once admitted, the "patients' " chances of leaving alive were almost nil since there was no rehabilitation; just detention. You might think then that I would be "Care in the Community's" greatest fan? If only!

The reality was different to the hype. Who can argue that my sister and most of the other 2,499 prisoners would have been better off if the vision of Care had been delivered?

Instead, the whole strategy was used by central and local government to leech money from the system to meet their short-term financial imperatives. St. Lawrence's was closed the government pocketed the proceeds of selling prime Surrey commuter belt development land. Local authorities were left with inadequate budgets and insufficient experience to absorb a wholesale shift to them of people who had spent their lives in such institutions with complex health needs and no clue of how to even help in their own care. It was ten shameful years of waste, unnecessary bewilderment and confusion.

The problem was not the intention. it was its implementation. If I could lay my hands on the mandarin that executed this appalling act, I would cheerfully throttle him.

Polyclinics - An Elegant Summary

George Monbiot writes for The Grauniad. his article on polywotsits is a standard of writing to which I can only aspire with little confidence of achieving.

Do read it here

Don't Confuse Me with the Facts

In our neck of the woods, "polysystems" are the flavour of the moment. They are the result of Lord Darzis's major review that in far too many words and way, way too much money, concluded that:

1. London has too many hospitals;
2. Lots more care should be delivered "locally" (which is healthspeak for "not in hospitals");
3. GPs should work in polyclinics (but we'll call them something else because polyclinics don't work).

I attended a meeting last month at which I said (yet again) that the wholesale disruption of existing referral processes can only work if the communications infrastructure is in place.

The director chairing the meeting agreed.

I then said that this would be especially true if the Darzi model is implemented (it is happening right now).

The director chairing the meeting agreed.

Then says I, but the current infrastructure is not in place; it's years behind schedule and billions over budget.

The director chairing the meeting agreed.

So, I went on, if you agree that it will only work if the comms are in place and you agree that the comms are not in place, the only logical conclusion is that it won't work???

The director said it was too early to say that!

Mmmm... now there is a good idea. let's wait until the system isn't working and patients are transferred from here to there, and then somewhere else, whilst their notes move from anywhere to nowhere.

Makes perfect sense to me.

Meeting Targets and Failing Patients

Our local general hospital shares with our own primary care trust a DH target of "eighteen weeks from referral to treatment". Laudable? Oh yes.! Achievable? Mostly! But ...

If you make an appointment but then, due to unforeseen circumstances have to change it, you can't! Your referral is cancelled and you have to go back to your GP and start all over again. There is a reason (although "reason" is the last word I would used) as explained in the hospital's standard appointment letter:

"PLEASE NOTE: To avoid delays (sic) you may only be able to re-arrange your appointment once as we aim to complete your treatment in 18 weeks from your referral."

It is reasonable that, if a patient delays their treatment because they have chosen other priorities, the hospital doesn't then suffer the opprobrium of the bean counters. The hospital's way of ducking under the bar is ludicrous.

It is even more ludicrous when the reality is that they do not allow even one change of appointment, even when it was the hospital themsleves that cancelled the original appointment made by the patient and the replacement appointment offered is not suitable.

Where else would "the customer" be treated like this?

If Only Patients Were Apples

On telly the other evening was an article about how farmers are able to deliver "fresh" apples to us all year round. The answer is that they store apples in reduced-oxygen cooled storage units. Similar things are done with the humble potato. The way in which Tesco et al monitor the growing, storage and packing of everyday food items is astonishing. Consider the following the next time you are holding a bag of spuds in the supermarket.

Mr Sainsbury or Mr Morrison can tell you everything there is to know the batch of potatoes in that bag:

• What day it was originally planted and the weather conditions (wind, temp, etc)
• What chemicals have been applied to it (batch number, date, weather conditions, etc)
• What day it was picked (weather, blah, blah ..)
  
• Where it was stored and all the records of temperature, location, etc.
• When it was removed from store and packed
• Which lorry delivered to where and then the same for final delivery.

It is an amazing system and it hasn't cost twenty billion quid!

Into the valley of death

Many, many years ago, I was a military chap. I look back on my ten years defending Queen and country with fond memories and an ever-increasing amount of nostalgia for an organisation that was just that - organised! Quite often I resort to military metaphors to try and get across what I see are some of the things our senior NHS dafties get up to.

Time to bring on Connecting for Health.

CfH is a big plan. No, bigger than that. It's bloody enormous! Conceived as a "let's do away with these little systems and get big companies installing massive systems across whole regions". Multi-million pound contracts that now have a couple of extra noughts on the price tag. A completion date that is moving away so fast you'd have the warp drive from the USS Enterprise to keep up with it. The functionality is poor. The user interfaces are "clunky" and the speed of the system often reminds me of telex. Apart from that, it's a winner?

It feels like a battle where the plan was to capture the enemies' gun emplacements on the hilltop so the infantry could advance in safety across the valley and engage the main enemy force. Good plan. However ...

The attack on hilltop fails. When told, the general realises that the main body of troops has already started advancing. "Well, they've started now so I guess we'll just have to let them carry on. It would be just too embarrassing to admit defeat before the main event!"

Delays to right of them, cost overruns to the left of them,
Into the Valley of Financial Death rode the 600 ... um ..milllion
nope make that 2,4 billion
ooops, I meant to say 12,6 billion
or should that have been 16,billion

for an electronic care record to be delivered in 2005,
2007,
2009,
2011,
2014 .....

Organisational Dementia

I have been in in my current job for over seven years. In that time, at my PCT I have seen the comings and goings of four chief executives, four directors of finance, seven directors/managers of primary care, two directors of commissioning, three finance managers, three directors of clinical governance and three directors of human resources. Not one of the heads of the major departments was in post more than three years ago.

This need not be a bad thing. indeed, for these individuals, it's usually a very good thing. New appointments usually mean promotion, more cash and new interests. For those of us left behind, it is often a source of irritation and frustration.

Why is it frustrating? Well, because quite often we find that the useful suggestions (and accepted as such by the management), we made about improving services fall by the wayside. The replacement arrives at the next meeting with a clean sheet, fresh start, and other manifestations of the lack of an effective handover. The good idea has to emerge all over again and the clock is reset. As far as the new incumbent is concerned, there is no delay because the count has just started.

Then there's the irritation. We negotiate an agreement with a director and do whatever the agreement requires of us. A couple of directors later, the new leaner, meaner, "we must reduce costs" senior gunslinger calls us in and says we're not doing it properly. Our response that "we are doing what was agreed" is brushed aside. "I wasn't here then" which is intended to mean: "that agreement doesn't count and we can and will ignore it".

Efficient organisations learn from their successes and their mistakes. The NHS doesn't seem to learn. I cannot see any evidence of any determination for our PCT to retain a clear view of who did what, when, and the outcomes. The process of finding a replacements for a departing senior executive usually starts after his or her departure. Frequent reorganisations mean the shifting of some duties from one person to another and departments are broken up and re-established with the energy of a Scottish country dance. In amongst all this organisational musical chairs, knowledge and experience evaporates.

Never mind, a new director will soon be here, brimming with "fresh" ideas.

Tidy processes but untidy outcomes

General Practice is managed by its local Primary Care Trust. Our PCT has a population of 330,000 patients and spends hundreds of millions of pounds of your money and mine. They are responsible not just for ensuring we are performing our duties properly, but also for introducing new services and the procedures to support them. They also commission new buildings; they modify and adapt the complex arrangements that are involved as a patient moves through the system from GP to hospital or to a specialist clinic, and then back again. From a general practice perspective, virtually everybody with who we come into contact is a "manager".

It may come as a surprise to you that so many of them have no specific previous relevant experience that they can apply to the tasks for which they have been recruited. The important essential criterion seems to be the ability to produce impressive word-processed reports with lots of tables accompanied by a multi-page spreadsheet with lots of colours. Too often, it is the triumph of style over substance.

Don't believe me? Then consider the following:

Yesterday I attended a meeting of a group meant to be steering an important screening service for people suffering from complaint found frequently in our population. There were seven of us managers and we all like to think we have the best interests of patients at the heart of everything we do. We were discussing the local hosptials failure to achieve a fourteen-day target for seeing urgent referrals.

Nice manager from the hospital: "We have a high rate (40%) of non-attendance in clinics."
Nice assistant director of PCT: "What are you doing about it?"
Nice manager from the hospital: "We're recruting a locum consultant to work thought the backlog".
Nice PCT service manager: "That's good to know. How long will it take?"
Nice man from hospital: "We are recruiting now and we believe it will soon make a signficant improvement".
Nice assistant director: "That's good to know."
Me: "Hang on a minute. If two in every five people aren't turning up for their appointment, why get more capacity when the capacity you've got sits unemployed for 40% of their clinic time?"
Nice man from hospital: "The consultants won't let us double book clinics".

Apart from the inherent nonsense of the consultants' stance, nobody else seemed the least bothered. They had dealt with the problem i.e. they had pushed and prodded it a bit (but not too hard) and had a response to write in the minutes.

Meanwhile, patients are still not getting urgent appointments within two weeks, and there is no date given at which it is forecast that this entirely avoidable situation will improve.

Their process is nice and neat but the outcomes which were poor are no better.