A&E Treatment Targets

It's been an "interesting" summer (as in the Chinese curse "interesting"). One of my more forgettable moments was taking myself down to St Thomas's one Wednesday evening with what I suspected was an unwelcome return of the double pneumonia episode a couple of months earlier.

I arrived into a pretty quiet waiting area at 20:45 and was booked in almost immediately. A few minutes later, I was taken into the treatment area and into a cubicle. Routine obs were taken and after a while the new JHO - Junior House Oficer (it was week one of the great August musical chairs) learned of my previous bout. She said she'd arrange an x-ray and this was done within the hour. Pretty good ... so far!

About 23:15 JHO returns and says chest is clear so they're going to take some more blood for some tests. Blood duly extracted. I wait in cubicle.

23:45   Still sitting in cubicle
00:15   Still sitting in cubicle.
00:30   I say to my wife: "You watch; in the next fifteen minutes all sorts of stuff will happen".
00:40  JHO returns and says they're going to admit me.

Me:   Why?
JHO:  Pardon?

Me:   I've been sitting here for the past 1½ hours. Why have you suddenly decided to admit me?
JHO:  We're still waiting for results of your blood test.

Me:   Can't I wait here?
JHO: No.

Me:   Why not?
JHO:  My care pathway coordinator won't allow it.

Me:   Well how long will the results be?
JHO: About an hour or so.

Me:  Well I'll wait here then rather than take up a bed.
JHO: You can't.

Me:  Why are the results taking so long?
JHO:  Um, um, actually there was a problem with path system.

Me:   What problem?
JHO. Er, we forgot to send them to the lab.

Me:   You are not admitting me to adhere to some arbitrary four-hour target which you will exceed because you made a cock-up.
JHO:   You can't stay here.

 Me:  Then I'll go home. I live over the road less than five minutes walk and you can phone me when you have the result.
JHO:  Oh, you'll need to fill in the self-discharge papers.

Me:   OK.

Two hours later the phone next to my warm comfy bed rings.

JHO:  The results are back. You need a CT scan. You need to come back straight away.
Me:    Does that mean I have the CT scan when I get there?

JHO:  No. They don't open until nine o'clock.
Me:  Then I'll come back then. Good night.

If I'd agreed to be admitted, St Thomas's would have charged my GP's commissioning budget because they'd cocked up their management of my treatment by forgetting to send my bloods to the lab. The likely cost to the GP's budget would have been hundreds of pounds because of the way it would be coded with my advanced years and a non-related chronic disease.

As long as this goes undetected. There is no incentive on hospitals to be more efficient when treating A&E patients long as they can be admitted, even without a diagnosis, after 3h:55min. In theory the tariff allows a set number of days for particular episodes but this was an episode that could have been completely unnecessary (e.g. my first ever attack of gastric reflux - which it wasn't).

Bad, like Tesco?

I attended a presentation yesterday about "Practice-based Commissioning". If you don't understand the term, may I suggest you click the "Next Blog" link at the top of the page? It would take too long ...

Anyway, one of the speakers was a passionate GP who explained what he and his colleagues were doing to ensure that the big, bad, Tesco/Boots/Sainsburys axis of evil didn't invade primary care. Why is this so bad?

Well, conventional GP thinking runs alongs the lines: They will open early and late so they will deal with our least-troublesome patients: the young, working people who don't want to take time off work to sort out their minor ailments. Under the present system of funding, we receive annually an equal amount of money for each patient. It doesn't matter what age they are, or how often they use our services. Since children and the elderly use us most, the loss of our least demanding patients mean we will find it hard to fund the same levels of care for these more vulnerable groups. GPs throughout the country are busy defending the status quo. I help ours to do so.

But before signing up to the received wisdom of the evil of Tesco et al, I think we all need to ask ourselves a number of questions about these companies and the services they provide:

1. Would you like your local McDonalds to be as clean as your local hospital?
2. Would you like to wait as long at the checkout as you do at your local GP?
3. Where do you buy fuel for your car and why?
4. Who deals better with complaints; Sainsbury or the NHS?
5. How much does it cost to park at your local supermarket and at your local hospital?
   

If you think I am being unfair, you are probably reciting a long list of the fundamental differences between a retail operation and a hospital. I don't see that cleanliness, punctuality, effective demand management, customer service and smart procurement should form part of that list.