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).

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?

I know, I know, I'm fat!

On UK television this evening, we watched an episode of a documentary series about Whipps Cross Hospital ( a large general hospital in north-east London). One of the featured patients was a man suffering from the usual complications of heart failure, odema, breathing difficulties, impaired mobility, etc. He was a very sick person and he freely admitted that his current plight was a result of years of over-indulgence.

At this point. a kindly volunteer arrives wheeling a mobile shop from which patients can purchase some 'treats'. Our patient buys Coca Cola, chocolate bars and other assorted confectionery that, if someone else had fed them to him, they would be at risk of being charged with attempted murder.

You might think that a rant now follows - you would be wrong! But ...

Next year, my GPs are almost certain to be given some targets for controlling obesity in our patients. I have no idea why the Department of Health thinks that we can make a difference. Who doesn't know about fibre, fat and five-a-day? Who always looks sheepish when their weight is mentioned? Who doesn't know all about eating less and exercising more?

In case you're wondering, my BMI is nearer thirty than twenty and my waist is only just surviving. Few of us do what we know to be right even when the chicken (and chips) have come home to roost like our Whipps Cross patient who confessed to sneaking into a cupboard during the night to top up his cocoa and refined sugar levels.