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?

It's an Emergency

I first started working in an NHS GP practice over six years ago. One of the first challenges was to try and get a grip of unscheduled care of our patients; people phoning us or turning up 'at the desk' demanding immediate care usually in the form of "seeing the doctor... now". Being an 'outsider' and a novice, I reached for ... The Contract. This was, and supposedly still is the document that defines what we had to do to fulfil our responsibilities as an NHS general practice. It didn't help.

It told me that we should provide urgent care when it was needed and so I entered the wonderful Heller-esque world of Catch 22. How do I tell which patients need urgent care? I'm not a clinician. Neither are my reception team. The only people who can decide whether something is urgent are doctors or senior nurses and that's precisely what the person at the desk wants. Thus we ended up in the situation that the way to get urgent care was simply to say: "it''s urgent". Actually what they usually say is: "it's an emergency". It rarely is.

During the week, our patients can always get to see a doctor within 24 hours. They may have to wait longer if they wish to see the doctor of their choice but if something is urgent, then that's the maximum wait. It's usually less. Anybody phoning before 11 am and who says "it's urgent" will be seen that morning!! Routine appointments (which last longer) are usually in a couple of days time, and if you want an evening appointment, then it will be anything up to a week (but if you're fit enough to get to work, then maybe that's not as bad as it sounds?

The upshot is that the anxious, the worried well, the over-dramatic, the unscrupulous, and the irresponsible get to the front of the queue; whilst the sensible, the responsible, and the reticent wait until an appointment is available. It didn't seem fair then, and it still seems unfair now.

I have asked "the authorities" to define what constitutes "urgent" but they duck the issue saying it is a clinical judgement. Clearly they can't generate a list of ailments, but they could provide us with something like "an impact scale"; a description of the sort of impacts that are "emergency", "urgent" or "non-urgent". It could be similar to the categories assigned to IT problems where the severity is decided by the effect of the fault (inconvenient, etc) rather than a definition of it. We would probably end up seeing the patient but at least, if they were taking the mickey, we could then caution them about their unacceptable behaviour.

Until that happens, the usual suspects will arrive at the desk, demanding to see the doctor of their choice, because "it's an emergency".