Thursday, December 6, 2012

The perfect storm...



Sunday. And on call physician of the day. When I was in my training days, that meant an occasional call, once in a blue moon by the on call registrar to discuss an ill patient, little else. Not anymore...now it's an occasion which causes trepidation....because you know the phone will ring...and on cue, it did. It was the duty manager, someone I knew, someone I knew to be a "good egg"...so when with a hint of desperation she said the was a queue formed outside the Emergency department and she could do with some help, what's the doctor of the year to do, eh? This wasn't the time to debate what I could do by going in, this wasn't the time to discuss about the geopolitics of the NHS, to debate whether out of hours services were not unto scratch...sometimes it's more simpler to shrug your shoulder and drive in. So I did.

What struck me were the staff. In the midst of the media blitz which details in gory details the ward sister who had mentioned that they were "immune to patients suffering", I met a bunch of nurses in that department. For the 4 hours, I spent with them, you had to stand back and admire what they were doing day in, day out. Many years ago, as the medical registrar on call, used to go to that department quite regularly and they remembered. There were the odd jokes about how my dress sense hadn't improved, the banter about whether I had come off the golf course...but to the patients in the queue or in the department, they were simply put, fantastic. Would I have any hesitation in having one of my own, god forbid, come to this department and be seen by one of the nurses? Not in the slightest.
Sure there was the disgruntled doctor, angry and cynical at the multiple changes to the system, the feeling of not being listened to, the frustration ....but nope they didn't flinch from reviewing that patient which needed to be seen. It was battle stations...a far cry from the world of chronic disease, a world of long term conditions. This was quick, fast and the pressure to meet targets was suffocating...a continuous feeling of trying to keep your nose above water. I met the duty hospital manager, trying to make patients flow quicker...looked tired, but still smiled...wanted to help...everyone seemed to want to do the right thing...and everyone had their own pressures to deal with.

And the instinct for anyone under pressure, especially when you know you are going flat out is to look for something else. Not just where I am..but everywhere in the NHS. I speak to colleagues elsewhere and the pressure isn't unique to us...its all pervasive, everywhere.

At the front door, it was about "inappropriate patients" being sent in by those pesky GPs..how dare they opt out of out of hours? Truths and half truths make up our lives..and when you want to look for reasons...you start believing in anything. You have patients who don't need to come in...sent in by NHS Direct to come to the hospital. For headache. Some clever algorithm had flagged "possible cerebrovascular event...while 3 questions from a trained doctor reveal she was under a lot of stress at home and it was related to tension.  You also see patients who come to the department because they didn't know what to do...and then you also see lots of patients who came to the hospital..because they are simply put...sick. There is no Telehealth, no community service, no slick mobile technology which would have prevented the elderly lady with drowsiness from a severe urinary tract infection from coming in.

Then you have the belief that no patients are being discharged...so the myth machine says it's because Consultants aren't doing their reviews. The reality is that with social care funding under continuous pressure, the capacity to send patients home gets squeezed by the day. How do I as a Consultant look at the elderly lady in the eye and tell her to simply go home when I know that she is better suited in a different housing environment and isn't safe where she is? Do I simply say I have treated you for your chest infection and my job is done? If so, then I have failed to do what I promise to do every day....it's not the numbers that matter..it's the person in front of you. I try to do that in my young diabetes patients...why would the patient on the ward be any different? And I worry everyday now about the risks taken...will she be safe, was that discharge too quick?

Don't get me wrong..the are ways we can improve..we can get our communication with primary care better, we can have more resources in the community, we can stop specialists from cherry picking their patients and ignoring that patients have multiple morbidities blissfully ignoring the days spent training in general medicine, we can tackle patient expectation more robustly, we can educate people why one should attend an emergency department..I am afraid that will only achieve a fraction of what we are all trying to do. It's no ones fault...the problem is we have an ageing population with multiple morbidities and a shrinking social care budget. We all keep hearing how community care needs to be bolstered, but with finances as tight as it has ever been, that can only happen at the expense of the acute trust.Factor in the perverse incentives of payment by results etc...and the need to have the locality hospital afloat to do even basic elective work and have an emergency department etc....you can't take the money out either. Throw in that all the increased admissions and reduced discharges encroaches on a trusts ability to deliver elective work, their lifeblood...and the vicious cycle crystallises into the incessant pressure all of us feel ourselves in.It just feels like playing chess..when you have just been "checked" for one more time...and inevitably leading towards that final "checkmate".

I am a born optimist..always have been, always will be...but on Sunday, I looked at all those tired faces of the doctors, nurses, managers..all trying...but with the fortitude of the boy on the burning deck. As a chronic disease specialist, I wished I could help in some way and we are trying by moving into the community etc...but the reality is gnawing. In spite of all the stories, and the half truths about doctors and nurses not being professional enough, my personal view is that the NHS has survived so long simply due to the extra bit most folks put in..day in, day out. That extra 5 or 10 percent, spread over so many professionals have carried the NHS for a long time.

What do we do when that drops down to even 100%... what do we actually do? The "storm" is no longer "coming".....it's well and truly,...here.In fact, it is nearly....the perfect storm.


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