Saturday, March 23, 2013

One number on the fridge door

Its Friday late evening...the 87 year old frail lady, living alone at home, finds herself on the floor. Not sure what happened, she is frightened...and to make things worse, her relatives are away for Easter too. Thankfully she has had all the relevant numbers stuck on her fridge door. Her own GP number stands out there...lovely young lady..but no, she isn't there at that hour. She used to have the number of NHS Direct on her fridge, but that's now changed. Drat. What about 999....but now she isn't sure if she is ill enough. Should it be 111? Oh dear.
So how about the lovely Consultant who knows her so well? Nope, neither him at this ungodly hour, bless him, he does work hard.

I suspect you are starting to get the picture.And then one way or the other, to complete the story,she gets to hospital. Discharged a few days later, she is seen by community nurses, has a visit organised to the falls clinic.....and the saga goes on. All of them..different providers, fractured, fragmented, different IT systems, different referral many things is the elderly lady supposed to remember? But hey, fear not, competition is here...and we need more of it, more provider, more phone numbers, more IT could it possibly go wrong?

A few days back,I tweeted an idea, how about if OOH services were run by the local acute Trust? would it, could it work? One provider running emergency or unscheduled care especially out of hours? Worried that this may result in over investigation by those "too clever specialists? Why not the Trust employ or contract to GPs or even use them as advisors? Why have another provider run it with little or no links or access to specialist clinics when needed? In 2004, primary care renegotiated their contracts to ensure their high workload during the day was adequately recognised. Nothing wrong with that except that it blew a hole in OOH care...and frankly I don't care about who shows me what statistics, my personal experience with OOH when my little one was unwell was appalling, the level of nonchalance and poor quality shocking....far better care, more kind and caring people in my local hospital A&E department.Yes the staff there were tired, but they were in one word...amazing.

So why not run OOH via acute trusts?One provider, minimal fragmentation and if one gets to the world of finances, revenue for Trusts helping them to keep existing services rather than losing money to yet another provider?
For a change, rather than being agent provocateur, this is a genuine thought and would love to invite opinions and thoughts as to why this wouldn't work...where are the flaws, what is being missed. All I know is that the present system of OOh care is simply put, not working.
Want to hear something clinical? ok here goes...locally, a new provider won our OOH. Within 7 days of them winning the new contract, as local Clinical director of diabetes, I emailed them offering support for any patients with diabetes who may need support OOH, eager to explore options, see what we could do to avoid admissions. After an initial "oh yes, that would be fabulous", any further contact from the personnel involved? Diddly squat...while I see admissions which I know could have prevented by offering next day slots or sometimes simply by education or advise. I know my type 1 patients and I could indeed help prevent admissions, in fact with direct access to patients to my email, we do indeed do...but purely out of good will, not in a planned, contracted manner.So you know what? If the local acute Trust ran this service, I know for a fact they would have access to my clinic slots or a chance to speak to someone as to whether the admission could be provided....because I on behalf of the department would have provided it. Does every patient with a hypo or blood sugar more than 20 need to be admitted? No they don't.

Now wouldn't it be nice for that elderly lady to have one point of contact, one phone number stuck own her fridge she could just call when she was person who could assure her, visit her and organise a specialist or GP review if needed? punch some holes in this plan...tell me what the problems are and I will sense check it and see how we can work our way around it. If we are moving to a culture whereby chronic disease, quite rightly, is going to be managed more in primary care setting ergo under community trusts, then by the same token, acute care should be held primarily by the local acute trusts?  Once we get past the problems, then a generous amount of innovative commissioning, a dollop of will to "make it happen" with some generous sprinkling of mutual trust between primary and specialist care....and you know may just have a gourmet dish.

Either way, it's worth a presently whichever way you look at it, the OOH system is broke.And till that is fixed, no amount of daily or even twice daily Senior ward rounds will help to prevent inappropriate admissions to hospital beds, The locum doctor who has turned up from "somewhere" to run the OOH services without little knowledge of local services has invariably one or two answer to the patient,,," go to A&E" or "call your GP in the morning".

Just a blinking shame that the elderly lady would rather be in her own home that night...Easter hadn't brought better weather, it was still too cold.She wished there was one number on the fridge who she could call...and who would join all the dots for her.

Maybe the Easter Bunny would help her next year.

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