Tuesday, September 10, 2013


Cobblers. Absolute cobblers. That would be one way of describing what's going on now with the 4 hour target. So you know what..I am going to say it..the 4 hour target issue is simply put..unsolvable.
Negative? No zeal to embrace a challenge? No- none of that...just simply practical.So you ask what does a chronic disease specialist understand about the front door and 4 hour targets?
As it happens, perhaps a little bit. In our Trust, happened to be the lead for the Emergency pathway...when I started our acute medicine colleagues used to work till 5 pm; when I finished, they worked till 10 pm- in shifts. Made a lot of friends in that department that Christmas! I have worked with Turnaround teams, have worked with ECIST (Emergency Care Intensive Support Team)- not once, but twice..factor in that as a team, we visit 80 GP surgeries nowadays through the year and have first hand experience of pressures GPs are under..and yep, have some knowledge. But you know what? For the first time in my career, I have completely walked away from that side of things. You know why? Because over 4 years a realisation has set in, this is nigh impossible to crack. Not because of "lazy colleagues", "process issues"...but simply because it feels like Ground hog day.

So you want some thoughts from someone who has seen all this, been in the middle of all this? Some suggestions or observations? Well, here they are:

1. 4 hour target: Making this the bastion or beating stick for the local acute Trust doesn't work. A patients journey is intrinsically connected to community trusts, social care, primary care set up. If none of the others are subject to the same targets, why on earth would they have any initiative to crank up the pressure or deliver to the same level acute Trusts do? As a result of this "isolated" target, acute trusts try and put pressures on areas only they have influence over- cue poor flow managers running around, cue inappropriate discharges, cue elective work being dropped...all of which only causes bad blood, fractured relationships...and the merry go round goes on.

2.Multiple avenues: Stop creating more and more avenues for patients to access. Either they are poorly thought out or implemented. Cue people still attending A&E inspite of money spent on these other venues. Stop blaming patients for attending A&E...if thats what they are choosing, stop the multiple channels, bloster A&E, put the resources there rather than spreading existing resources thinly, depriving the local A&E and causing more of a backlog.If the NHS is about patient choice, then maybe listen to the patients? Yes, it would be fantastic to have all GP surgeries working 24/7, but a) lets be practical about it. They are doctors and human beings plus not twiddling their thumbs and b) its going to take some serious time and megotiations to achieve that..so till that El Dorado is achieved, some support for the local A&E would be nice.

3. Publicity: If you are going to tout A&E as a place where 95% will be seen within 4 hours- and mostly by seniors, then don't be surprised when patients prefer to go there. It's natural.So either decide to make A&E the only hub or go easy on the publicity blitzkrieg. Evidently we want the NHS to believe in the principle of "markets". Well, in a "market" system, you don't build a swanky shop and then spend time educating "customers" not to go there.

4. Tariff: Beyond the quality issue, Commissioners see A&E attendance as expensive. Well, anyone thought of changing the tariff? Money makes the world go around- maybe even something radical like fusing budgets between all local providers, make a common target...hang on..its not radical- people have been talking about it for..years.

5. 24/7 Consultant cover: If you genuinely want that, stop playing silly politics and either invest OR decide which work needs to stop. I am happy to do all sorts of cover and don't need an extra penny- but do please let me know which pituitary clinic or adolescent type 1 diabetes clinic you want me to shut down. I work on average 60 hours a week- and frankly, don't want to do more, even for more money. If you want me to be there at 2 am in the morning, then I need some sleep next day morning. I can't do a clinic-its dangerous- and as amazing as I am, I need sleep- like any ordinary human being. So let me know which clinic to cancel or provide me with resources to get another colleague. For the patient who needs help with their pituitary tumour, that clinic cancellation is as important as the person admitted at 2 am.

6. Finally, STOP reinventing the wheel. Stop bringing continuous flow of new people- well meaning no question- who think they have a brilliant new idea. They don't- its an idea other people have had, tried..and failed. Find out what plans were there, what worked, what didn't work. I see plans nowadays being advocated on twitter etc gleefully as the "new thing". I hold my head in despair when I check my emails from 2009-2010..same plans..same glee,,followed by "lets find another idea".

Am sure there's plenty more..but unless something big and radical happens, I can tell you for a fact that this winter will be back to the wall stuff. Till then, all power point talks, all plans are nothing but hot air and playing politics with the NHS.

Actually no, its all just...cobblers. Absolute cobblers.

1 comment:

  1. Passionate stuff Dr. Kar and lots of common sense. From a patient point of view, I ignore all the hype in the media about A&E (and lots of other things). I believe you can only go by your experience and from my recent experience with A&E (and the MAU ward) I was dealt with in good time and by excellent people in what is always going to be a difficult situation (critical care). Politics only seems to make things more difficult, not easier.