Saturday, September 14, 2013

Smoke but no fire

Waited expectantly for this one. After all it was the Royal College of Physicians. Ignoring all the snide remarks from doubters about the College being an "elitist" organisation, one "out of touch"..I hoped, perhaps even prayed for a robust, ground breaking recommendations as regards the "Future Hospital". So it came to pass...and expectedly jumped on to it. Without fail, the PR machine whirred into gear..twitter was abuzz about the amazing report, the path-breaking findings..so one read it..even while in the middle of a busy day. 

So what's the verdict? Well from my point of view , unless the last few years didn't happen or all my conversations with colleagues are in a dream world, then I have struggled to find anything which any physician wouldn't clamour or ask for. They all make absolute sense- recommendations hinging on clinical judgements, based on patient needs....the problem? Absolute tiddlywinks about how to implement them. 

Let me give you one example: "Once admitted to hospital, patients will not move beds unless their clinical needs demand it". Brilliant...well said..and there is no physician who will disagree with that. My question to the ones who put that down in those glossy prints...how the bloody hell do you do that? In the middle of the night when the front door is heaving and there is the pressure to somehow transfer a patient out of A&E to ensure the 4 hour target is not missed, the 88 year old lady gets moved from the base ward to an outlier ward- not because there is any clinical need but because a bed is needed. You could argue the patient in the queue has a clinical need, but that 88 year old lady? Nope- none whatsoever. Still moved irrespective of whether the clinical team had suggested contrary to that. So any suggestion how to do that ergo avoid the patient move, how to help the poor flow manager? Er nope, the college stays silent.

Want another one? OK.."There will be a Consultant presence on wards over 7 days". Again, superb..no question or debate about that. Patients need it- and indeed some specialities who are blessed with numbers do indeed do this. So how do you make that uniform? Well, its possible but the present conundrum is this. To achieve 7 day cover, you need to "time shift" work of existing personnel...which simply put means that those who do the weekend will also need a bit of time off in the weekdays (shock and horror, Consultants actually are human beings and have families too)...which means that unless someone else is backfilling their job, their outpatient work has to be cancelled. I hear about "priorities" and colleagues in the front door thunder about where ward consultants should have their priorities. Let me distil that one then..I get paid enough..I don't need a single penny and am more than happy to work 7 days a week. Do please, someone let me know which pituitary clinic or adolescent diabetes clinic I should cancel and let the patients know. What all these front door policy makers sometimes forget is that for the patient who has a pituitary tumour..me cancelling their clinic appointment is no less traumatic than the one in the front door of the hospital awaiting a senior opinion. Not sure? Ask anyone with that pathology.

And finally, the best one..the one where the College really needed to show strength."Generalists and specialist care in hospitals"... Come on guys, tell us who the generalists are!! 
Why in a DGH cant you say ALL need to have a generalist role? Why should a cardiologist or a gastroenterologist be separate and be "special"...should I use the same ethos and walk away and be a "specialist"..or do the patients admitted with DKA not warrant highly enough compared to a patient admitted with chest pain or a bleed? Why can't I provide a 7 day service for all diabetes patients only too? This is where the document underwhelms and fails to deliver...fails to grasp the nettle and lay out what the vision is..fails to give Trusts or managers the wherewithal to change the way service is delivered.Did you say there is a lot of bowel screening to be done? By all means do so (though one wonders about the evidence base) but please when in a DGH, stop pretending you are in Guys or St Thomas Hospital. Its simple..either its "all in" i.e. ALL specialities contribute OR its "all out" i.e. ALL run their own speciality on-calls and leave the acute physicians and geriatricians to deal with the rest.You can't have it half way house- as the present situation is...causes friction between colleagues, a 2 tier system, burn out, morale...all the negatives you can think about..you got it.

So the overall view? An ambitious, well meaning vision...but without any clues as to how to deliver all of the recommendations. A lot of smoke but sadly, little fire.The future? Some will happen, some won't..in some places the debates will rage on and in some places, some specialities will be coerced. Uniformity across the NHS? No chance. A hospital can do all it want, all it can..but till the budgets between health and social care are fused, till the targets are fused, then simply put, in an ageing population with ever increasing morbidities, a future utopian hospital will always be that...one for the future. 

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