Saturday, September 9, 2017

More please?

You know it that time of the year- its pretty much become like a well scratched vinyl. And on cue it appeared- the ask for more money- as the "worst" winter is about to hit. More money for the acute Trusts, more beds needed to somehow scramble past yet another winter. I must admit to finding it all very fascinating - not to mention even more so now- as our local hospital -like most others- try to fill in gaps-helping out acute medicine- as a shortage continues to recruit folks to do that role.

Over the years, I have always taken more than a passing interest in this- and my recent experience has  piqued my interest even further. Our desperation to get more senior staff to see patients has now ended in square pegs into round holes- somewhere, somehow exists the belief that "any" senior seeing the patient is better than one of those pesky, unsafe, untrained folks called "junior doctors". So we all pile in- the drumbeat for generalism beats louder- sadly showing signs of losing focus at which point a generalist seeing a patient is actually more dangerous than the patient seeing a specialist at the right time. Lets give you an example- I would say I am reasonably ok as a generalist- is it safe for me to review a patient who has issues which have made the cardiologist admit the patient to a cardiology bed? Do I do anything apart from saying " Carry on?" Should I? Could I? Somewhere it clocks as a senior review- when what that patient needs is the right senior seeing them to progress their care.There is a balance- cross that- and a generalist has their limits- you move into areas of uncertainty prompting further investigations, more delay, more angst…Beyond that, all you are doing- well…you may as well as call me a "Senior Registrar".

So is more beds the answer? And if it is, why would that change now? What exactly is changing that would make the need for beds less next year? For this blog,I have a couple of things (beyond the usual of social care) -improving which, in my mind- would go a long way to solving -at least a few things.

To begin with? Process. Look at all the hashtag campaigns running- whether it be #Red2Green or #EndPJparalysis the fundamental is about process- the process to get patients moving quicker. You can't quite quicken up the pace of antibiotics- but you can certainly quicken up the post -recovery period. We, in the NHS, run process in some of the most archaic and frustrating ways possible- all aimed at short term gains- without any note of the future. If you want to invest money? Worth their weight in gold- are operational managers who know how to hold their nerve.

Secondly? Over investigations. You think juniors do that? Wrong. So do seniors who haven't had exposure to high end specialist stuff or indeed much stuff beyond their specialism for years. It is a fruitless exercise- it doesn't matter the tag says "Consultant"- they are as much laced with self doubt as anyone else when seeing someone they haven't seen for ages. Defensive medicine rages all around us- and in a litigious culture, cue "image" anything that moves. Ask any radiologist- how unnecessary requests clog up their time while those who need it- wait. A Consultant is only as good as what they are keeping themselves up dated with, what their existing jobs are- we forget that, we put others at risk. A senior review isn't the mandate, the appropriate senior review is perhaps more apt. Right people, right seniors. Push everything else into a herd, you slow down the process.

Finally, throwing money into acute hospitals will solve- nothing- unless you believe a sticking plaster on a  compound fracture is a good thing. Money is awash in the acute system for those who want it-especially as a senior. So many gaps in acute medicine - you can pick up shifts at any point of time- I get emails on a regular basis asking. Its called locum rates- internal or external- or Waiting list initiatives in old parlance. It helps no one- bar the senior making some more money- that is the brutal truth. Why open more beds- when you don't have the staff- and stretch existing staff to do more? You want to give more money- then lobby for more money into the system- into better community services, better primary care, NOT more beds. We cant man the ones we have at the moment- while better primary care support is what will help.

The freudian irony of NHS Providers leading this call hasn't escaped me either. They now lament the lack of staff- an organisation which was one of the few to ask of imposition of the junior doctors contract. "Look after your staff" should be more than powerpoint sound bites- the actions must match that. Many, including me, had said that this would come back to bite- and it is now. There now is a lot of money to be made if you want to do "front door senior work"…I would respectfully suggest that money be put to better use, not acute Trusts - especially in a system where we are now all supposed to be "one", not "separate". And if you do want to use money in an acute trust, get the process right, get the right people seeing patients- then- we may just make some headway.