Sunday, February 17, 2019


It’s like an annual trip on a carousel. And as inevitable as the sun rising in the morning….a winter and descriptions of A&E department overcrowding; 4 hour targets melting; hospitals in strife, annual discussions of the worst winter ever…till the next trip on that merry go round
Now you may be thinking -what does a chronic disease specialist even understand about the front door and 4 hour targets? Shouldn’t he just stick to…type 1 diabetes or whatever he babbles on about on twitter? Niche topics- why doesn’t he stick to that!

As it happens, perhaps a little bit. In our Trust, happened to be the lead for the Emergency pathway back in 2010...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 over the course of time, you realise the futility of it…national roles do give you a broader view of life…you actually understand this is nigh impossible to crack. Not because of "lazy colleagues", "process issues"...but simply because it feels like Ground hog day.
And before you say anything anymore? Finished my tenure with a 4 hour target result after 12 months of work- at 97.4% - the heady days of 98% targets

A few reflections from my experiences for what it’s worth?

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. I have worked in community trusts- and the view there? The 4-hour target is intrinsically the hospitals problem. An isolated target? You can’t shift it- without pulling all into that target pressure.

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 in spite of money spent on these other venues. Stop blaming patients for attending A&E...if that’s what they are choosing, stop the multiple channels, bolster 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 negotiations 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 >90% 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.

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. History:We forget all too quickly what we as a profession have done to ourselves. First, we created a specialty called acute medicine- and left the rest of general medicine to rest of the medical teams. Then one by one, we made every specialty special- they left general medicine- and then we were nearly left with only geriatricians and acute medics doing most general medicine work- the rest were a combination of a few genuinely interested- and the rest seeing it as a chore…then we discover we have a workforce issue willing to go General medicine- and try to go back to what we broke in the first place. Well, duh.

7, Social care: Decimate this, you decimate ability to flow. In an ageing population with multiple morbidities, you don’t need to be Einstein to figure that one out. The simplicity of that is ..well..simple…yet? We are where we are

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- it’s 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 "let’s find another idea". And please stop doing hashtag gimmicks – it doesn’t help any flow- bar achieve a few more followers and some talks around the country. 

Am sure there's plenty more..but unless something big and radical happens, I can tell you for a fact that NEXT 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.
Ah well, I will go back to Type 1 diabetes and the rest. To be honest? What do I know about unscheduled care? Somebody give me a call when this problem is solved. I promise I wont be waiting up for that one.

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