NHS and politicians

[RogerS]

I found this timely piece on the web ...

The tick box, target-driven culture of the NHS is neglecting the quality of patient care, a senior doctor has warned.

Craig Gannon, a consultant in palliative medicine, described the fragmented care of an elderly woman who was treated for cancer and eventually died from kidney failure, which he said could have been avoided........

.......He said all the teams did what they were asked to do "but, sadly, they did no more than what was required".

"The patient's waits in the accident and emergency department were less than four hours; the three referrals were met under the two-week rule; and her operation was timely. But clearly such a potentially star-earning description would flatter the care actually delivered and underestimate the resources wasted."

Written within the last few weeks, you might think. Actually no. This was written in 2005. Eight years ago.

So why can't the effing politicians of all parties realise this and get rid of this target-driven culture? Bring back Matron. Bring back Ward Sisters and FFS get rid of whole swathes of managers. It is really NOT rocket science.

 

[Jacob]

Agree! Ultimately Parliament is responsible but the whole extensive target and blame culture, the language of "failed" institutions, is governments way of passing the buck and dodging the issues. A failed hospital or school is the responsibility of the appropriate ministry and the politicians - they have the power, it's they who are failing to use it.

 

[AES]

@RogerS:

Agreed 110%!

And the silly "burgers" over here (Switzerland) are trying to bring in the same sort of rubbish. Over my dead body (and as I'm a citizen I DO have a vote here), so guess I'll be posting from the grave soon!

Krgds
AES

 

[deema]

A child dies due to an incompetent consultant not detected because their work was not monitored?
Waiting 12 hours an A and E due to no measures being in place or accountability?
Waiting months if not years for an operation as there were no measures on waiting times?
No clip boards and tables to filled in to reference when it all goes wrong and you need to claim compensation?
Poorly paid nurses?
Inadequately equipped hospitals with antiquated equipment?

Yep, I can see the benefits of letting the old systems to come back again. My wood working may need improving, but my memory is still intact.

There are a lot of issues that need to be addressed, but not as many as there were twenty years ago.

 

[Phil Pascoe]

I'm on ten prescription drugs ( with payment exemption) and I've had to go to hospital more than a hundred times in the last nine months, so it's probably wise for me not to be too critical of the NHS.


And I've just come home from hospital with a present - M.R.S.A.!

 

[JakeS]

There are a lot of issues that need to be addressed, but not as many as there were twenty years ago.

To my mind there's nothing inherently wrong with targets - the problem is setting the wrong targets.

If you grade/reward/punish people by targets, they will work to those targets and nothing else, because that's the entirety of what their work will be judged by... so you need to make absolutely sure that the targets encompass everything you want them to do.

If you can't do this, of course, then it's far better to have no targets than poorly-thought-out targets - but I suspect that in 95% of cases it would be quite possible to do so, and probably in 95% of cases the problem is just that the wrong person with the wrong expertise was actually responsible for setting the problem targets up in the first place.

 

[Reggie]

I think it's wise for anyone to be critical of the NHS, no matter what your circumstances are, if they've done something wrong, they need to know otherwise how will they know what to fix? I also have an ongoing medical condition that means tablets and treatment for life. Defend the good but expose the bad, otherwise the NHS will never get better.

I had first hand experience of the nhs on friday, I won't describe my ordeal in detail, suffice to say that I was pushed from pillar to post and it actually took 5-6 phonecalls to get to speak to someone who knew what they were talking about and even they failed to give proper care and attention. There are so many pointless people in the NHS it's no wonder it struggles.

 

[Kalimna]

Consider those of us working within the NHS. The number of pointless people is staggering, and unlikely to diminish any time soon. Basic problem is one of promoting people beyond their capabilities. And a transference of reason for becoming a nurse, clinician, etc from one of caring to one of performing work. It is very wrong to tar everyone working within any profession with the same brush.

Reggie, Jake, I honk between you, you have hit the nail squarely on the head. Targets are, in principle, a good idea. But they make too many assumptions that just don't pass in the real world. If everyone behaved in a similar fashion (I mean with regard to their disease process, not with their interactions with other people!), then there really wouldn't be much of an issue, but people are different, and that can cause upsets in a conveyor-belt approach to treatment.

Oh, and phil.p - sorry to hear that your return from hospital came with an unexpected partner, but there is a good chance that you, along with most people entering hospital, took MRSA in with you. I wish you well in your recovery from whatever took you into a ward in the first place.

Cheers,
Adam (just finished a run of night shifts, not much fun trying to day sleep in this weather, a rather tiring and emotionally draining week. So, apologies if this comes across at all rant-y)

 

[Random Orbital Bob]

Don't forget that the NHS is the biggest employer in the country (one of the biggest in the world) with over a million staff. It's highly distributed with a scope of care requirement being absolutely monumental. So even with the best management systems in the universe, that sheer scale will create multiple problems and challenges.

But the real heart of the problem (which target culture are symptomatic of) is the short term nature of political thinking. The NHS needs solutions that take years, decades to implement and it needs solid and dependable management that understand the running requirements of each facility. But what happens every 5 years or less? Parliament shuffles the deck chairs on the titanic and some bright shiny new health minister has to "be seen" to reform the health service! What that really means is they re-organise (again)....shuffling people who are just developing some useful knowledge and skill in a facility...and break it up...attach this bit to that and change the goals and indeed the goal posts. That institution must have undergone more organisation designs than any other in the world.

I for one feel eternal sympathy for the staff. And, in the main, I have received excellent service on the few occasions I've needed to be there. Not perfect by any means, but dam glad they're there when I need them.

My acid test is this....if I were to fall sick, which country would I prefer to be in when the pain starts? For me it's here every time.

If the politicians just left them alone to create their own accountability structure and organisation design for say....20 years, I'm convinced the efficiencies would come through.

 

[Hardwood66]

I have a mental health issue ifI want to see a gp I have to normally wait 4-6 weeks

 

[RogerS]

Adam...no rant at all. I think we are all grateful for the care that you and your colleagues provide.

Bob (Random Orbital)....you have hit the nail on the head.

However, what prompted the OP was recent experience by the Mother-in-law. Elderly....84..living by herself. Woke up in the early hours in a panic thinking that she was having a heart-attack. Her sister came round, as did the paramedics who thought that she was not having a heart attack (none of the 'normal' symptoms were there) and that it was most likely a muscular spasm. But to be on the safe side she went into A&E. Who ran a battery of tests and kept her in overnight. She was told to take in her medication with her (aspirin and something else...not sure)..which they promptly took off her.

Definitely not a heart attack but, oh me, oh my, she is now on the conveyor belt well and truly. In one of the scans they detected polyps on her liver....but they are benign...but they still started talking about her having an operation to remove them....why?...no-one would say..just 'that it was procedure'. She then goes home with a new bag full of extra pills...again, no explanation....no-one available to discuss/willing to discuss......(curious to know just where doctor/patient confidentiality boundaries are when you are dealing with an octogenarian....surely daughters should be given relevant information?)....

No-one tells her to stop taking her 'normal' GP prescribed medicine so a couple of days later she is in a panic as her legs have started going blue because she is over-dosing on aspirin!

Then the conveyor belt continues and she gets a letter from the hospital telling her to come for an x-ray of her stomach...which panics her as she has had breast cancer....the x-ray technician then told her that she had polyps on her liver. Ever heard an octogenarian swear before?

So the general impression is that once onto the conveyor belt no-one actually takes a step back and asks the question 'why are we doing this'. Do we need to do this ?

 

[Random Orbital Bob]

That's uncanny....I've just been on it myself. That's all down to poor patient records. They keep manual records for each patient and pretty much never read them...that's why when different shifts end/start or consultant/nurses etc come into the picture they re-ask the same questions time and time again. Their patient handover skills and information management are I would agree pretty poor.

Bless her....give her my best and tell her she is indeed on the treadmill and try not to worry......poor love.

 

[Kalimna]

Bob, whilst I sympathise with your patients' view, life on the other side of the bed isn't always straightforward. It simply isn't feasible for doctors (and nurses, but that's slightly different again) to always carry around in their head concise, accurate information on the 20-30 patients seen on a daily basis, all at different stages of investigation or treatment, and often changing both in number and location each day. Add to that the fact that many patients have a considerable number of letters etc in their case notes (imagine reading three or four magazines worth of typed or written info cover to cover, trying to find the three or for lines of pertinent info each time you see a patient). Also add to that the fact that patients frequently (thou not always) tell the doctor what they think we want to hear, not what we need to know. And on top of all that, the considerable time constraints placed upon clinicians. In other words, it is frequently more efficient to ask the patient first, and then follow up by reading the notes for confirmation or refutation.
Remember the woodworking adage to measure twice and cut once, well it applies to medicine also.
We do read patient notes, you just don't see us doing so all the time.

Roger - thank you. I will also add that your last few lines represent one of my greatest frustrations - the "why are we doing ths?" Issue. I do hope your mother in law recovers well, and in good time.

Adam

 

[Cheshirechappie]

The politicians damn well SHOULD get hold of the NHS and give a really good shake at fairly frequent intervals. If they don't, then the running of the NHS is entirely in the hands of unelected and seemingly unaccountable bureaucrats. Those of us forced to use the NHS (because we can't afford private healthcare) and forced to pay for the NHS (£120bn this year, or about £2000 for every man, woman and child in the country), would have no way of influencing the very grand NHS senior managers except through our elected representatives, however feeble their interventions tend to be. Senior managers spend a great deal of time and money making absolutely sure they don't listen to ordinary people like patients. They are adept at burying and brushing off any complaint that any ordinary patient might have the temerity to make. Result - a crap service.

There are still quite a few people trying to do their best in the NHS, but they seem to be outnumbered by time-serving apparatchiks and people who daren't do anything off their own bat in case they get reprimanded.

The NHS needs to concentrate on doing the basics really well. Over my lifetime, this has really slipped. Twenty years ago, if you rang your GP's surgery for an appointment, you got one either the same day or the next day. Now, you may have to wait a fortnight. Also, you can't get any (sensible) GP service outside normal business hours. Twenty years ago, out-of-hours cover was normal.

Perhaps the NHS needs some competition to focus it's mind and sharpen up it's act. It needs to remember that it's us that pay their wages. We are the customer. At the moment, they can get away with shoddy and (as we've recently seen) sometimes downright criminal levels of service, because we've got no choice but to put up with it. For what the taxpayer pays, the taxpayer has a right to expect far better, and every right to have their voice heard when things are not as they should be.

Politicians - kick NHS senior management ass. That's what you're elected to do.

 

[Phil Pascoe]

Someone in the press a while back made an interesting observation - it's the people who maintain that the N.H.S. is perfect that are the very people that prevent it's improvement. And another one - if the N.H.S. is so perfect, why has no other country in the world copied it?

 

[Eric The Viking]

I'm married to a time-served GP, who also spent years in hospital medicine, in unfashionable specialities like geriatrics and psycho-geriatrics. Frankly, her workload is going to break her if something doesn't change soon.

She has the 'wrong' sort of patients - inner city, heavily immigrant area. They have a translation service on speed-dial for consultations. She can't meet QoF* targets because they don't turn up for screening etc. Working hours have become daily 0800-1900h (sometimes until 2030h).

Four weeks ago, they had several days with over a hundred calls into the practice each day, on top of the usual GP sessions. Every caller wanted an urgent appointment or a visit; every caller had to be called back and screened by a GP in case it was serious.

One example encapsulated the problem (she narrated this over dinner that evening): "Can you take a look at my son? He's been off colour for a few days and I'm worried about him. I'm wondering if you could just drop by later this afternoon to check him over." My wife: "We're very busy at the moment, and it's now practice policy that we don't do home visits unless the patient's condition is serious enough to merit it. Can you tell me a bit more about what you think is wrong? Can you bring him into the surgery?" Mother: "Oh, I can't do that, he's in school today."

The GPs take shifts handling the phone calls. It doesn't save them much time. She eats lunch at her desk in between patients (sometimes during consultations. After surgery she has to check all the reports that come in from patients that have been referred for hospital & blood tests, in case something serious has been found. If she misses anything, she's liable.

When she gets home she has 3-5 hours reading every week of medical journals, practice management meetings (often on scheduled days off), and presently every third Saturday morning in surgery too.

The practice is borderline viable (commercially). Until this year she's had three consecutive years with quite chunky drops in income. We've never met a GP earning the fabled £200,000. We don't expect to. The only difference this year is that she's been forced to do more hours, because they're three GPs down (two salaried+one partner) and although they've recruited two, they won't start until September/October. It took the practice a year and over £20,000 in advertisement and recruitment agency fees to find these two. Everyone's hoping they'll stay. Others haven't.
. . .

One of our friends was a radiologist, who became the chief executive of one of our bigger local teaching hospitals. This was about 20 years ago. Soon after starting, he removed FIVE tiers of middle management, and all their performance and efficiency measures improved.

I worked for a Fortune 100 global company with 200,000+ employees worldwide. It only had five layers of management in total, between any individual employee and the CEO.

Go figure, as the Yanks say.

E.


QoF* "Quality Outcomes Framework" is a way of "incentivising" GPs for behaviour the DoH wants from them: points = prizes, for things like smear tests, diabetes management, Well Woman clinics, surveying patient lifestyles, etc. If your GP hands you a survey, it's because some bureaucrat wants them to be doing that (usually).

 

[Cheshirechappie]

I think this article puts it far better than I could; especially the last two paragraphs.

http://www.telegraph.co.uk/health/healt ... ouble.html

 

[Phil Pascoe]

Last time I was in hospital, I was in a ward with a bay that only had four beds. I'm sixty, and the others were quite a bit older than me, I used to press the button when any of them got into a situation that they couldn't manage, and struggle out of bed to close their curtains when they were having problems with a bed pan or bottle. No one else was there to do it, and one of the nurses said one day that they they tried to come as quickly as possible when I rung the bell because they knew it wasn't a false alarm. When I went home, one guy called me back and all three of them thanked me. That is just WRONG WRONG WRONG!
I am in no way condemning the the nurses.

 

[Phil Pascoe]

Eric - a relative of mine who's a G.P. asked to see my repeat prescription one day. oh, beauty! he said. Your G.P.'s making a fortune out of you!

 

[Eric The Viking]

GP surgeries are remunerated according to the money they SAVE on prescriptions. They have a system on their computers (instigated by the DoH, I think), that tells them the cost of each drug, and about any generic alternatives, etc. They are at liberty to prescribe a brand name or a generic (if a generic is available). Meeting drug budget targets result in funding to the practice, BUT contractually that money can only be spent on equipment and facilities, NOT staffing and NOT GP personal income either.

The prescription payment is part of the pharmacist's remuneration, not the GP's, who sees none of it.

Whatever your relative meant, it can't have been what you are suggesting.