Monday, 17 September 2007

Ringing all the bells

Watching the Panorama involving the blogger PC Copperfield reminded me more than just a little of the NHS. In fact it was quite remarkable to see how the government's stupid target based approach is failing in policing and in health care in the same ways.

The government cares not for protecting the public from crime or from ill health, they have put the emphasis solely on the gathering of meaningless political propaganda at any cost. In this way trivial misdemeanors are criminalised at vast expense, just so that the statistics can be spun. While in the NHS ill thought out blanket targets result in sick patients not being given the priority they deserve, ahead of those with far less urgent and more minor ailments.

The professionals, whether they be doctors or police officers, are treated like idiots by clip-board wielding halfwits who have no idea about the practicalities of doing a good job for the public. Clinical priorities are ignored by our political masters who do not understand the concept of clinical need, while practical policing is ignored at the expense of statistic gathering. The parallels are obvious, the government seems too stubborn to learn from its rather glaring mistakes; and the public are the ones to suffer, as we now have public services that are set up to manufacture propaganda, as opposed to providing a good service for the public who fund them.


dreamingspire said...

Don't agree with you. Targets (as several management gurus have said in the last few years) are a useful temporary tool to shake up an organisation full of complacent people. Those setting the targets then need to set about getting the management sorted out - that requires a lot of expertise and judgement.

Garth Marenghi said...

'expertise and judgement'- indeed.

proble is that the NHS management and HMG have precious little of either, meaning their targets tend to make things worse.

Targets created in conjunction with staff/clinicians that use common sense ahead of blanket generalisations may be of use, howevere this is not what we have.

the A&E Charge Nurse said...

Ferret - I can remember [as an A&E pup] being slumped head in hands after a particularly difficult night shift [long waits, inadequate staff, nurses unable to maximise years of skills/knowledge, stressed docs etc,] wondering if I had made a dreadful mistake choosing the A&E specialty.

Staff & public alike were perenially frustrated by the tortuous system [sometimes it was 24hrs+ from time of GP referral to being warded] - and typically waits of 5-8hrs [or longer] for non-life threatening conditions such as wounds/fractures, etc, on nights.
Very occassionally a minority of patients could spend up to 72hrs in A&E, usually waiting for a side room when they were known to be MRSA+

Yes, everybody agreed the situation was pretty desperate, especially when an elderly patient bled to death from a leaky annyeurism after WAITING 9HOURS to see a doc - I mean how crap do things have to be before somebody realises that there is something rotten in the state of Denmark, and that ACTION was needed rather than another bout of chin rubbing, and hurrumphing ?

The official report on the death found that A&E staff had come to accept the dire situation as the norm, so there was no escalation policy in place whenever they were overwhelmed [which was more often than not].

Now I accept the 4hr A&E target is far from ideal, and I would not dispute that the vast majority of departments are cheating when they say they are consistently hitting 98% [including my place of work which fiddles to the tune of 5-8%, if we include fudging, such as discharging patients from A&E to have an x/ray en route to the ward, or holding onto patients for an extra 20-30mins so they can be seen by the specialty consultant on the post take round if there is a possibilty of discharge, etc].

But on balance most A&E staff I have spoken to [and God, how we drone on about it] all prefer the imperfect target to the bad old days when consultants simply did not have the clout to make the sort of changes that were so obviously called for.

Garth Marenghi said...

I think that many factors are responsible to AE care improving in some ways, for example improving access to radiology has made a massive difference, as well as improving access to getting quick blood test results.

I think AE staff have a slightly warped view on how 'good' things have actually got, as chatting to a lot of specialists who take referrals from AE I have to say I am appalled at the poor rushed care that AE offers at times; this is certainly not helped by the blanket target.

I suggest you take a trip to the average run of the mill CDU, where people just sit for hours so that they were not deemed to have breached. I have heard some terrible tales of very sick patients not being sorted out due to the time pressure and just being dumped on CDU to fester.

There is definitely an argument for having some locally driven measurements, for example seeing chest pains within a certain time frame.

However I am still utterly unconvinced that blanket poorly thought out targets have resulted in any improvement for patients.

It may well help the stubbed toe be seen within four hours, however the sick patient bleeding to death may well just get dumped on a CDU because they cannot be seen to be 'breaching'.

the A&E Charge Nurse said...

No Garth, patients bled to death in A&E due to horrendous waits, nothing to do with CDUs.

Thomas Rogers, 74 died at Whipps X [after a 9hr wait] while Marion Rees, 59 died at Prince Philip Hospital in Llanelli, both from annyeurism, both deaths associated with long waits in A&E.

In 2001 John Heyworth [president of the British Association of A&E Medicine] remarked "Casualty Units have become WAREHOUSES where patients end up waiting in corridors and all sorts of undignified and inappropriate clinical areas" - "the result of years of neglect" he added.
Don't forget these trolley waits sometimes went on for DAYS.

I think your specialty mates are a bit cheeky complaining about standards of care in A&E - have any of them bothered to read Wanless ?
Don't they realise that 19MILLION punters turn up to A&E each year [thats a third of the countries entire population by the way] - and this represents a massive upsurge in attendence in recent years ?

I can't help thinking that doctors who complain about A&E might have a completely different take on things if we where to turn the clock back, then stick them in triage night after night in order to trot out lame old cliches about why an 80odd year old lady with a fractured wrist can't be seen for hours on end because their injuries are not 'life-threatening' [same for a myriad of other significant complaints].

I dare say this sort of bullshit [concerning interminable waits] was trotted out to Thomas Rogers and Marion Rees before they both bled to death.

Maybe you have direct experience of A&E in the 90's [although I doubt it somehow].
There may be a trade off between setting what after all is not an unreasonable standard of a 4hr wait [although very few doctors, in my experience, sit quietly in the A&E waiting room for this length of time, once they or their loved ones are directly affected] and providing optimum care in every single case for 19million patients.

We have a CDU and it works well for renal colics, cellulitis, pylonephritis, small pneumo's, etc, etc, sure, a percentage of patients find their way over there to avoid breeching but this does not mean that they are no longer entitled to decent standards of care [including C/T KUB or head scans, IV Abx, parenteral fluids, analgesics, O/T asessment, etc, etc].

If medical staff are allowing patients to fester for any reason then they need to start completing clinical incident forms and bringing it to the attention of the relevant consultant[s].

Garth Marenghi said...

You can have your opinion, I can have mine.

My personal experience and that of many of my colleagues is that AE care is still well below par in many ways, and that the 4hr target is a hindrance in several ways to improving care.

I don't want a return to the trolley days, but then again I don't believe everything is quite as 'optimal' as you seem to think.

Strange as it may sound to you, there were a lot of excellent AE units before the government introduced targets that didn't have much of a problem with the trolley phenomenon.

One thing I am not particularly fond if is assuming that one thing is the causal factor behind claimed 'improvements'. In fact as I have already stated changes in technology and increases in capacity have had much more do with improvements than the targets have.

The targets are lacking common sense and this results in clinical decision making being wrongly prioritised, I am surprised that you think this is progress, I do not.

Areas which have stupid targets attached are not particularly helped, they are arguably hindered; while areas that have no targets attached are the new trolleys waiting for days.

The answer is not more targets, it is to introspect and apply a bit of damn common sense so that medicine is managed clinically not politically.

the A&E Charge Nurse said...

Quite right Garth, and long may diverging opinions continue to prosper.

I'm not so naive as to be unaware of the cynical political motives driving target culture - and I also accept there are failings in A&E, I doubt if anyone would dispute this point, although I do worry that some of the specialty doctors might have forgotton how to cannulate ;-)

We will just have to agree to disagree on this occassion - but maybe we can resume the debate after the 4hr target is inevitably abolished - then I think we might introduce docs who triage 24/7 for a fresh perspectives on how the 200 or so A&E departments can safely manage the 19 million "emergencies" that pitch up each year.

Garth Marenghi said...

It is a good point about the 19 million, there are quite a few reasons for it I think, including the fact that PCTs don't pay GPs to deal with minor injuries- this is an utter disgrace and farce.

This results in loads of minor stuff going to AE which could easily be done by their GP, not a good use of resources.

If targets are used, then minor non urgent conditions must be excempt from targets, as part of the reason that minor non urgent rubbish is prospering and contibuting to the 19 million is that it all has to be seen within 4 hrs.

Some things should be left waiting for hours when they turn up to AE, if there are sicker patients that need the staff's help.

The internal market and the ludicrous way in which money moves around from bureaucracy to bureaucracy is responsible for a lot of utter stupidity.

The sooner all these managers, and I add their masters HMG are the real culprits for believing in their nonsensical ideology, start realising that we are all on the same side for patients- the better.

It is crazy that GPs are not paid for minor injuries by PCTs, this kind of policy is f*cking moronic.