Sunday, 12 October 2008

The dustbin of training

Whatever one chooses to prioritise can have massive knock on effects on other things, many of which are completely unforeseen. It's similar to engineering, when you change a certain property of something deliberately, it may alter other properties that you did not expect and it may have a quite catastrophic effect. The Titanic is a great example, supposedly unsinkable, however as we know it's design left it open to massive disaster.

The government's butchering of the health service to satisfy short termist political demands has had so many devastating knock on effects. Few politicians would have predicted the untold damage that the blanket Accident and Emergency 4 hour wait target would have had. AE is now no more than a glorified triage service thanks to the 4 hour target. The best way to improve AE care would have been to increase AE capacity so that a high quality service could have been developed to attract more talented doctors and nurses. Instead the 4 hour target has created a triage service that drives the best staff away and that has no incentive to sort out patients properly. The 4 hour target and the unnecessary excessively rapid movement of patients has also been a rather key driver in the rise in certain Hospital Acquired Infections (HAIs).

Likewise the current top down bullying from the DH to enforce the 18 week target. Superficially it seems like a sensible idea, however when one learns of the unforeseen side effects in does not seem too clever. A lot of patients simply do not need to be turned around in 18 weeks, they have minor problems that are causing them only minor symptoms, often a bit more time waiting is good for some conditions, it can result in a lot of them going away during the waiting period. The worst aspect of this target is that it is not clinically driven, for example the patient who is living in agony and needs a joint replacement quickly cannot be prioritised as well as they should be, as there are numerous other patients with much milder symptoms who have to be turned around within the 18 weeks. The 18 week target has also led to a culture of fiddling the statistics, as if there is no increase in capacity then no more work can be done anyway.

The long term sustainability of the health service has never been at the top of the government's agenda, they only care for the next election, much like our economy, it's no surprise that we meandering down sh*t creek without a paddle in this regard. Our economy has been run in an incredibly unsustainable short termist manner, we are now seeing the rather significant side effects of this stupid policy.

Training is a key if one hopes to sustain a high quality health service, no wonder the government has completely ignored training in recent years, all the policy has been directed at improving superficially gimmicky statistics to spin their network of dishonest propaganda. The current thrust at increasing output has seen trainees struggle to get the experience that they so desperately need to become the high quality doctors that they want to be. In surgery for example Trusts are under so much pressure to increase output that the training of tomorrow's surgeons is no priority at all, trying to get operative experience in this climate is not easy at all.

The government has also taken power away from the independent professional bodies, the Royal Colleges, and handed a lot of unaccountable power to useless organisations like PMETB and the GMC. Training posts are now ten a penny, the training content of jobs is not regulated properly, meaning that trainees are woefully inexperienced for their grade. Medicine is no longer the apprenticeship that it once was, the educationalists and politicos have far too much say in the training process, their emphasis on waffle and paper chasing have done nothing to improve training. Nursing training has also been subject to a same ridiculous politically correct forces, the loss of the apprenticeship has seen standards in training plummet.

The emphasis is also not changing. The short termist policies are the drivers, and training is still being left to rot. Darzi's review does nothing for training, the establishment of NHS MEE is just a token gesture, it is simply a powerless advisory body that will be made up of the same old government friendly cronies who have overseen the disasters of MMC and MTAS. Hospitals are invariably run by jumped up morons with clip boards who care nothing for the quality of care provided, they simply have certain top down government objectives to satisfy or else, and if the quality of care and good training get in the Trust's Stasi's way then they will trample over them. There are rumours this week that first year doctors are not being allowed to put in IV lines due to 'infection control' concerns, if there was an example of the lack of joined up thinking that our short termist politicos have forced upon us then this is it. The economy is crumbling, as is medical training, and this is because the politicians care only for today and never tomorrow.


Anonymous said...

Yes Dr Ferrett it is scary how bad training has now become, though the things that you write of do not include the difficulty of dealing with substandard trainees.

There are not many, but at Borsetshire General we have a few. The Deans do not back us when we want to evict them from the programme, and the training place is denied to a more likely trainee. Endless correspondence occurs but it seems repeated incompetence despite remedial teaching is not enough to be evicted.

So we similtaneously have good prospective trainees denied training, duffers being kept on, gaps in rotas and people unable to get consultant posts. If Medical education recovers at all it will take a decade.

I am due to retire in a decade, and may need to retire to the antipodes to get good care.

In sadness

Dr Phil

Garth Marenghi said...

good point Dr Phil,

I have heard these very same problems with duffer trainees before from many independent sources,

as you say the system for dealing with them is completely inadequate,

if a trainee is completely substandard and not up to the task then the trainer is blamed, even when the trainee should never have got a medical degree in the first place,

it's in the interests of the trainer to simply brush the duffers under the carpet, as flagging them up will only result in problems for the trainer,

in reality there are some trainees that need a bit of extra help, fair enough, and there are some that are beyond help,

the current system has no way of dealing with those that are beyond help

Anonymous said...

Glorified triage service, A&E ?

Next you'll be arguing that GP's provide little more than the "three P's" - a prescription, pain killers, or piss off.

The 4hr-target is NOT just about A&E, far from it. The care of patients in A&E has ALWAYS depended on how effectively the rest of the hospital is working, not to mention how well primary care services are able to cope.

In my experience A&E departments are doing MORE than ever before - in our department, for example, we thrombolyse strokes, provide conscious sedation [ketamine] for paediatrics, run clinics every morning [consultant, ENP, dressings, etc], we often end up with numerous patients receiving cardiac monitoring, while intubated patients [especially children] end up in resus for many hours pending an ITU bed.

Then we have Section 136 patients who get stuck in A&E for many hours awaiting various protagonists, such as the ASW and S12 approved psychiatrist, and then finally a psychiatric bed [please, no laughing at the back].

Nurses request x/rays, suture, cannulate anything that moves, apply POPs not to mention a steady production line of ECGs - we are working harder and doing more than ever before.

A few patients might be sent directly to EGU for a scan rather than being left in the A&E waiting room while they miscarry - but surely this is an improvement on the scandalously poor service prior to the target ?

Nowadays virtually every hospital has a direct admission ward for GP referrals, although ours doesn't - patients still need to be washed through A&E [with the obligatory CXR, bloods and ECG] before a specialty doctor ever gets near them.

In fact, whenever a team calls down to inform A&E about an "expected" they invariably request an array of investigations before the house officer finally trots down [3hrs later] - he/she still has to speak to their SpR before confirming a definitive plan.

I remember when it was first mooted that nurses should be permitted to book beds before a medical assessment was complete - that led to all sorts of objections [from the medics] but in the majority of cases the nurses got it right, and when a medic asked for a bed at 3hrs and 58minutes they would usually be informed that a bed had been requested 10 minutes after the patient had been booked in.

The target may be problematic but these problems are seldom as bad as a semi-permanently gridlocked A&E department [IMHO].

Anonymous said...

What is it?