Sunday, 28 April 2013

The ‘bed blockers’ who can make or break the NHS - practical pathway mapping urgently needed.

Andy Burnham, Shadow Secretary for Health has now outlined his ‘ideas’ for additional healthcare reform if Labour should win power at the next election. He was quick to state that these are just ideas at this stage but confirmed that he is identifying a ‘clear direction of travel’ for his policies.

The main thrust of his ‘direction of travel’ was to merge social care with the NHS. It would be hard to disagree with Burnham’s assessment that ‘Councils and the NHS don’t work well together’ and most involved with care would endorse a ‘fully integrated system’. His concept of one owner for the responsibility physical, mental and social wellbeing is worthy. But is it workable? What does fully integrated care mean? And how can we make this a reality?

Burnham is absolutely right that a major challenge facing NHS hospitals are the elderly patients who need ongoing care but have no current need for the acute care for which most hospitals are designed. This vulnerable section of the community make up between a quarter to a third of hospital occupancy at any one time which explains why they are sometimes referred to as ‘bed blockers’.

In the same way that that increasing the number of lanes in a motorway can only ease traffic congestion if the slip roads lead somewhere, so NHS improvements can only work if there is a suitable onward referral route for patients ready for discharge. Many patients stuck in acute hospital wards no longer need hospital care but need to continue their convalescence with ongoing care in the community. This care can take place either in their own homes with additional support or in a community care facility.
When I was working on stroke improvement initiatives in North West London, we made fantastic progress on providing specialist targeted care for stroke patients. The London Stroke Model defined that stroke patients should be admitted to hyper-acute stroke units within stringent time limits from the initial call for an ambulance. After up to three days of intensive treatment and therapy these patients would be transferred to stroke unit where the specialised care would continue. This system works extremely well, with every stroke unit in North West London reaching the required standards for accreditation and additional funding within a few months. Stroke patients received world class diagnosis, assessment and urgent treatment, vastly improving their chances of not only survival, but retention of a good quality of life.
An additional bonus was that each hospital that reached and maintained the required admission times would earn significant uplift in their tariff. Every stroke patient not admitted directly to the specialist unit would count against the hospital. As part of the accreditation process, I joined inspection teams in hospitals to ensure that these stroke units met their targets for accepting stroke patients. The most challenging aspect of applying this stroke model was freeing up beds in these units to enable new patients for admission. Time and again, a patient who no longer required specialist care but needed community support would languish in their hospital bed because there simply was nowhere else to go. In one stroke unit, we had a patient, a homeless man, who was well rehabilitated and no longer needed intensive therapy, but had been in the unit for 66 days (the average length of stay in a stroke unit is around 20 days) because he simply had no home to go to. (We actually threw a leaving party for him when he finally had somewhere to stay). This bed blocking creates a damming effect (and damning for that matter) on the entire system, back to the moment when an unfortunate patient first has a stroke.

Burnham’s ideas of an integrated system are coming from a good place but his direction of travel is fundamentally flawed. Burnham’s ideas are:
·        NHS leads on the physical, mental, and social wellbeing of patients
·        Councils should hold the budget and define the health and wellbeing strategy to make a better link between health and social care
·        NHS should lead on provision, council lead on strategy and commissioning

Opposition is a luxury in politics. You can make bold statements without actually providing an explanation of how highfalutin’ claims can be made real. Burnham’s plans sound like a rehashed, but even less workable solution than the current Health and Social Care Bill, currently being led by The Health Secretary, Jeremy Hunt.

Yes we need more integration between health and social care.  But let’s not make life even more complicated than it is already. Councils are NOT the right bodies to set strategy for healthcare but they should lead social care, and maybe public health. Integration is needed at the interface between the two. To try to reform all at once is terrifying and unworkable.

What we need is multidisciplinary pathway mapping – from cradle to grave, from diagnosis to cure, from acute to chronic care. Individual responsibilities to be defined for each area of care and ownership identified for coordination and cooperation.

Mr Hunt and Mr Burnham – if you would like a lesson in clinical and social pathway mapping, I would be more than happy to oblige.

Sunday, 21 April 2013

Good care is about personal responsibility

What is the best way to take the temperature of the NHS? Ask the patient’s relatives. This is why the Cure the NHS organisation has such a powerful voice – or at least it should have,

I try to avoid hysteria and over reporting of bad news stories about the NHS in this blog but every so often I have to share a ‘tale from the front line’

A friend’s husband, a fit and active 70 year old (I’ll call him Tom), recently fell and broke his hip while walking his dog. Two weeks later, he is a frail, broken elderly in-patient with bed sores and a post-operative infection. The care he has received in the hospital in Hampshire has been poor – very poor. Tom’s wife, we’ll call her Liz, is a retired nurse, so she knows something about care and standards. Liz was horrified to note that Tom had bed sores, nasty places on his back and ankle, and challenged one of the nurses about how this could happen. Surely he was being turned regularly – the essential protocol to avoid the breaking down of thin skin due to pressure, lack of movement and poor circulation. ‘Ah’ said the nurse in charge, ‘that would be the agency nurses’. A cheap shot and a poor example of ownership, leadership and responsibility.

Liz also noticed that untouched food was left out of reach from Tom and now makes sure she is there at meal times so she can make sure he eats.To add insult to injury, Liz noticed that the floor beneath Tom’s bed was filthy, with unidentified stains and dust. It was clear that this was of no concern to the nurses when Liz pointed out that this dirt could be an infection risk, so she asked if she could borrow a mop and bucket and clean the floor herself. She was advised that there were no cleaning materials kept on the ward (apart from antiseptic solutions and wipes), as the contract cleaners were in charge of that. Liz enquired whether the contract cleaners could be called to undertake this task and was advised that they only appeared on the ward on pre-arranged times.

Have we learnt nothing from the Mid Staffs scandal? How come if you drop a bottle of tomato ketchup in a supermarket a cleaner appears within minutes? How often have we all heard ‘could a cleaner please go to platform 1’ at our stations but not so in a hospital?

A visit to the NHS choices website gives this particular hospital some reasonable ratings. 8.9/10 for cleanliness, 7.74/10 for overall care and 4.5/5 for patient feedback. Perhaps Tom has been unlucky – maybe an unfortunate set of circumstances has led to this isolated, but nonetheless, unacceptable lapse in service? But this is a very personal crisis and Liz fears that Tom, a normally robust and positive personaility, has given up and may not survive this episode.

Professor Don Berwick, the man tasked in improving patient safety in the NHS, says that redesign of service delivery is needed to make ‘zero harm a reality’. He lists seven imminently sensible criteria to be assessed and improved:
  •  Identifying aims for improvement in quality
  •  Building capacity through training and education
  • Oversight, accountability and influence
  • Patient and public involvement
  • Measurement, tracking, transparency and learning
  • Impact for legal penalties and criminal liability on patient safety
  •  Leadership
I absolutely agree with all of the above and will be fascinated to see the outcomes of this initiative. But in the meantime, let’s try to keep this real. Behind the jargon and theory, there are two key players – the care givers and the care receivers. If you ask any patient or their relatives what they want out of the care givers I would guess that their number one request would be simple. Ownership and responsibility. Don't blame agency nurse, contract cleaners, the doctors, targets, budget cuts, reform, phase of the moon or anything else. Ultimately – whoever you are, if you are caring for a patient, it is your responsibility to be the best and do the best you possibly can.

Or am I being naïve?

Saturday, 6 April 2013

Damned if you do and damned if you don’t.

I have a great deal of sympathy for Sir Bruce Keogh, Medical Director of the NHS and anyone else tasked with the challenge of interpreting patient safety figures. Like it or not, (and most of us don’t) – medicine is not an exact science. The nearest we can get to certainty is clinical governance - assessing outcomes and constantly monitoring effectiveness of treatments, surgical interventions, procedures and the departments providing these services. Clinical governance relies on statistics and as with any such analysis, validity and relevance needs to be verified and there is still room for error with interpretation.

The accepted wisdom that centres of excellence are the best way forward for specialist services and that there can only be a limited number of these special units in the UK means that some very tough decisions have to be made. None more tough than selecting centres of excellence for children’s heart surgery.

When it comes to NHS units, the natural human reaction is the absolute opposite of the NIMBY (Not In My Back Yard) response for unwanted local development or activity. In fact – we are all most likely to be YIMBYs (Yes In My Back Yard) for most NHS services on offer.

But patients, clinicians and parents must get real. Funds are limited, special skills are limited and high tech equipment is too expensive to be used only periodically. Specialist centres are the practical and cost effective way to ensure that the very best of outcomes are achieved. Of course, it is so much more convenient to take your child for life-saving surgery to a local centre, but if the quality of that local centre is in doubt, however lovely and committed the staff may be, then parents must take heed.

It is in this context that Sir Bruce suspended surgery at the paediatric heart unit in Leeds last week. Initial indications from figures recently acquired suggested that the mortality rate at the unit was unacceptably high. There was an immediate reaction from clinicians and families refuting this claim but Sir Bruce took, in my opinion, the only sensible decision that was open to him – to temporarily suspend surgery. The spectre of Mid Staffs Trust where statistics as early as 2007 that highlighted concerns were ignored (or even worse, covered up) and 1200 unnecessary deaths later, action was finally taken, continues to define the way forward for decision makers in the NHS. We simply cannot allow another Mid Staffs horror to happen. In the same way that a car manufacturer would be widely criticised for failing to recall vehicles with potentially dodgy brakes, so must NHS managers police care facilities, review statistics and act accordingly.

A spokesman from the hospital Trust said: "As we have stressed, the data and other information raise questions. They do not provide answers. These are for the Trust's review to determine. It must be right to put the safety of children first. It was therefore a highly responsible step to suspend the service. We hope that Leeds will shortly be in a position to restart children's heart surgery secure in the knowledge that everything is OK."

Sir Bruce has quickly reversed his decision on the Leeds unit and paediatric heart surgery will resume shortly as the figures have been proved to be erroneous and no doubt the staff, patients and parents will all be relieved and delighted.

This reversal of decision also took courage. We must trust that the majority of those involved in decisions regarding patient safety really do have the best interests of those patients at heart. If we don’t believe that premise, and that politics and personal grudges are creating bias and misinformation, then the NHS faces an ever bigger challenge than we all feared.