NHS – the movie. Romcom or horror story?

The NHS movie rolls on, an on-going  franchise to outshine Harry Potter and nearly as long running as arguably the greatest film of all time, Citizen Cane. But is the NHS genre a romcom, family adventure, farce or horror? A bit of all of course as just a few hours feedback confirmed yesterday.

The day stated well – an 8am meeting in the operating theatre suite of a North West London hospital with a dashing surgeon. (yes – romcom would have done very nicely thank you…) We were discussing a project that should benefit patients, staff and the Trust and the consultant kindly spared an hour of his time before starting a full operating list. Just for the record, over the past few years in my role as a project manager, 99.9% of consultants I have met have been courteous, charming and constructive. They have given their time and shared their knowledge freely, often in their own time at the end or beginning of a long day.

Several other meetings later, I could confirm that many of the doctors, nurses, medical secretaries, IT and finance teams were all upbeat, busy but positive in their efforts to balance budget and care. I then visited to the stroke unit to find a community coffee morning going on to celebrate the unit achieving a high level of accreditation (a set of standards required to earn a higher level of tariff for the hospital – note to Andrew Lansley – targets can work). Stroke physicians, specialist nurses and therapists were welcoming patients who had previously been treated at the unit. There was a jolly atmosphere as medical teams were reunited with those whom they had cared for.

I realise this all sounds a little too good to be true and I have no doubt that the staff at this hospital continue to face the challenge of staff shortages, budget cuts and lumbering bureaucracy that is the daily grind of the NHS. However you could also be forgiven for assuming that this particular hospital is still functioning effectively with a viable future.

But then I got home and took two phone calls. One was from a friend whose 86 year old grandmother had broken her hip a couple of days before.  Suffering from early stage Alzheimer’s and osteoporosis, this poor frail lady epitomises the financial nightmare facing socially funded care but nevertheless she should expect exemplary care. Just a few hours after admission and confused at her surroundings, the poor old soul fell out of bed and broke her arm. It is highly likely the reason this happened was that someone forgot, or didn’t bother, to put the side guards up on her bed leading to increased suffering and further mobility challenge for the lady when she finally gets home.

Another friend, a counsellor, called to tell me of a case of a very sad young man who had just lost his mother. The tale he had to tell about the shameful standard of his mother’s care was shocking. Deeply disturbed, this tragic woman had attempted suicide on numerous occasions and had been let down again and again by her local mental health services. After taking yet another overdose and after a couple of nights in hospital, she was discharged without her family being advised. Clutching a ‘bag full of pills’ (probably her ‘take home’ drugs), she was taken to a bus stop to help her catch the bus home. Bless her – of course she didn’t go home and of course she took the pills but again survived. For some reason, she wasn’t sectioned (compulsory or voluntary residential mental care order) and continued to live with inadequate community mental health support until she finally succeeded in her tragic quest and killed herself.

You cannot help but wonder if these two tales of woe would have been different if those unfortunate patients had been treated in the hospital I described at the start of this post.

And this is the dichotomy of the NHS movie, feel-good plot lines, uplifting stories and exhilarating adventure tempered with farce, horror stories and tragedy.

The scandal of the NHS isn’t just about inappropriate funding – it’s about inefficient use of resources, and worst of all – inconsistency and inequality in standards of care.

Prescriptions and patient safety – it’s all about teamwork

Another shock horror medical story has been widely covered in the UK press today. ‘GPs making too many errors when prescribing drugs in patients, the official regulator says’  Another headline is enough to make any patient choke on their tablets, ‘lethal errors in 2 million prescriptions’

A BBC presenter on a radio phone-in programme dubbed pharmacists as ‘heroic’ in picking up and correcting the majority of prescribing errors.

As they say in all the best courtroom dramas – ‘let us look at the facts m’lud’

Yes – the study, by the General medical Council, based on 1200 patients confirmed that there are a significant number of errors in prescriptions written by GPs. To be precise, the figure quoted was 1 in 20 prescription items showed an error. Many patients are prescribed multiple medications, so this translated to an error for 1 in 6 patients and naturally this is more likely to affect the elderly who tend to take a variety of regular medications.

Only 1 in 550 of these prescription errors had lethal potential. Yes, this is still a frightening statistic but if you consider that the majority of the 900 million (yes, 900 million in England alone) prescriptions are checked and dispensed by pharmacists, the number of dangerous errors slipping through the professional net will be relatively small.

And as for heroic? It’s a pharmacist’s job to spot mistakes on prescriptions. These errors can include over or under dosage, drug interactions, inadequate monitoring, unsuitable treatment and lack of clarity on usage. Regular readers will know that I qualified as a pharmacist in another lifetime and practiced in hospital, community and industry. It was an acceptable part of my role that I discussed prescription anomalies with the prescriber and was never really a big deal.  Pharmacy training is complex, comprehensive and lengthy. A year’s post graduate tutelage follows a four year degree with on-going registration and education. For GP’s (and hospital doctors) on the other hand, prescribing is a small, but key part of the consultation/treatment process

That is why pharmacists are such an essential link in the treatment pathway. Not to trip doctors up but to identify and rectify prescribing weaknesses, and to support fellow clinicians in ensuring that treatment for every patient is as appropriate and safe as possible.

I welcome the GMC’s initiative with this survey and agree with their statement that ‘it’s important that we do everything we can to avoid all errors’. In my opinion, reducing the number of ‘dispensing doctors’ and ensuring that the pharmacist continues to act as a permanent safety net has got to be the best way to do this.

Andrew Lansley (remember him? Secretary of State for Health) said that the government would be working with GPs to improve practices, continuing ‘the vast majority of prescriptions are checked by community pharmacists who spot and put right any errors..’

As the NHS reform implementation continues and GPs become embroiled in budgetary control and potentially become distracted with commissioning, I suggest that pharmacists stay on high alert as this error rate could increase.

Maybe our older mothers need as much education as their teenage counterparts

There is a truly shocking statistic reported in the Sunday Telegraph today. The number of women dying in childbirth in London has doubled in the past five years and at 20 maternal deaths per 100,000 births this is more than twice the level in the rest of the UK.

It is thought that this disturbing figure is due to several factors, including an increased number of older mothers, rising obesity, increased popularity of fertility treatment and higher levels of social deprivation, all more significant in cities. Throw into the mix the extreme pressure on NHS maternity services and this may be a trend that’s going to be difficult to reverse.

My last post focused on the need to not only offer contraception to young teens but to expose them to targeted education. It would appear that the need for tailored information is just as great for their older, and one would hope wiser, sisters (and mothers). Just as vital in teaching the need for pregnancy planning, wellbeing and responsible behaviour in teens, there is clearly a major public health requirement for maternal education at all ages.

The number of women over 40 giving birth has doubled in the UK in the past decade. As more and more women delay their planned pregnancies for financial and possibly career reasons the spectre of reduced fertility rears its ugly head. Those lucky enough to get pregnant over 35 are exposed to increased risk of high blood pressure, diabetes and placenta previa. General state of health is vital to support a successful pregnancy and birth so obesity and other conditions more common in middle years will have an adverse effect on birth outcomes.

Sadly, it’s not just the mothers who can suffer – the rate of genetic abnormalities in babies rises to 4 per 1000 in mothers over 40 years.

Not everyone is lucky enough to have a baby while they are still ‘young’ for all sorts of reasons and I wish every ‘mature’ woman who hopes to get pregnant all the very best of luck and good health for her and her baby. But we must do everything we can to reduce this worrying maternal death rate in UK’s capital city. Increased education for all fertile age groups regarding healthy lifestyles, planned pregnancy and pregnancy management, supported by wise investment in maternity services will be cost effective and life-saving.

It’s not just the young who need help.

Contraceptive Pill for young teens – sometimes rules need to be broken

A recent NHS report has suggested that the contraceptive pill should be available at pharmacies, without prescription and to girls under 16.

This has unsurprisingly triggered wide debate, spanning religious, moral, social and medical views. The age of consent in the UK is 16, so to promote contraception to under 16’s is seen by some as condoning illegal acts. Let’s get real here – it’s 2012, the ‘permissive society’ is now ‘society’. Behaviours, attitudes and social stigma have changed radically over the past few decades. Unpalatable as it may seem to some, teenage sex is now a genie long ago released from the bottle.

I find this quite a difficult debate to comment on as my maternal instinct is screaming ‘no’! But the healthcare commentator and pragmatist within takes a wider perspective. A straw poll in the office produced diametrically opposing different views. Interestingly, but again, not surprisingly, the mothers of young children were horrified that the NHS seems to condone under-age sex, removing a GP’s influence, and most importantly the exclusion of a parent’s involvement in contraceptive decisions for their teenage daughters. But we mustn’t forget that so many of these young girls at risk of early pregnancy are sadly lacking positive role models in their home.

On the pro side, avoidance of unplanned pregnancies in young girls is a worthy goal.  The teenage pregnancy rate in England is one of the highest in the Western World and 50% of conceptions in the under 18’s in England since 2009 have led to abortions. If this trauma and personal dilemma can be reduced, surely this must be a good thing? Another pro is access. If a 13 year old is intent on having sex, there won’t be much that will stop her.  So if she can easily and confidentially obtain contraception from her local pharmacy rather than jumping through hoops to get an appointment with her GP, surely this must also be a good thing? Pharmacists are highly trained, extremely knowledgeable healthcare experts and will seriously take the responsibility of ensuring that young patients understand the implications of their decisions.  To encourage youngsters to take a proactive approach to contraception is a vital aim.

On the other hand, the contraceptive pill is a powerful medication with potentially serious side effects (but less serious than the risks associated with pregnancy) so pharmacists must be diligent in ensuring that the pill recipients fully understand the side effects to look out for. Sadly the ‘safe sex’ message has been widely ignored, hence the high teenage pregnancy rate, so I suspect that offering the pill to youngsters won’t increase their risk of sexually transmitted disease significantly.

And here’s the point. This increased access should not be introduced in isolation of a targeted, continuous educational programme.  This approach should help to reduce to unplanned pregnancies and subsequent chaotic socio-economic, emotional and personal fall-out. On-going educational programmes are already aiming to teach the benefits of waiting before coming sexually active at such a young age. STD’s, unplanned pregnancy and abortion should be seen not as an occupational hazard, but a horror to be avoided if at all possible. By giving the youngsters the information to make informed choices and easy access to contraception, then we are doing our very best to get this right.

Some rules really are made to be broken.

NHS – it’s business as usual

As the dust is settling from the government’s (hardly surprising) victory over NHS reform there are several options open to anyone involved in the state funded health provision.

a)    Suspended animation – wondering what to do next and getting nowhere fast while pondering.

b)    Mass exodus as those who decided to stay and tough it out give up.

      c)    Panic.

d)    Gritty determination to fight or block any changes that they don’t support, rightly or wrongly.

e)    Get on with the doing the best job they can in difficult and uncertain circumstances.

f)     Plan the best way forward, creating realistic strategies and keeping an open mind.

I suspect there is a little of all of the above going on up and down the country in GP practices, hospitals and community service centres. However, as predicted and thanks to the majority of excellent individuals and teams still committed to the NHS, options e) and f) appear to be flourishing. I have three front line examples of business as usual this week:

The emergency hospital admission: Never far away from drama, another family member was urgently admitted to hospital at the weekend. Point 1 – she saw an emergency doctor within half an hour of calling the out of hours service. Point 2 - she was admitted via the emergency department with very little delay. Point 3 – she made it onto a ward and into a bed within a reasonable amount of time. Point 4 -  although diagnosis was complicated, she had a CT scan and a comprehensive range of tests all within 20 hours of admission. Point 5 – she stayed in hospital for five days until the condition was diagnosed and controlled and discharged at a manageable time.

The urgent primary care consultation: A colleague had a nasty cat bite which by midday yesterday was looking very angry (the bite not the cat). She called her GP to make an appointment and was told there were none available that day. She then explained the situation and was invited to come along to the GP surgery and join the emergency queue. She was seen and treated with antibiotics within the hour.

Community nursing: A neighbour is recovering from an ulcerated leg which requires daily dressings. She has been given the option of going into the local surgery or receiving a home visit from a nurse who dresses the wound daily. The situation is not ideal because, unlike the old days, it’s not the same nurse every day but any one of several from a central pool. They take polaroid photos daily to enable some sort of continuity of care and to assess the healing process. Not once has a nurse failed to turn up as agreed and the wound is healing nicely.

Just mundane tales of everyday folk interacting with the NHS.

Yes, we are facing some real challenges ahead - the uncertainty of necessary budget restraints, the disruption of some unnecessary  beaurocratic changes and the terrifying public health epidemics that modern living is creating. Yes, I know that not everyone’s experience with the NHS is as text book as the examples above.

But despite all this, let us not forget that every day, and night, across the UK, most of us are receiving good care, free at the point of delivery, given by people who are committed to our wellbeing.

NHS bed management - back to basics

It has emerged today that each year an estimated 400,000 discharges from hospital take place between 11 at night and 6 in the morning. Shocking as these figures seem, the reality is probably considerably less as some of the statistics include ward transfers, deaths, patient request and voluntary maternity related discharge. However for the patients involved with late night discharge, this must be a traumatic and upsetting experience.

 The spectre of a frail elderly person being bundled into a taxi and sent home to an empty house is something to be avoided vigorously by hospital trusts and admission targets have been blamed as a major contributory factor. This could well be true as Accident and Emergency departments race against the clock to admit patients within 4 hours of arrival. My stay in hospital last year involved a 3 hour 58 minute wait before I was whisked (literally – I’m sure the porter ‘driving’ my wheelchair created some serious G force with excess speed) up to my allocated bed at midnight. I must confess at the time, it hadn’t occurred to me that some poor soul had been ejected to make way for my arrival. I assumed that this was down to inefficient bed rotation.

Regular visitors (either as patient or carer) will know that achieving a timely discharge for a patient can involve considerable skill, some deception and an element of luck for the dischargee. Clinical staff, quite rightly, are cautious about letting patients in their care go home too soon and reducing the number of re-admissions is a worthy aim. However, getting someone to ‘sign you out’ can be frustrating and at weekends, nigh impossible. With fewer consultants around and the junior doctors rushed off their feet, a weekend discharge can be a thing of rare beauty. And what about the time it takes to actually leave? How often does a relative schlep up to the ward, with an optimistic one hour paid for in the car park, to be kept waiting for the best part of a day for their loved one to be ‘allowed’ home. I reckon checking out of prison is often simpler.

The system for delivering ‘TTO’s’ (take home drugs) is usually a weak link in the discharge chain and I have known patients to wait up to 8 hours simply for their prescription. Beds are sterilised between patients and delays in bed turnover are sometimes due to inefficient cleaning regimes.

As always, another story lies behind NHS statistics. Yes – of course late night discharges should be avoided, especially for the elderly and those who live alone. But efficient application of the basics could make such a difference. The basic principles of holistic care - thinking about the patient as so much more than a bed filler and considering their lives outside the microcosm of the hospital. Streamlining the discharge procedures, efficient bed changing, and slick pharmacy services would all make a positive contribution to ‘patient turnover’

Small changes can make a big difference and the patient pathway that needs close attention. As always, it is not rocket science but simple joined up thinking that needs to be applied.

NHS Reform – what next?

As predicted, Andrew Lansley, UK Health Secretary has had his way and the Health and Social Care Bill has been passed.

It was interesting to watch Mr Lansley being interviewed on TV over the weekend. With the legal mandate safely secured, he was much less defensive and more confident in trying to explain just how the reforms will improve patient care and save money. One has to admire his resilience and self-belief, and his absolute determination to push ahead with this top down reorganisation of the NHS despite so much vociferous opposition from powerful adversaries.

Maybe it’s the pseudo petrol crisis, the hoo-hah about tax on hot pies or just the prospect of unlimited chocolate on Easter day, but all seems very quiet on the NHS reform front at the moment. A lull before the storm? I don’t think so – possibly the reverse. The storm has blown itself out and the lull follows.

After all the excitement (the debate has kept the pages of this blog busy for over a year), it all feels like a bit of a damp squib. The posturing and politicing, pausing and reflecting, debating and demonstrating, letter writing and voting has all been to no avail for the anti-Bill lobby. Just for the record, anti – Bill is not the same as anti-reform and I suspect that the majority of those closely involved with the NHS would agree that some improvements and efficiencies were badly needed.

As extensively reported, many of the changes listed in the Bill are already underway. Hospital managers are looking at ways of controlling increasingly tight budgets and coming up with constructive ways to work with the private sector to make best use of resources and reduce costs or increase income. Some GPs are either engaged in learning more about the commissioning game and enjoying some new found power while others are suffering in silence and struggling to balance patient time with administrative burden. Other GPs, possibly an alarming number, will be seriously considering early retirement to avoid the new regime. Health workers will be an unwilling audience as some layers of beaurocracy are deconstructed and replaced with other, unfamiliar ones.

What does this all really mean for the millions of stakeholders directly affected by NHS reform? Only time will tell.

And what about patients? They will be the real judges of what happens next.