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.

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?

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.

 

Commissioning – we must keep the fox out of the chicken coup

It is only natural that the most commercially minded General Practitioners will become actively involved in Clinical Commissioning Groups (CCGs). It’s also logical that these commercially minded GPs will already have some involvement with private companies delivering care to both private and NHS patients. There is, I believe, nothing wrong with that, especially as we must not forget that GPs are, after all, privately contracted to the NHS in the first place. This only becomes a problem when GPs are given the power to choose providers for their patients and may have a financial interest in one or more of the providers being selected.

According to a recent report, more than a third of GPs on the boards of new NHS commissioning groups in England may face potential conflict of interest in the commissioning process. The investigation, undertaken by the British Medical Journal, estimated that 426 out of 1,179 (36%) GPs surveyed who are in executive positions on NHS Commissioning Boards have a financial interest in a for-profit health provider outside their practice.

This entirely predictable predicament now has to be subject to guidance to be issued by the NHS Commissioning Board.

However honourable and decent these GPs are, (and I have no doubt that most, if not all, are) – to be faced with a choice of the best provider for a particular treatment pathway, knowing that you have an intimate personal or/or financial relationship with that provider can be at best challenging, at worst, impossible. If you exclude a provider on the grounds of conflict of interest, you are at risk of reducing appropriate choice. If you exclude a commissioning GP on the grounds of conflict of interest, you may be denying a population of patients of an expert opinion. Catch 22.

I am pleased to see a growing number of recruitment adverts from CCGs and Commissioning Support Groups for pathway mapping, service redesign and cost reduction experts to enhance the whole process and deliver an effective and independent commissioning service. Considering the high proportion of GPs with declared private interests, each CCG may need to appoint additional independent advisers to redress the balance and maintain an impartial majority.

Ideally – there should be an independent organisation to commission clinical services in a region.

Ah yes – there used to be. They were called Primary Care Trusts, and they are due to be abolished next month.

 

As predicted – NHS reform is proving to be divisive.

 Perhaps it’s because I was brought up as the difficult middle child, but I love a good spat – it gets issues out in the open and can often clear the air. If only it were that simple with all the siblings of the complex NHS family, a family that appears to be more dysfunctional by the day as the Health and Social Care Act is implemented.

No-one could doubt  the good motives of the former Health Secretary Andrew Lansley as he formulated the transfer of power to give General Practitioners not only the lead when it comes to commissioning of services, but the key to around £60 billion. But as many of us are already aware, the consequences of these changes are not all beneficial.

As predicted, GPs appear to fall into three camps. Those who don’t want all the hassle, paperwork, responsibility of balancing commissioning with face to face patient time and therefore vote with their feet through early retirement. The second group are probably the silent majority who either take an active role in a commissioning group because ‘if you can’t beat ‘em join ‘em’ or maybe take a lesser commissioning role while trying to spend as much time with their patients as possible. And the third, possibly more vocal and active group are those who favour the changes, relish their new found spending power and appear to be planning world (or at least UK) domination.

Those GPs who embrace the additional responsibilities placed on their shoulders by NHS reform are to be congratulated and supported and I have no doubt that many of the clinical commissioning groups will do an excellent job in difficult circumstances, especially when they have the good sense to bring in the appropriate commissioning and clinical pathway mapping experts. But I fear that the side effect of the bullish comments by, for example, the NHS Alliance could do much to damage interdisciplinary relationships and ultimately the patient experience and clinical outcomes.

Without doubt, the priority for any health professional must be joined up care for patients – literally from cradle to grave. Forgetting this awesome timespan, let’s just focus on a patient needing some non-urgent care that may involve some sort of surgical or specialist led intervention. In an ideal world, the clinical pathway for the patient’s condition has already been agreed within the local CCG and this pathway entails full cooperation between primary and secondary care. But according to a letter to The Times newspaper by Drs Michael Dixon and Chris Drinkwater and some of their colleagues ‘hospitals are dangerous places’ and they must ‘as an immediate imperative, shift all non-urgent care into the community’ One could argue that this makes sense but it must be viewed in context. Services can only be shifted into the community if the infrastructure creating the desired capacity is there.

 

It isn’t.

The letter goes on to mention the NHS Alliance Manifesto which is ‘formulated by frontline doctors, nurses and professionals in primary care’ Manifesto? A manifesto can be defined as ‘a published verbal declaration of the intentions, motives, or views of the issuer, be it an individual, group, political party or government’. This very much suggests a group in isolation of the whole NHS family. The NHS Alliance manifesto spells out some worthy aims but is positioned in a political, territorial way. There is more than enough bad press about hospitals without such powerful GPs proclaiming what dangerous places they are – just imagine how a Times reader with a visit planned to hospital this week must feel?

Needless to say, two days later, a response from a surgeon was printed in the newspaper and he politely points out that one of the issues with non urgent care is that over the years he ‘has witnessed a derogation of out of hours care, exacerbated by the GPs contract in 2004’ and doctors deputising services are often ‘staffed by doctors who do not have requisite skills’.

Fair point well made.

So there we have it – just one small, but potentially significant spat between primary care and secondary care siblings generated by the parent who didn’t think things through when dividing the spoils of his inheritance.

What a sad reflection of a familial relationship that should engender the very best for the patients in our care. It has  generated some unwanted side effects for professionals, trying to do their best for their patients but having to win ground and hold position all at the same time.

What a difference a week makes – not.

It really is same old same old at the moment in UK health.

David Nicholson hangs on:

With the tenacity of a desperate mountain climber teetering above a crevasse, the Chief Executive of the NHS grips to his position. Insisting ‘I am the right man to lead the NHS’ his performance at the parliamentary select committee hearing this week served only to confirm that this man is either seriously lacking in a layer of human emotion and humility, or is incapable of showing that he really does care. Either way, this is not the type of persona that the NHS needs right now. Word on the street is that he will be gone by August, so if that’s the case, why not let him go now? Apparently he has a ‘tight grip on the NHS’. If his grip was as tight on the organisation to achieve the right balance between quality and cost as it is on his job maybe there would be some hope. This man ain’t for shifting. No change there then

Julie Bailey and Cure the NHS continue to impress:

And long may she continue to voice the concerns of millions. Speaking outside the Houses of Parliament with her comments on Nicholson’s culpability, the compelling Ms Bailey was, as always, calm, eloquent and convincing. Her late mother, Bella would be proud of her – and so should all of us. Keep doing what you are doing Julie and all your friends and colleagues at Cure The NHS.

‘Billions in extra cash fails to stop the rot in the NHS’ (Daily Telegraph)

A report in the UK press this week told how Britain is slipping down the ranking in public health, compared to other Western countries. Life expectancy is increasing – which in itself could be depressing as our pension pots run out – but we are now 14^th in the list of 19. I would be more interested to see a table listing quality of life and health and wellbeing – just being alive doesn’t tell the whole story. But the key point is that spending has increased from £46 billion in 1990 to £122 billion this year but we are not seeing an improvement in the health of the Nation. The effects of a past generation of smokers, and a new generation of the obese and inactive who eat junk food continue to pile on the pressure for our struggling state funded system. How do we stop the rot? We are still looking for answers.

Jeremy Hunt attacks 'complacent' hospitals (BBC)

Apparently Jeremy Hunt, the Secretary of State for Health will announce during a speech today  that ‘too many hospitals are coasting along, settling for meeting minimum standards’ He will ‘attack a culture of "complacency" and "low aspirations", which he believes is holding the NHS in England back’. Mmm – so that would be a culture led by a Chief Executive who has a ‘tight grip’ on the NHS? So that’s another thing that doesn’t seem to be changing – the disconnect between logic, good sense and NHS reform.

Change for change’s sake is bad. Change to improve, innovate, rationalise and consolidate is good. What a pity - it’s mainly the things that need to change that are staying the same.

What a difference a year makes as NHS Reforms become real.

How interesting… Michael Dixon, Chair of NHS Alliance and Interim President of NHS Commissioners has warned that doctors would "start getting bogged down" in dealing with competition and would end up taking their "eye off the ball". He is concerned that the wording on competition in the Section 75 of the Health and Social Care Act will mean that doctors could get "bogged down" in the process of commissioning and distracted from patient care.

Reality is really beginning to bite for a GP who has been a huge supporter of NHS Reform, which transfers the shift of power to give GPs the majority of the NHS budget to commission care and services. Dr Dixon has been a bullish proponent of GP led commissioning and last year relished the new powers to be endowed on GPs, but his ardour now appears to be waning. What a difference a year makes. Less than a year even. Last May, I attended an NHS Futures Forum and struggled with Dr Dixon’s enthusiasm for this shift in power. An extract of my blog that week follows:

May 18^th 2012

‘…..Oh dear oh dear oh dear. I must be very careful how I put this but Dr Dixon’s presentation fuelled my worst fears about the effect of these NHS Reforms. He started his talk with ‘I am an independent contractor, like a plumber’. ….…..Michael is massively in favour of GP Commissioning and leads a pathfinder GP practice. He was in my opinion (I must be careful not to upset my lawyers) positively salivating at the prospect of complete control of a big chunk of the NHS budget. I found his talk of a café in his practice, his views on specialist representation and his apparent lack of empathy with secondary care quite worrying……He made no secret of the fact that a desired outcome of the reform and GP led commissioning was to migrate services away from Hospital Trusts. He continued – and I quote, as near as my notes allow, ‘I’ll be moving stuff from hospital to my practice and I’ll get money for it, therefore there needs to be total transparency’.  Baroness Young (the chair of the event) was brilliant as a devil’s advocate with her careful wording. She asked Dr Dixon his view on the fact that many patients, especially those with long term conditions do not wish to be ‘discharged’ from the care of their specialists to be handed over to a general practitioner……I asked Dr Dixon if perhaps that figure [that 30 -40% hospital admissions are avoidable] could be due to the fact that patients couldn’t get in to see their GP and how would GP commissioning improve this state of affairs. For a moment I thought he had morphed into Andrew Lansley as the question was effectively side stepped. When I queried the impression that he didn’t want specialists on ‘his’ commissioning board, he clarified that he doesn’t want hospital specialists on the board who are ‘trying to protect their budget’.  A phrase that springs to mind includes ‘pot and ‘kettle black…….’

Back to the present…

There is some merit in Dr Dixon’s demand that the wording of section 75 of the Health and Social Care Act should be changed as it appears to encourage a scatter gun approach to opening up competition for services which could be unsuitable for private involvement either due to expertise, location or supply issues. Commissioning isn’t easy. If it was, the NHS would be in a better state than it is. I would much prefer seeing GPs looking after patients, directing their care and referring them on to appropriate specialist services. But the nitty gritty of preparing tenders, assessing responses and monitoring contracts is a full time job.

I believe that carefully managed competition in targeted service areas can be a good thing for the NHS. But commissioning is a specialised, time consuming, detailed and burdensome job. Being a GP is a specialised, time consuming, detailed and burdensome job. How can GPs realistically be good at both? Dr Dixon continued in his interview with Pulse magazine that offering the tendering process for most NHS services to private firms could mean that the reforms are ‘a complete waste of time’ and that ‘GPs will walk’.

Last year, referring to his desire for autonomy and lack of interference, Dr Dixon famously said ‘GP’s don’t want to be managed – we want to be seduced’

Fun as seduction may be, it often results in consequences that aren’t always positive. I am tempted to say ‘I told you so’.

Instead I shall settle for ‘Be careful what you wish for….’