Cradle to Grave – the New Battleground?

© Robert Bayer | Dreamstime.com

© Robert Bayer | Dreamstime.com

It all started when I was on the Tube last week and a woman in her 30s gave up her seat to an elderly man on walking sticks, he thanked her and took the proffered seat…next to the child, whose mother didn’t think it necessary to get her little girl to stand for the man.

I suppose when you think about it, the question is “Does this show a lack of respect?”

From the mother, from the child? To me it seems to be the norm these days, in a Britain that is too cool to stand up (no pun intended) for what are now see as old-fashioned values.

In Britain in the 1900s, respect was demanded by those who held the power, money and status, but it was likely to be a sham respect, not earned by the actions or manners of the one demanding it. In the 1940s it was all about “being a lady” or a “real man”, and good manners earned you respect and “genteel” was something people aspired to. Following the levelling of society’s powerful and the upper classes in the World Wars, being polite and respectful developed a bad rap to be rebelled against and was becoming viewed more as “putting on airs and graces”.

Is it any different abroad?…probably not. There seem to be many people like me, stuck in the past, who don’t get the modern vibe around the culture of self, self and more self.

Showing respect for others these days seems to be a sign of weakness, almost as if giving respect selflessly, detracts from the giver in some way, maybe even making them look naïve or a bit dim.

Once respecting others becomes an act that attracts a personal cost, where do we go from here?

How about the case this week of the 6 care workers sentenced for ill-treating residents. The son of the abused resident said of the convicted “there was no respect”. The strong generations now having their day, seem to have little if any respect for older people, who might be viewed as just living longer and longer and using up resources that could be conserved.

What about those at the end of their life…often treated with indifference in the health sector as seen in its discredited use of the Liverpool Care Pathway and more recently in a new report claiming that hospitals continue to fail patients at end of life.

To take this to its inevitable conclusion…with the assisted dying legislation paving the way for an “acceptable” solution, and with respect for others on the slide, will we slip into a future we weren’t expecting?

The future “cultural war” to be waged is likely to be young v old, as the scary prospect of a world populated by millions of old people, who need care, but aren’t valued, overwhelms a generation who were never taught to respect older people anyway.

Sixties sci-fi at its most horrific.

The Glorious 12th – the new NHS Killing Season?

Apparently, grouse in the UK aren’t yet healthy enough to shoot this year as the bizarre weather has stunted their development…in other news though; the month of August has triggered the annual influx of newly qualified doctors into hospitals across the UK, signalling the start of the annual open season on patients.

© Tolchik | Dreamstime Stock Photos

© Tolchik | Dreamstime Stock Photos

The ’Killing Season, so called because research shows that the 6,000 new doctors that are already in place at our hospitals are putting patients at risk, prompting a six per cent rise in unnecessary deaths. We know this as a matter of record, and the Government finally responded to the issue last year.

There is now a mentoring scheme to ensure that graduates have access to support from more senior medical staff as they learn the ropes. The Independent reported that the mentoring scheme requires junior doctors to shadow their predecessors for a minimum of four days before they start their jobs on 1st August. It must be nerve-wracking for them suddenly to be faced with real live patients…and four days sounds like being thrown in at the deep end to me.

But then…it’s worked well in University Hospitals Bristol, figures showing that there were 52% fewer errors made by the junior doctors on the scheme in the first four months. This is great news for all those patients who might not want to replace the grouse as “fair game” this August.

So, problem solved then? Well, this certainly goes some way towards it, but we can’t congratulate ourselves just yet as the EU’s Directive around working hours has been thwarting those same junior doctors since 2009. Senior medical professionals have argued that the EU’s strict rules on working hours have been frustrating the development of graduates who need to experience the fullest range of conditions and treatments they can in their first few weeks…or first 4 days if they’re really lucky.

But, by limiting the hours junior doctors can work and train, the EU’s rules are putting them under a strain to perform well while learning an enormous amount of information in a stop/start manner. In October 2012, Professor Norman Williams, President of the Royal College of Surgeons, argued that shorter working hours meant that junior doctors are failing to meet a full range of challenges and applauded the Government’s effort to instigate a change to the directive. He wrote that a “48-hour straitjacket has led to too many unnecessary handovers and has resulted in a fragmentation of patient care.”

In February this year, the GMA highlighted the results of the restrictions imposed by the EU working hour’s directive, also. They cited some issues around providing out-of-ours care for patients and being given less opportunity for valuable training causing even more pressure. When so many health authorities agree on a topic, it’s worth noting as it is a rare event…

Working in the medical profession is not like any other, it is literally life or death, and not just statistics. The NHS is at least trying to support new doctors, but with their hands tied by the Directive, how are we to maintain the take up by graduate doctors and save patients’ lives?

I’m with you on this one, Professor Williams….Pull!

 

 

Bullseye…or a shot in the foot?

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The recent reports of A&E waiting times are an about face worthy of Alice Through The Lookinglass…”Shock 250% rise in patients waiting more than 4 hours in A&E: Six-month total soars by 146,000 – as Labour says crisis is worst in 20 years” from the Daily Mail.

Apparently, since the Government took over the “4 hour wait target” for A&E patients introduced by Labour in 2002, waiting times are supposed to have rocketted.

Not long ago, in the days of Labour, the Press were tutting over the fact that the 4 hour wait target was causing patients to be left in ambulances rather than being brought into A&E departments for the clock to start ticking…now it’s missing the target that is the issue.

The Guardian further explains that “NHS failed to meet four-hour A&E targets for past two months” and that 93.3% of patients have been dealt with under the 4 hours instead of the required 95%…and this is with 1 million patients more being dealt with than in a similar period last year.  Ahhh…that explains it then…there are just too many people presented at A&E…

The Scotsman seems to have it right with their stirring story “A&E patients told: If it’s not an emergency, visit GP” and quite right too. Its the worried well that cause prolems not only in emergency situations at A&E but also with England’s new 111 Service where the volume of call to this urgent number have brought down the systems.

If I was in A&E with a life threatening problem and the guy next to me was being treated for a cut finger as he was nearing the 4 hour wait target I’d be pretty vocal. Surely it’s the triage professionals that should be making the decisions about who is seen first? About who is emergency and who is urgent?

They could always install direct lines to the 111 Service in the A&Es for those who are fed up of waiting.

 

 

 

Legs 11 (1)…thoughts on the NHS lottery

It's a lottery out there...Don’t you just despair over the constant stream of NHS bad news? It’s like a lottery out there if you’re sick…
The main cause of recent Press hysteria is the NHS 111 Service…and yet reading the various articles there is no consensus amongst journalists about what really is the problem. Of course, there is “The Computer System”, that baddie from the sci-fi genre of the 50s and 60s. If you are my age you will recall that computers are violent towards humans and are looking to take over the world.
There is no grasp that today’s services are brought to us through many systems working together (or not) and in the case of the NHS 111 Service I imagine there to be Call Centre Systems, Triage Systems, Patient Record Systems…which has failed us? Or are we blaming them all?
The BBC talks about high call volumes. Is that the Call Centre system causing the long wait? Or is it the staffing levels?
While the Daily Mail sees the Triage System as possibly the main problem…or could it be that staff with only 10 days training, who are so desperate they admit “I don’t know what to do”?
Reports of IT crashes are common in all reports and maybe that was a reference to the Patient record System…or maybe not. Or could it be that as usual a Government project of this size is suffering from flawed planning, know-nothing procurement, poor project management and inadequate testing?
All of the above I suspect, the bigger-is-best policy wreaks havoc again, it never changes and it never will until leaner, meaner, providers are given the chance to prove themselves on Government projects.
I feel a twinge of sympathy for the solution designers as, having worked for years within Government, call volumes have probably been vastly underestimated. The NHS 111 Service is designed for “urgent” calls; the NHS 999 Service for “emergency” calls. However, if you give the public an easy option, they will take it…and hey, who wants to wait two weeks to see a GP?

Love like you’ve never been hurt…outsource like there’s no one watching

The Virgin rail deal and the G4S security contract for the Olympic Games has brought government procurement to the attention of the general public…people who would not normally have outsourcing outcomes on their radar.

Over my career of 30-odd years in the public and private sectors, I’ve been involved on both sides of the fence as contractor and outsourcer…poacher and gamekeeper. We used to say, “this is not our core business, let’s find someone to do it for us”. The assumption would be that a contractor whose business it actually was would have the skills and expertise to be able to do the work cheaper and better than we could.

In those far off days we used to have the concept of the “Intelligent Customer”…this was a tiny group of knowledgeable staff who stayed within the outsourcing body, able to oversee the work of the contractor and to monitor performance.

Roll forward 30 years and as civil servants became more relaxed with having “someone else” do the job the concept of the Intelligent Customer seems to have disappeared…along with any pretence of monitoring and management of outsourced delivery.
Channel 4 News asks “Do you know who runs your world?”…and the answer is probably “No”.

Government departments are now just “kitemarks” with approved contractors wearing the “badge” of the organisation they have replaced….the skills have been lost in government and there is no going back.

Very few people realise that they are now dealing with private business operators and their rights to question the service and get a response have vanished. Transparency is one of the biggest issues…freedom of information does not apply.

Some of the biggest companies…G4S, Serco and Capita have been awarded business to the point that they are bigger than many government departments. The supply chain is deepening and so many public sector staff have been transferred to the new business providers that the culture has been imported along with them…they are becoming indistinguishable from the civil service they have replaced.

In fact, they could well be in a similar position to that of 30 years ago…asking themselves “is this our core business?”

If the difference between public and private sector workers cannot now be seen by the public how blurred has the line become for those who remain behind in government? How close are the links? And can the taxpayer ever know what sort of deal their getting?

Don’t get sick…just yet

Last week, alarmist headlines warned readers of an NHS ‘killing season’…a period when the average mortality rate increases in UK hospitals due to the intake of newly qualified medical graduates. To counteract this dip in the quality of patient care, the Department of Health has published details of a plan to better provide trainees with the skills they need to hit the ground running. But is it enough…after all it seems the Department of Health are happy to inflict on us medical staff who can’t speak English, so are we any worse off under inexperienced doctors?

We need more than a quick-fix solution…we need to be pre-empting both problems earlier on and providing sustained support to junior staff in the UK by better nurturing their skills and attracting, retaining and developing the very best home-grown talent from the start.

At present, it is reported that patients admitted to British hospitals in an emergency on the first Wednesday in August have, on average, a 6% higher mortality rate than those admitted on Wednesday the previous week. The Department of Health’s measures to eliminate this ”blip” look to smooth out the change-over period in August by introducing strategic, targeted training which aims to better prepare trainees for the reality of life on the wards.

The Department of Health has stressed the importance of a better transition period: “Our aim is to ensure that all junior doctors spend a minimum of four working days shadowing the job that they will be taking up and completing a Trust-based induction.” It’s this kind of exercise that will lessen the shock-to-the-system reaction which seems to be fairly common when juniors first have to face the literally life and death situations that they come up against on duty…another shock to them must be the hours they are suddenly expected to work and the exhaustion that results. Most of the working world has already worked out that by helping new starters to become more familiar with their new working environment, combined with a thorough handover of their responsibilities, they will be better prepared for flying solo.

Indeed, it’s encouraging to see that trials in Bristol of week-long shadowing and additional teaching have reduced mistakes made by new doctors by 50%. If this is truly representative of the benefits, I’d say that we’d be short-sighted to set this kind of skills development at just four days. The plans put in place so far are a great start, but more can be done both in advance and in the longer term to not only bring these statistics down, but to ensure that the very best doctors are providing the very best care in our hospitals.

To attract home-grown talent we need to be encouraging Britain’s young people into medical training, from an early stage. Over the past eight years, nearly 200 UK nationals have headed abroad to train as doctors and dentists at medical schools in the Caribbean alone. We need a system in place that can attract and retain the skills we have in the UK in a world that has become globally competitive for such talented individuals.

It’s important that we’re looking at the longer term effects of the culture too when shaping the way we go about training juniors. A recent report highlighted that during their training junior doctors do not feel valued by their superiors or the organisation as a whole: managers (83.3%), the chief executive (77.7%), the organisation (77.3%), the NHS (79.3%). These figures are not a surprise when you poll at the bottom of the heap…same in most professional sectors I would say.

So what’s in store for all of us who might fall sick next month? It’s thought that 7,000 junior doctors will voluntarily begin the new induction scheme later this month, before they start their posts in August. Compulsory from next year onwards, this personalisation of skills development is a big step towards improving patient care at this crucial time. Whilst more can be done to improve training, it is certainly a good sign that at least things are moving to bridge the massive gap between being a student and becoming a medical professional…safer too!

Change the Record

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Earlier this week Health Secretary Andrew Lansley published the Department of Health’s long awaited Information Strategy whitepaper “The Power of Information”. It details plans to take all patient records online by 2015…but haven’t we heard all this before?

Back in 2002/3 the National Programme for IT (NPfIT) was born. It promised to do much the same thing, as part of the overall revolutionary plan for NHS interoperability. We all know what happened next – at the last count the Programme had spiralled to £12.4 billion and was officially ‘axed’ in September 2011 with us being years older and no wiser.  I accept that we are a little closer than before to the goal of a standardised, electronic system for patient records across the NHS…but what needs to change to make Mr Lansley’s vision a reality this time around? Here are some pointers:

  1. Break down barriers to change – the NHS Spine has been in existence for many years…it’s not the technology that’s holding us back but the attitudes. However, things are moving and nearly 15m Summary Care Records have been created. It is interesting to note that a patient’s ability to “opt out” was a huge sticking point…to date only 1.29% have chosen to do so.
  2. Identify patients by one unique number – incredible as it may sound, a patient’s NHS Number is not always the primary identifier for an individual across all sections of the NHS. This needs to change so we move to a one patient, one record system.  This is a key message from the Information Strategy.
  3. Clean up ‘dirty’ data –in the last couple of months we’ve had news that 20,000 pregnant men and 95,000 ‘ghost patients’ remain on the NHS books. This needs sorting and much of this process can be automated.  As an example, Quicksilva’s orQestra® system is helping our customers to verify NHS Numbers…in one case resulting in a 1.1% improvement in verified records in the first month…when you’re talking about 1.3m records, that’s getting us there.
  4. Pharmacies need to be encouraged to provide electronic transmission of prescriptions using barcodes – the Electronic Prescriptions Service (EPS) shows promise, but is far from the universal standard. Greater take-up will improve the quality of the data online and remove the need for routine appointments, a significant overhead for GPs.

No one can pretend that any of this will be happening quickly. One of my main concerns is that there is no optional central guidance as to what solutions can be used to deliver on the Strategy. Mr Lansley has instead called on GP surgeries and hospitals to use “imaginative solutions”. It’s true that the top down approach of NPfIT did not work but I think more guidance is needed for those healthcare providers who cut their IT budgets leaving them with no-one to help them make important decisions which will affect their future in competition with the private sector.

NHS Data – which one are you, again?

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Last week’s news that the NHS has saved £6.1 million by removing about 95,000 ‘ghost patients’ from its GP lists sounds impressive, but it only exposes the tip of the iceberg.  Removing these outdated records from GP lists is a step in the right direction, but there are other pressing reasons why a concentrated clean-up of patient data is needed.

The quality of data supporting the NHS has been poorly controlled for years and now that healthcare information is beginning to be shared between care providers the true extent of the issue is set to be highlighted.   With NHS Trusts under relentless pressure to measure and publish quality outcome indicators and with the increased accountability that directly affects their budgets the need for clean, accurate and accessible data is more important than ever.

To enable health care providers to identify which patients they are actually treating the NHS maintains its Personal Demographics Service (PDS).  The PDS is where data on every recorded NHS patient is held; it’s used by hospitals and other care-providers as the most up-to-date repository of patient identity available.  However, matching the details a patient has given about who they are against the hospitals own database and then verifying with PDS is not always straight forward.

If patient A is recorded in one database as living on ‘Salisbury Road’, and on another database as living on ‘Salisbury Rd’ then to a computer you have a failed match and there is an error, whereas to a human user the records are clearly the same and perfectly usable.  However, where the flow of information is electronic, and interpretation performed by computers the situation becomes very much more polarised and a minor error can lead to the failure of the referral mechanism, resulting in a patient being unable to book treatment, or to unknowingly receive treatment under a separate identity.  Such situations are often propagated as treatment staff, having recognised registration problems, will often not have the authorisation to make the changes needed.

It is not surprising then that A&E departments find themselves treating unknown or non-NHS patients which results in the hospital not being able to claim back the cost from the Department of Health.  As part of the NHS Reforms hospitals will become reliant on their own income to fund treatment.  Without being able to verify who they are treating, hospitals will lose out to “ghost patients” and “health tourists” meaning they won’t be paid and won’t have the cash available to maintain their service levels. It is vital to address wider data quality issues now, before the Reform Bill changes the NHS beyond recognition.

NHS Bill – the devil’s in the detail

Last month I commented that the NHS Bill risked losing hearts and minds and drew some parallels with the way differences of opinion on NHS reforms have been handled in the past, that is, by just ignoring them. Well, the reality is now upon us and whether we like or not, the thing is signed.

Many of the arguments against the Bill have been deeply emotive with health sector groups denouncing the Bill with evangelistic fervour…an ideal scenario if you want to dilute and detract from the smaller voices warning that the Bill is privatising health care by the back door. If you’re wondering whether this is the case or whether I am just scaremongering, then maybe it’s worth considering that this Bill has been ushered hastily through at a time when surveys show record levels of satisfaction with the NHS.
Being a “business person”, you’d think I would see the sense in privatisation and in most markets I can, but how can directors of private companies put patients first when their statutory duty is to put shareholders first?

These questions are the ones that generate a most unhealthy response in me:

  • Once hospitals are forced to take the Foundation route, they become independent of government and subject to GATT rules (showing my age) and EU competition. What will happen to them should they start to fail?
  • What will happen to the supply contracts currently in place with NHS orgainisations that are being scrapped? We’re talking about everything from cleaning to catering to IT and building maintenance. Will they be novated?…or worse, who’s left to manage the suppliers?
  • Even before the bill was passed, we had an example in Hounslow where the new GP consortium has appointed a multi-billion dollar American company to vet patient referrals according to a set of rules. How is this improving patient choice?
  • What happens when GPs start running out of money to commission services? If I should suddenly get ill in March, would I have to wait until the new financial year in April until I get hospital treatment?
  • Where will the 1 million staff work whose jobs are set to be privatised by 2014?
    Most patients do not see GP practices as private sector organisations, but they are, and at least in the past we have had referrals to hospital staff to provide treatment for the patient independent of profit considerations.

This Bill will take that safeguard away…and personally I would rather be treated by an NHS not-for-profit organisation than a “multi-billion dollar American company”.

NHS Reform – follow the money

follow the money

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The Government’s NHS Bill is causing more unrest than any other bill I can remember…and yet it appears that it’s being pushed through far too quickly for something as important as this, leaving outsiders and insiders alike feeling railroaded.

The recorded aims of the Bill is to: create an Independent NHS Board; promote patient choice; and reduce NHS costs seem reasonable; so what’s going wrong?

Firstly, Mr Lansley’s approach to consultation has yet again got stakeholders’ backs up.  The Government seems to have learned nothing from the last major upheaval following the formation of the NHS National Programme for IT (NPfIT) in April 2005.  By August of that year, health sector bodies were complaining about the lack of consultation, an issue which dogged the life of the Programme and made every change unpopular with front line staff regardless of its expected benefits.

And now history is repeating itself…the latest news is that David Cameron has organised a summit with healthcare professionals to discuss how to implement the reforms excluding his critics.  Press reports say that some of the Royal Colleges such as the Royal College of General Practitioners have been excluded.

In life, most successful people learn that it is better to engage with their dissenters and work through the issues patiently and methodically…or face challenge at every step.  Half-hearted attempts to “listen” won’t cut it, especially where an institution as precious as the NHS is concerned.

The Government have already had one “pause for thought” and are saying that they are not planning a second indicating that they will be pressing on with what seems to be the most unpopular reform to hit the NHS…even in the light of an e-petition on the government website attaining 120,000 signatories calling for the bill to be dropped.

Secondly, what are we all missing in the small print?  I have been hearing the arguments for and against, but I am now beginning to feel uneasy enough to see for myself.  I thought I’d have my own reading of the Bill, which seemed like a good idea, except that the bill has over 350 pages, containing over 280 clauses.  Not many people will have read the Bill and I doubt whether those voting on it will have put in the time and effort to understand the consequences of its reforms.

My suspicions have increased…in situations like this my key thought is “follow the money”…who will be benefiting financially from this? Is that why it needs to be so complicated?

Over the next couple of weeks I’ll be reporting on my findings.

Watch this space.