Stupid people who should be charged if they do so. Though as I've said quality triage from ambulance control should sort this issue out before it gets out of hand.Originally Posted by Mike T
Stupid people who should be charged if they do so. Though as I've said quality triage from ambulance control should sort this issue out before it gets out of hand.
The NHS does not need more money. It does not have an efficiency problem. It has an effectiveness problem that is being treated as though it is an efficiency problem. Same with social care, and of course, the two are mutually causal.
If you study demand, i.e. who hits the system, where, when, why, how often etc, you learn that 1.5% of the population consume about 50% of the resource. Last hospital I studied was interesting - 16 people consumed 1% of the resource. 16 patients! The system didn't know this because it treats people episodically, that is to say it takes each presentation as if it were the first. It deploys according to presenting need and wonders why people keep coming back. The system has focussed on faster throughput and competition as a means to efficiency but it just does the wrong things faster, cheaper. Except it is not cheaper because managing unit costs drives end to end costs up.
Those 16 people who consume 1% - who were they? Cancer patients? Victims of long term illnesses and/or effects of trauma? Well one of them was. The other 15 were old people who had a few afflictions that the system thought were being 'managed'. We looked more closely and they were all turning up in ambulances at night, being triaged low in A&E, waiting 3hr 59 mins in A&E before being admitted (we can't risk sending them them home can we having not examined them because that would make us culpable in the event of a problem and we can't breach the 4 hour target in A&E - the system manages risk to itself, not the patient), we stick em in a gown and on a ward, they go 'off their legs' and we end up discharging them with a package of care whereas their presenting need was simply anxiety. The same pattern of consumption happens in social care and GP surgeries. The system designs in demand and locks in cost by trying to manage unit costs and meet arbitrary targets that bear no relation to purpose, as we would define it.
On average, the system amplifies one demand (help me/fix me or both) into five. The variation around this is huge, with many older folks, including our top 15, hitting the system hundreds of times with their one problem - help me live my life well.
I ran a prototype with Doctors, Social Workers and Therapists where we took away the eligibility criteria in social care, took away standard medical assessments and simply said to skilled people - "work out what matters to this person, attend to it and see what happens". They were not allowed to refer on, instead they pulled expertise towards the problem (rather than shunting the problem off as happens now once you've done your bit the best you can). What happened was 50% drop in cost, 80% drop in demand, everyone had better outcomes, including those terminally ill people who died having got their affairs in order and, as one of them put it, "was allowed to die a good death".
Demand is not rising, but failure demand (that caused by the system's failure to do something or do it right) is rising ever faster thanks to more inspection, more subdivision, more screening and fighting over who pays and more attention to managing cost (i.e. GP appointments no longer than 8 mins) rather than managing value (i.e. GPs deciding how long they need to ensure problems are understood and solved).
We learned that the NHS and Social Care need to focus upon learning to 'Understand and Help' rather than endless cycles of 'Assess - Treat - Refer'. We're off to the House of Lords soon to say, "Oi! Look over here". Wish us luck...
That's a good point. If I thought petitions made any difference, I would sign one that said we should put money to healthcare and not Trident.
If the NHS had more money it could employ more A+E Consultants to see elderly people well before the 4 hour limit, assess them, and if possible discharge them, contributing significantly to their quality of life. We also need more, not fewer, GP surgeries to keep people out of A+E, where they are often seen by junior inexperienced doctors, who tend to over-investigate and over-admit and miss important diagnoses. If GPs can recognize and treat minor problems in the elderly it could prevent many a prolonged expensive admission.
If an elderly patient was presented to me as suffering from "anxiety" I would be looking very carefully for the diagnosis that was being missed - infection/minor stroke/metabolic disarray/drug side effect ....
What we saw, through the GPs we worked with, is that non-medical problems were medicalised because the lens the GP was looking through. quite reasonably, was medical. When the surgery was focussed upon providing solutions rather than services, and by doing so was free to draw in anyone that was needed, be they therapists, the next door neighbour, social workers and in one case, the RSPB (she had 200 birds in an aviary in the back yard and so sorting out that was the best 'cure' for what drove the dozens of presenations to GP in and out of hours as well as A&E, not that she knew this until the GP was freed to ask better questions through a different lens, i.e. what matters? what's making you feel like this?).
Understanding people (rather than assessing them) meant that the GPs were deploying a wider set of skills and expertise beyond their own and in doing so, grew their own. The result was a practice that meshed community provision to help people and stopping them presenting to A&E. BEfore the prototype, between 2 and 11 people from that practice cohort (mean of 5) would predictably show up at A&E each day. The practice did not even know this - why would they? The system isn't designed that way. After this prototype, it went down to between 0 and 4 per day, average of 1. The lever for change was demand into A&E not more money for throughout of people that we should be keeping out of there.
The GPs were central to the design, but no more so than voluntary agencies, social care and district nursing. Treating wellbeing as a single aim for a single system with one pot of cash and one set of measures relating to people and purpose makes a huge difference and questions everything. The GPs were initially chastened because of how little they knew about their practice cohort, but learned fast that this is a design problem and not one of capability or intent.
If the consiton surgery went, it would be interesting to measure the impact on the rest of the health and social care system. The data I have suggests a hypothesis of a net increase in cost across the whole system and worse outcomes. We;d be paying for it to get worse.
Last edited by Mark Smith; 02-12-2013 at 05:18 PM.
If you're using anxiety as an example I really struggle with why anyone would send someone suffering from anxiety to a&e. And if they do get there a consultant, reg, sho , ho or even nurse will refer to mental health services in the blink of an eye - often without any long winded assessments/interventions that you speak of. More a&e consultants with there god complex certainly isn't the answer, neither is more gp's.
Let me take a wild guess - You're a doctor?
It's reasonable for doctors to take a view that we need more doctors because there is a view that demand upon them is rising.
It's only when you study the demand does it become apparent that doctors are hamstrung by the system's procedures and rules. Demand is not rising, but it is recycling. They can't fix it alone. I'm not a doctor by the way.
The whole notion of health and social care needs redesigning from communities upwards. Focussing on A&E, say, is just squeezing the air from one bit of the balloon to another. It's moves the problem elsewhere, but it's cyclical and ends up coming back in the form of more demand (actually the same demand unsolved).
I have plenty of sympathy for GPs and hospital doctors and everyone else in this divisive system that causes people to have to justify their actions and attribute blame to some other bugger somewhere else in the system (usually social workers). It's a thinking problem and a design problem, it's not bad doctors or social workers (quite the opposite).
[QUOTE=The devil's own;566128]If you're using anxiety as an example I really struggle with why anyone would send someone suffering from anxiety to a&e. And if they do get there a consultant, reg, sho , ho or even nurse will refer to mental health services in the blink of an eye - often without any long winded assessments/interventions that you speak of. More a&e consultants with there god complex certainly isn't the answer, neither is more gp's.
Let me take a wild guess - You're a doctor?[/QUOTE
Anxiety often presents with physical symptoms - dizziness/breathlessness/palpitations and so on - but most elderly people with these symptoms have a physical illness - most mental health services know this and are very reluctant - quite rightly - to take such patients without a full physical assessment, if at all.
Yes, retired geriatrician, hence my interest in comments about the elderly. Unlike many, I was not an empire builder - but we do need more GPs - or more accurately more GP time - doing the appropriate things that Mark Smith has touched on, and a bigger Consultant presence in A+E to keep out those who do not need to be admitted, deal appropriately with the walking wounded, and direct those needing admission to the right ward/specialty. Too many A+E patients start off being seen by one of the most junior doctors in the system - they should start at the top.
Any admission on the physical side has to be discussed and agreed with the receiving medic - usually a reg out of hours so more a&e consultants won't make a difference - other than the extra £100,000 plus each one will cost and you'll have a few more arrogant god complexes in the department.
The receiving reg however may not have the balls to say no to a referring consultant - which is a shame sometimes as the receiving reg who is working in his/her chosen area may have more knowledge of that said area that the jack of all trades a&e consultant. Doctors are a funny breed though - they don't like to hear the word no, and often refuse to believe they can be wrong.
Last edited by The devil's own; 02-12-2013 at 09:44 PM.
Many elderly admissions become medical by default as no-one else will take them - even cases of broken bones/bleeding noses/acute abdomens become medical as the other specialties claim "the main problem is their age and all the chronic problems that go with it".
Consultants need to work shifts - so it will be a Consultant seeing the patients at 2 am, not a junior fresh out of university; it takes decades to reach the salary you mention - I never got there despite 30 years in the NHS.
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