Category Archives: Systems Thinking

A&Es further hampered by staff having to get wretched ‘Friends & Family’ test completed…

Twitter: ‘Your Humble Servant ‏@yrhumbleservant  “Tales emerging that A&E crisis being worsened by staff having to take time out to get Friends and Family Test filled in by patients.”‘

Sounds entirely plausible.

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A Sticking-Plaster For A&E: the ‘Walk-In Centre’ fail…

If your A&E department is over-flowing with ailing but not expiring citizens who have had the nous to realise it is the one place in the whole of the NHS that is open in the evening or at weekends; who calculate that a 4 hour wait to see a junior doctor is better than a 2 hour wait just to get through on the phone to their GP receptionist during the week; who with the patience of Job and a small picnic packed by Nan are prepared to sit it out until seen: then ‘Something Must Be Done!’ Something, at the very least, must be done to separate the critically ill and injured wheat from the mildly dyspeptic chaff.

Nursing triage is now a standard place to start – though whether it is a good place to start is moot – an initial prioritising discussion of history, presenting signs and symptoms, and, one hopes and prays, having the ability to make an instant yet sound differential diagnosis between little Johnny’s runny nose and indications of possible meningitis: ‘Red’ for “Immediate threat to life. Treat now!”, down to ‘Grey’ for “Worried well. Let them stew.” That sort of thing. Nurse-led triage, though, can only be an effective tool when the totality of patients-in-waiting fits within the intended remit and flow of A&E, not when the rising headcount in the waiting area pushes it beyond its safe competence and capacity.

One response to pressure on triage is to increase its resourcing by number and by clinical experience and expertise, the evident risk being creating a secondary department within a department, which any half-decent systems theory would acknowledge as being inherently contrary to efficient and effective ‘flow’. Another option, now widely in operation, is the ‘Walk-In Clinic – located within A&E but a separated provision of GP-led primary care that can attend to the many for whom primary, not secondary, health services are all they really need and, in truth, want. The not unreasonable reasoning seeming to be: “They’ve come here to A&E only because they can’t access a GP out-of-hours, so let’s give them just that.”

Good thinking, maybe. But how does it work in practice, does it do what it says on the tin, or do we wretched patients kick the can all over the place until it is bent quite out of shape? First off, word soon gets around that here’s a GP resource for which you don’t have to phone to book an appointment days in advance: just pitch up when you fancy – with Nan’s sandwiches once more for the inevitable wait – and you will be seen eventually. Maybe just by a locum, but then you get seen by a different GP each time when you go to your registered practice so what the heck? It’s conveniently there in the evening when you get home from work, and if Sunday afternoon telly is particularly tedious you might as well go and be bored there as anywhere else: you’ve run short of the blue pills and if you can get home in time for X-Factor with your renewed prescription it’s a clear win-win.

So within days – hours – of opening your wonderful, new and problem-busting Walk-In Centre it is stuffed to the gills, not only with those people who would have been unnecessarily cluttering up A&E and whom you’ve been able to divert there, but also by a whole host of others who probably would have stayed at home but who now grab the chance to get sorted soonest.

Perhaps you’re beginning to feel like the Sorcerer’s Apprentice – just wishing you’d never started to mess with a system you don’t really understand and certainly are failing to control. What, though, are you going to do to attempt to manage demand for the ‘Walk-In Centre’? You’ve built a waiting area for 20, but now over 60 people at any one time are lining the corridor all the way back to the door off A&E.

Something, yet again, must be done! [This is, I hope you gather, a real example of a hospital on the edge of East London – and collapse – a few years ago.] So how do you stop people simply walking in to your Walk-In Centre? Why, easy! You introduce an appointments system! [I kid you not.] When people phone up to ask about the Walk-In Centre, you instruct your receptionist staff [true story] to tell them that they must make an appointment before coming down. This is both truth and lie: there is an appointments system because you’ve introduced one, but no one has to use it – if they know better – because both processes are running in parallel!

So now your corridor is stuffed half with people clutching a ticket for an imaginary timed appointment, and half with people who’ve just walked in off the street on the off chance. Both sets have, anyway, to queue in order to sign in with the Walk-In Centre receptionist, who can only tell everyone what she’s been told to say – people will be seen in strict order of arrival, no ifs or buts and if that’s tough then it’s just that – tough. (Fancy that job? No, nor I.)

The systems analyst has a decent metaphor for the situation: you’ve laid a carpet, but not flat: there’s a trapped bubble of air lifting one section. So you stamp on the bubble and, hey presto, it’s vanished. Or, rather, not. It’s simply moved somewhere else. Solution – lift the carpet and re-lay it flat second time around. Answer – lay it flat in the first place!

If too late now for the answer, what’s the solution? I don’t claim to know, though Jeremy Hunt does: it’s all GPs’ fault for abandoning out-of-hours care. The system having been dismantled under Labour is to be mantled (apologies to P G Wodehouse) under the Coalition. A review, with proposals of how to effect this volte-face is due at the end of the month. I, for one, am totally confident that the report will be replete with whole-systems thinking and proposals – fully acknowledging the challenges and complexities of reversing course – and will make it perfectly clear that whatever is done will have dire and unintended consequences if not designed, planned and delivered around the real world of how people and patients have learned to behave in order to make healthcare systems work for them. Has to happen one time I suppose.

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As The NHS Crow Flies…

“Southend Hospital, Prittlewell Chase, Westcliff-on-Sea, Essex.”

via Urgent care services – NHS Choices.

…not that I would – as there are closer options – but if decided to haul my carcass down to good old Southend Hospital for a viewing, NHS Choices handily can provide me with the distance between my billet and the hospital: fifteen and half miles give or take. Very useful.

But then it also informs me, in parentheses, that the distance quoted is “in a straight line”. Hang on a minute, any crow flying from here to there would not only have to find its way across the emptiness that is the Dengie Peninsula, it would, first, have to make it over the Blackwater River and later the River Crouch, before over-topping the suburban fastnesses of Rochford and environs then finally swooping down on its prey. As it were.

Fine if you are that crow – though if you were a wounded crow in need of hospital treatment for a broken wing say, perhaps not so fine after all. Utterly meaningless in any case to the human, land-fast, traveller.

Google Maps more usefully gives the real door-to-door distance as over 31 miles; twice the nominal NHS Crow Road.

I  am all for the NHS giving information to its patients and the wider public about how and where to access its services (though to be honest anyone who doesn’t know where their local hospital is or how to get there is perhaps not worth saving), but when the information is systemically duff – i.e. it has duffness built into it – you have to ask: 1) Who thought this was a good idea; 2) Who decided to waste public money on such a non-runner? Or flier.

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“Elderly patients will get personal NHS worker to coordinate health care, pledges Jeremy Hunt.” Brilliant idea Jeremy! Not.

“Nobody disagrees with the concept of a case manager,” [Jeremy Hunt] said.

via Elderly patients will get personal NHS worker to coordinate health care, pledges Jeremy Hunt – UK Politics – UK – The Independent.

…don’t they? You sure about that?

For starters, the scheme is dead in the water unless the scope is widened to include social care agencies, whether statutory, voluntary or third sector. That care of the elderly, in particular, requires the co-ordinated efforts and inputs of health and social care is at least and at last accepted in theory, if all too often lacking – or indeed absent – in practice. Even up to the mid-Nineties you could meet a Social Services commissioner who would ask: “What’s Chronic Disease Management [as it was then known] to me; what am I to CDM? That’s changing leg dressings, that’s a matter for the District Nurses.” Similarly, health professionals would be resistant to receiving progress reports or alerts from Home Care workers who were not medically qualified.

If the Great Leap Forward of the ‘Single Assessment Process’ [NHS Plan 2001 – remember that or it?] achieved anything other than massive organisational disruption to deliver the blindingly obvious – talk to each other professionals! – it was in opening eyes to the mutually necessary contributions health and social care each made, not only to individual older people but also to respective organisations and systems; and their all-important purses. Road to Damascus moments did indeed occur as silo inhabitants suddenly got it that they hung together or were hanged apart.

So if this next GLF – this plucked from the manual of integrated care rather – notion is to be of any use whatsoever it cannot only be a matter for the NHS alone. But then, having accepted that, does the task become any easier; is it still incontrovertible that a ‘case manager’ is the thing to do – the big thing that will 1) work, 2) deliver what’s needed? It isn’t.

A ‘manager’ implies someone with authority to act and, where necessary, to instruct. A ‘case manager’, therefore, requires not only a skills set that may well be absent in a worker with specific but limited operational skills, but also an agreed role and function to command and control if needed.

A Community Nurse may well aspire to a hospital based re-enablement team completing their work before a consultant decides the older person recovering from a double lower limb amputation is medically fit for discharge home; a Social Worker may equally hope that the social housing agency has completed the necessary adaptations to that person’s home before they arrive, and that the GP has arranged for Community Nurse attendance, or that the Home Care agency has the capacity to provide a three times a day double-handed crew with specialist knowledge in the use of hoists and tracking. But neither can insist on it. Open communication between agencies, careful and negotiated planning between individuals, are both needed; but you simply cannot just put one person in charge and say “You’re the Case Manager. Get it sorted.” That way madness and a stampede for the door both lie.

Where there is an established pattern of services for an older person with a chronic, progressive disease or illness – for example, in dementia care – there may well be an existing and integrated team of health and social care professionals (a Dementia Resource Centre) who are the natural, go-to hub of both activity and oversight. Regular monitoring occurs and reviews can be held to assess the stability or otherwise of the placement, with agencies able jointly to consider adjusting or re-aligning their inputs in order to avert any potential or impending crises; though even here front-line workers are unlikely to empowered and authorised to agree changes without reference to line-managers.

But there are also many circumstances in which an older person, as any other, may need to travel down a health path with discrete, time-limited interventions. A suspected cancer diagnosis, for example, requires a progression from primary to secondary health services (general then specialist maybe), through perhaps surgical teams and on to other oncologists, rehab workers – physiotherapists, S&L therapists – counsellors, support groups, then on to social care agencies and back to primary care for pain management and review. Who within all of that is ideally – or even usefully – placed to be the ‘Case Manager’. The initially referring GP? The diagnostic or treatment specialists? The rehab workforce? No one but the GP will have been there from the onset, so unless they take on every case – yeah right! – there would need to be lead hand-overs to other disciplines over time, as and when they come to the fore.

But hang on a moment! Isn’t there one other person who is present throughout this or any other progress through the complex, inter-related yet not often speaking to each other, systems that comprise comprehensive care of the elderly? Why of course! It’s the older person themselves! Now there’s a scary novelty – put each person in charge of their own case; give them the authority to communicate and co-ordinate, to command and control.

You’ll never see that happen of course. The NHS would have an attack of the vapours, Social Services would faint clean away. But that’s what you would do isn’t it, if you could and if you had to? Would you leave it to ‘them’ to do it on your behalf? You would the one, and you wouldn’t the other.

Tell that to Jeremy Hunt. Someone should before he wastes everyone’s time and money coming up with grand schemes – with ‘delivery teams’ who meet every second Monday for something to do, and evangelical ‘champions’ who are always desperate to make eye contact in corridors – that are badged ‘Case Management’ to keep the policy wonks happy and management quiet, but which deliver little good or – more likely – simply more muddle, mess and mayhem.

I won’t say ‘if Jeremy Hunt thinks something’s a good idea, it isn’t’; but it’s a decent working rule of thumb, and a temptation harder to resist by the day.

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A&E chaos is the predictable result of GP contracts and EU interference – Telegraph Blogs

“But if a large proportion opt out of evening and weekend work and there are insufficient locums to cope with the demand, what then? The likelihood is that people who would otherwise be seen by a GP will instead flood the already over-stretched casualty departments at the local hospital….So how will the system cope if it has to deal with greater demand caused by the GP contract? More to the point, how will it cope when the Working Time Directive, the European law that limits the number of hours to be worked, hits the NHS?”If I could foresee this fiasco, presumably Health Department could too but chose not to do anything about despite the pleas of many professionals. In 2004, James Johnson, chairman of the BMA council, said: ‘‘We have been trying to alert the Department of Health to the scale of the impending disaster for at least three years.”

via A&E chaos is the predictable result of GP contracts and EU interference – Telegraph Blogs.

– Philip Johnston in the Telegraph today, quoting his own warning and that of James Johnson, the then chairman of the BMA Council, in 2004 about the stone obvious dire consequences of the Labour Government’s astonishing, insane offer to GPs that they could opt out of direct responsibility for out-of-hours primary care if they so chose.

The causes of the current A&E crisis are legion; the 2004 changes to GP contracts a significant but not sole reason. The lesson though that leaps off the page, then as it does now, is that if you attempt to change one facet of a complex system without being willing, at the very least, to attempt to predict the possible consequences of that discrete change on other parts of the system you are not merely inviting catastrophe you are sending it a map and its train ticket.

And so how does this shower respond – in a ‘whole systems’ way – to the approaching whirlwind? Jeremy Hunt announces he’s going to bung some money – that may not even exist – at A&E services in the vain hope that by painting the picket fence he can stop the tornado flattening the farmhouse.

Hunt also says it’s all the GPs fault anyway. So that’s all right then. Sadly, political point scoring when you should be undertaking comprehensive root-cause analysis fixes nothing. ‘Tis hard not to recall the Guardian [bias sample accepted] and the Museum Associations Journal [same bias] surveys that asked if Jeremy Hunt had been any good as the Culture Secretary: a resounding 100% ‘No’. As Health Secretary? Who could possibly say!

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Stroke survivors and their families left to deal with the emotional impact alone, says report – Health News – Health & Families – The Independent

“Of more than 2,700 people surveyed at the end of last year, 79 per cent claimed to have received no information or advice on how to cope with the emotional consequences of strokes.”

via Stroke survivors and their families left to deal with the emotional impact alone, says report – Health News – Health & Families – The Independent.

“The damage caused by a stroke can be widespread and long-lasting. Many people need to have a long period of rehabilitation before they can recover their former independence.

The process of rehabilitation will be specific to you, and will depend on your symptoms and their severity. A team of specialists are available to help, including physiotherapists, psychologists, occupational therapists, speech therapists and specialist nurses and doctors.

The damage that a stroke causes to your brain can impact on many aspects of your life and wellbeing, and depending on your individual circumstances, you may require a number of different treatment and rehabilitation methods. These are discussed in more detail below.”

– NHS Stroke Recovery online

A seeming massive disconnect between the NHS aspiration and intention and the reality of the ‘patient experience’. The NHS says it is aware of the enduring consequences of strokes and that it offers on-going treatment, help, support and advice. Patients, however, are reporting that they hear little or nothing from the NHS about what their needs are likely to be – physical, mental, psychological or emotional – and what the NHS can do, either directly or indirectly by referral to external agencies such as the Stroke Association. 

A question then – one to which no ready answer emerges – why is this so, what is causing the disconnect? Does the NHS, for example, see itself as the provider of initial medical treatments and first-phase rehabilitation/re-enablement, after which the burden and baton passes to Social Services [where eligible] or to the voluntary sector? Is there a failure of a person-centred ‘whole systems’ approach, replete with organisational boundaries, with restricted funding or ring-fenced budgets, or with professional fiefdoms that control who or what is in and who or what is out?

Assuming the validity of the disconnect it would be worth finding out the causes, not least because longer-term failures to deal with the consequences of strokes will, eventually, be more costly for the public purse: increased risks of further, catastrophic strokes; family breakdowns; financial consequences of not being able to work; carers having to give up jobs; stroke patients needing treatment for depression, etc.

In the absence of knowing the cause/s it would be facile to recommend action, beyond perhaps a mandatory one-year follow-up for all stroke admissions to hospital in order to learn from real patient experience what happens to people after discharge. What the Vanguard method would call the necessary first step of ‘Check’. Find out what’s really there, not what is planned, intended or believed to be the case.

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