Monday 22 December 2014

Ambulance + A&E Crises: A Sorry Tale

The perennial winter 'A&E Crisis' stories are with us again, this time with all-too-plausible rumours of targets and statistics about to be manipulated.  Burnam's response for Labour was very nuanced and oblique, so he's obviously been told by Ed Balls to tread carefully and not make anything that might look like a costly promise to do better if Labour come to power.

One of my nearest and dearest had a 5-week involvement with the NHS a short while ago, including an ambulance service / A&E episode.  I'm only too happy to acknowledge several aspects of the story that reflect well on the services we encountered (because there were some) but, from this very recent first-hand experience, there are some shockingly bad and wasteful practices in the emergency services that need sorting.

At a particular point in the saga a District Nursing team determined that 'immediate' hospitalisation was necessary.  I was actively involved throughout what followed.  The degree of urgency was, it is fair to say, below that of a heart-attack or ongoing stroke, but this was no leisurely admittance.  The 999 call centre said that according to their prioritisation scheme an ambulance would be forthcoming in no more than 80 minutes (stated more than once, in a manner that conveyed a strong whiff of Statutory Target).

After 3 hours, two more 999 calls and no ambulance, a senior District Nurse attended and worked the 'phone to get a bit of priority.  At 4 hours a team of 2 'first responders' showed up.  They made a few simple tests, administered oxygen, and asked a heap of questions.  Shortly thereafter a one-man 'ambulance' turned up - in an estate car jobber that wouldn't ever have been a suitable conveyance.  The new man on the scene brought into the house even more portable equipment and had a load more questions - not directed to the DN or me, but to the first-responders.  Finally, a 'proper' bed-ambulance arrived with two more operatives (and a load more questions, this time posed to the first ambulance man).  More than 3 hours after the 'maximum 80 minutes' we now had 5 NHS staff and 3 emergency vehicles on site, to get one patient into one ambulance . 

I'll maybe recount the A&E saga another time.  For present purposes let it simply be noted that although the (uneventful) 15 minute drive to the hospital allowed the ambulance attendant to complete a raft of paperwork (I was sitting alongside the whole time, answering yet more questions), upon arrival the attendant went to a desk to be interrogated from square one by a reception nurse, going over all the same ground once more (the fourth time).

Let's put to one side the suffering and distress, and address the effectiveness of the operation. 

The first lesson: despatch, deployment and coordination of vehicles, crews and resources wasn't just sub-optimal, it was appalling - how come that after 4 hours we wind up with 3 vehicles plus 'highly-trained' crews, only one of which is actually needed ?  Somewhere in the worlds of, oh I dunno, Air Traffic Control ?  RAF casevac mission control ?  Minicab despatchers?  24-hour emergency plumbing firms?  - there must be people and software that can marshall limited resources a damned sight better than that.  Until the gross inefficiency is sorted, please don't tell us there is a shortage of anything.

Secondly, the transfer of information was worse than primitive, it was utterly ineffectual.  The crazy sequence of chinese whispers conducted right under my nose was an outrage to any system of communication anywhere, any time.  Why, during the first 3 hours, hadn't the District Nursing service equipped the ambulance and A&E services with all the basic info, if only by 'phone?  Why were they asking each other all the same questions in turn? (Well, because they were all there, I guess - and all had log-books to complete in due course!  I'd be interested to compare them all ...)  Why didn't they direct the questions to the horse's mouth?  Why was there such a low level of fidelity in successive verbal transfers?  The number of times I had to correct inaccurate chinese whispers was well beyond a joke, and I shudder  to think what might have happened if I hadn't been standing right there to do just that.  

Finally, why was it all by word of mouth, when at several stages there were really obvious opportunities for bluetooth transfer of digitised info, or at least recourse to everyone using an SMS-based central system?  We all know how quick those systems can be.  The time in the ambulance was essentially wasted, not to mention the consequential waste of time at A&E when both the reception nurse and, perhaps more importantly the ambulance crew, could have moved onto the next job five minutes sooner.   (I might add that within the hospital itself the 21st century has been embraced in this regard: they have got basic single-keystroke and direct-from-sensor info-transfer via hand-held devices down to a fairly fine art - so the understanding and technology do exist in the NHS.)

These basic process-and-systems deficiencies are grotesque, and must in some instances (though not directly so in this case) be life-threatening.  'Soft' issues like suffering and distress are much alleviated by slick, optimised processes.   Costs are cut by eliminating waste - again, via slick, optimised processes.  Everything screams out for this to be brought into line with readily available modern methods.  Shame on the management that soaked up the billions pumped in by Blair and Brown without addressing these basic imperatives.



MyShibbolethName said...

This is how it starts; you call an ambulance and it takes an age to come, or doesnt come at all.

This has been my Shibboleth for 'collapse' and I am disheartened to see it written about here. With this I am more inclined to agree with last weeks posters on FT Alphaville who last week forecast a Sterling crisis for H1 2015.

btw - much improved Captcha text thingy....
The Daily Mail will now be full of 'waiting time' stories for pensioners and the like. When will we figure that the ONLY way out of this is to tax land and property to fund the gigantic burden that is about to fall on the NHS and pension funds.

Either this or we must engineer one hell of a flu virus this year....

Budgie said...

ND, please bear in mind that the junior doctor doing his stint in A&E will often have worked long hours, like his predecessors did in the 1960s.

This is because NHS management developed the wheeze of, essentially, 3 weeks on + 1 week off, to take advantage of the averaging available in the Working Time Directive.

In addition it appears that junior doctors are routinely threatened by management with being labelled "inefficient" if they work beyond their shift. But booking in a patient who arrives near shift end may take hours. So overtime is usually worked, just not paid, and not even logged. This defeats the WTD's intentions and means the politicians don't know what they are talking about (as ever).

Many of the things you see in the NHS that look inefficient (and are), or don't make sense, happen for an imposed reason: a "target" or a management intervention.

Nick Drew said...

Budgie, we haven't reached the A&E act in the drama yet. As it happens the junior doc who featured in that scene did a cracking job, one of the stars of the piece

maybe averaging explains the 3 ambulances ? 4 hours divided by 3 = 80 minutes, or something ???

sorry to have disheartened you, MSN (and not sure how we get to land tax - is it a kid of Godwin's Law?). If I can bring myself to keep writing there are aspects of this tale that impinge on the 'gigantic burden' you mention

Jim said...

The answer to your main point - why has technology not been implemented to streamline the operation, is that were it to be done there would undoubtedly have to be job losses somewhere along the line, and that would never do in the NHS, which is primarily a job creation scheme for the middle classes, with a sideline of healthcare. If at any point the primary aim conflicts with the secondary aim, the primary aim is always paramount.

andrew said...

I have seen enormous amounts of waste and inefficiency in the NHS as well.
In bristol, the day patient team regularly did not start until 9.40-10 rather than 9 because one of the 6 people needed was stuck in traffic.
Instantly losing 15% of their productive potential.

The thing is that no-one noticed as invariably someone didnt turn up and if everyone did (never whilst I was there) they could simply bump one or two unlucky people off to the next day.

There are 3 reasons why things wont get better quickly:- expectations, management and process engineering

The processes behind managing a hospital trust (I think) are considerably more complex than managing a large sainsbury, but many of us start with the opposite view.

We have a number of professional groups in place (doctors / accountants / supermarket managers) who have been doing that pattern of job for 40-800 or more years.

The current generation of NHS managers are often ex-clinical staff who have fallen into the job and as such are not really managers.
As a profession (many would say it isn't) it has only been around for the last 20 years or so.
I think it will take about another 10-15 years before we see a large group of reasonably competant NHS managers emerge (assuming the govt dont make a lot of changes)

Process engineering:
The processes inside a hospital are vv complex. this is not a shop or assembly line - you could argue this is not really a process driven job.
On top of that, there seems to be something almost pathological in the relationship between the NHS and IT.

Part of it stems from the complete bunker mentality the senior clinical staff have when faced with any change - in any other workplace they would be invited to find another job.

Another part of the issue is that the senior clinical staff are usually right. They embody decades of experience and have usually seen all the new ideas 20 years ago and know which ones dont work.

Many of the managers left the clinical front line before they could gather this experience.

So in my considered judgement, we are all doomed.

Merry christmas.

Anonymous said...

Having had several experiences with the 'system' recently I can attest to this level of dysfunction.

The over-riding impression is of individual effort dwarfed by systemic incompetence. Like the episode described above, the sheer number of times it is necessary to repeat the same simple information to successive layers is breathtaking and, in this day and age, inexcusable.

However, when I mention this to friends in the NHS they are adamant: The system works! We only need more money and staff. It can all be solved with more, more, more...

I can't see it changing.

DtP said...

I work at what is now the HSCIC - a merger of the NHS Info Centre and Connecting for Health which ostensibly serves as the IT function of much of the health service. Bill asked me to do a post a while back but I didn't really feel capable of judging the entirity of its effectiveness at the time as I was quite new but i've subsequently learnt quite a lot more.

I think the main problem as with any devolved system is adding value and responding to customers needs. We have all these systems, many of them good but they seem planned by committee rather than by requirement. The infrastructure is fine, almost there for electronic summary care records - pretty secure apart from this North Korea or NSA thing - anonymisation pretty good allowing the potential of the best epidemiology in the world but there's a huge propensity to run before walking - to predict rather than to respond. It's not so much cultural (although that's an issue) but political - I get the impression that much work is commissioned because exec diretors in either HSCIC, NHS England or the Dept of Health feel like they should be innovating rather than improving. It also seems that the relationships between exec directors of the 3 agencies are just cock measuring rather than avoiding duplication or seeking economies of scale.

Bill, ages ago, mentioned that it would have been wise to build a virtual hospital with its primary & secondary care functions, its ambulance service and GP orgs built around it, the local government, hospice, palliative functions as feeder and get clinicians, patients, techies and managers all participating in and with the available environments that are now available but that just doesn't seem to happen - what we have is a disjointed, peacemeal, application based landscape where no one really takes responsibility for anything so no one can be fucked by it when it goes tits up which it inevitably does because no one steering it. Sure, the infrastrucure is fine as they're headline functions which scupper everything else but the ancillary stuff, the stuff that adds practical value seems half arsed and boring so it's just kind of kicked about.

It is a genuine shame that Landsley went off on one where he could have used his power to genuinely attack so now we have the prospect of another 5 years of Hunt or Burnham and both haven't got anywhere near the political capital to be relevant - hell, NHS England was fucked before it even started with that cunt David Nicholson using it as a blackmailing edifice for his own power grab (and a bloody good job he did). So we've got Simon Stevens, who, to be fair, seems like an impressive chap - saw a select committee a couple of weeks back and the guy's learning curve has been pronounced but he ain't the gaffer so why should officers listen to him when his boss is wasting away his day talking bollox to anyone who'll listen?

Nil desperandum - it's not fubar but the politics don't help and commissioning all to fuck as well and now Foundation Trusts are buying out of PFI so that's another thing. None of this is difficult but....

Jan said...

A sorry tale and not confined to the ambulance service but indicative of our public services in general. How anyone can bear to work there I have no idea. Perhaps you could've bypassed the whole system by delivering the patient there would have been a lot quicker and safer for the patient too as they would undoubtedly have been seen by a doctor more quickly.

The best thing we can all do is look after ourselves as best we can physically and pray we never need to use the NHS.

dearieme said...

"Perhaps you could've bypassed the whole system by delivering the patient there they would undoubtedly have been seen by a doctor more quickly."

That's the opposite of our experience. My wife delivers me and I can sit in A&E unseen for four hours. An ambulance delivers me and I'm seen in minutes.

Nick Drew said...

in this case (a) we'd been told by the DN to summon an ambulance, and (b) it would also have been my own, uninstructed judgement that patient really needed ambulance transport

BTW, in this case A&E was always intended to be just the gateway to full hospital admission

Budgie said...

ND, maybe you have not reached the A&E yet, but I have. I assumed that my knowledge of the NHS (such as it is) may help to explain your experience with the ambulance service.

Nick Drew said...

yes, thanks Budgie - I am genuinely facsinated by the 'averaging' phenomenon, hence my query @ 8:08

Elby the Beserk said...

Once a bureaucracy reaches a certain size, it's all down hill. I think history largely agrees with me on that point. It is not possible to manage an organisation of 1.4 million people with any efficiency at all.

DtP said...

Health and education - 2 easy ends to a political career.

People want ambition around me and it kinda hurts. The Rubicon is distant, only play to work the room. Show then grace usually works.

People aren't as thick as we know they fucking are: Soros brought down the BoE! How is inflation measured now?

Proper love you lads but Ricky's seen it all before. Let's do fucking art instead?

Cheers very muchly


BrianSJ said...

No surprise that a managerialist computer system is involved. The great NeeNaw