The NHS needs money. It also needs to change

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In 2011, the UK had 2.8 physicians/1000 population compared with Germany 3.8, France 3.4 and Australia 3.3. The UK spent 9.4% of its GDP on health compared with France 11.5, Germany 11.3 and Australia 9.4; the UK’s spending was forecast to drop to 6.6% by 2020/21 though all bets are off with Brexit looming.

The NHS in England needs more doctors. I work for a large trust across two hospitals where the 6 different anaesthetic rotas at middle grade/registrar level should theoretically provide plenty of cross-cover. It doesn’t: I regularly receive requests to fill gaps in rotas, often with “HELP!!!!” in the subject line. This is no different at smaller district general hospitals.

Criticisms from the BMA of Jeremy Hunt during the doctors’ strike and Theresa May are correct. Seven-day elective services do little for emergency care provision. Moving GP opening hours to 8-8pm is not the same as increasing capacity. If two GPs work 9-5 and then change their working hours to 8-4 and 12-8, the surgery will still be open 8-8 but there will be the same number of appointments.

Opposition to change in the NHS is widespread

That said, trying to change something in the NHS is nigh-on impossible. Healthcare professionals blame managers. Managers blame healthcare professionals. Everybody blames IT.

Let me give you an example. Patients in acute medicine are allocated to consultants in 24 hour blocks, 8am-8am. Patients who arrive in that time, fall under that so-called “take” consultant. If not discharged on the day, they are added to a “post-take” ward round the day after.

There is software which produces an active list of patients who need to and have been seen by Acute Medicine. There is a list for yesterday and today. From 0800-0900, it moves forward to the next day. The issue is, at 0730, secretaries print the previous day’s “take” list. Between 0730-0900, patient’s deemed seen by a junior doctor may get added to the previous day’s list after it has been printed. Today’s take consultant thinks the patient has been seen by the previous day’s consultant. The previous day’s consultant – now on the post-take ward round – doesn’t know about the patient

This could be solved simply by having the system refresh at 0630-0730. However, this doesn’t happen. Instead, at 8am, junior doctors print a physical list and after 0900, add the information. Of course, doctors may forget, may be new and not realise or there may simply be a clerical error on paper leading to patient not being seen.

At another hospital, the portering system had gone electronic and theatres had lost their dedicated porter. If there were no operations, previously that porter went and helped with other portering jobs.

On the new system, the most urgent your patient will be picked up is “urgent”. However, I have frequently waited an hour or more for patients who were acutely unwell. Theatre staff were instructed they should not be leaving theatres to collect patients – this makes sense as if the patients arrived in a timely fashion, theatre staff would be preparing theatre. This was not an issue prior to the introduction of the electronic system.

These issues may seem minor but they are legion. Each one adds a layer of inefficiency. Occasionally, you get workarounds (like in the first example) but these aren’t really solving the problem. Steven J. Spear’s excellent book The High-Velocity Edge looks at how to improve processes – to paraphrase him, this is not a solution, rather solving the same problem every day.

Efficiency savings or quality improvement?

As a junior doctor, largely you feel powerless to change these things. You usually spend 4-6 months per placement, too little time to effect change. This is made worse by healthcare professionals who aren’t willing to at least try change. Change is not always good – yes – but that’s necessary risk to take. Indeed, in research, it’s acknowledged that change is necessary. Without it, we would not have seen the medical advances of the last 70 years. Ultimately, the “low-hanging fruit” of research have been taken. With quality improvement, we have barely scratched the surface of what the NHS is capable.

The difficulty is two-fold. First, any criticism of the NHS is perceived as bad. “Efficiency savings” have become a euphemism for cuts. However, what kind of organisation isn’t constantly trying to make efficiency savings?

Under Tony Blair, healthcare organisations worked on expanding services, a very different set of managerial skills to improving current ones. It takes time and effort but mindless calls to #SaveOurNHS, whilst useful at times, perpetuate the image that the NHS doesn’t need change, it just needs more money.

Secondly, many healthcare professionals engage in management begrudgingly, interested in clinical practice only. Though we receive little training in management, our reluctance to change processes kils our patients as much as any funding gap. They are as important as our clinical skills.

To be effective, these changes need to solve problems from the bottom up. Managers should call for small problems to be highlighted and praise staff for doing so. Staff, when change is implemented, should go with it, at least at first. And managers should listen to the things that do and do not work. No amount of money can change this.

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A really fun post about death

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Last year, there was quite a bit of chat about famous people dying. The BBC examined this and found they had published more pre-prepared obituaries than usual in the first 4 months of last year in particular.

This sounds callous but I find it difficult to care.

Don’t get me wrong – if Sarah Michelle Gellar (I liked Buffy) or Claire Danes (I like Homeland) die, I will be taken aback. However, I am not going to be personally affected should Gellar die. And whilst it would be sad if Homeland got cancelled due to Danes’ untimely demise, this is not reason to grieve.

When people on social media express their sadness at a celebrity’s death, mostly this is in tribute to their body of work. However, there sometimes seem to be genuine expressions of grief as though they were a loved one.

In hospital, whilst most relatives are realistic, it is not uncommon to encounter impossible expectations of healthcare. Arguably the most challenging aspect of critical care medicine is making the decision about when to provide or more crucially when not to provide critical care.

Being on a Critical Care Unit/Intensive Care Unit (vs being on a standard ward) involves a host of unpleasant interventions. Whilst this is worthwhile if a patient has a reasonable chance of survival, in futile cases, this is tantamount to torture, a word I use when explaining ceilings of care.

I worry that both the unrealistic expectations and grieving for celebrities are symptoms of our general aversion to discussing death. How can one seriously grieve for somebody unknown to them?

In the original Get Carter (1971), Michael Caine’s character (the titular Jack Carter) has to attend his brother’s funeral. The body is kept in the family home. These days, bodies are kept in mortuaries and taken by funeral directors prior to burial or cremation. It would be unheard of to keep a body in the family home.

I am not trying to make you feel bad for your sadness at George Michael/Alan Rickman/Victoria Wood’s death. Still, posts can seem as grief-stricken as those from the genuinely bereaved.

Death is a fact and it is something we consider too little and discuss too infrequently. It leads to the situations where people with cancer are abandoned by their friends. I have had multiple conversations where bereaved friends have found others unable or unwilling to discuss the death of a loved one.

And because of this, it seems uncouth and unhealthy to act as though a celebrity death should be treated similarly to personal bereavement.

Talk about death; when your relatives became unwell, doctors are going to ask what you think they wanted. That is a much easier discussion if you have had the decency to talk about it. It is for them as much as you.

You and everybody you know and love is going to die: get comfortable with that. On that note, I am going to have a banana and go to bed.